Resuscitation Enhancement to Avoid Rearrest Through Evidence-based Strategies in Prehospital Post-resuscitation Care

NCT07239908 | Recruiting Phase 2 DMC

• 1 other identifier: 801/2568(IRB4)
• Study Type: interventional
• Target: 318
• Locations: 1 country
• Sites: 1

Brief Summary

Out-of-hospital cardiac arrest (OHCA) remains a leading global emergency condition with low survival to hospital discharge despite advances in cardiopulmonary resuscitation. Return of spontaneous circulation (ROSC) rates have improved; however, 30-50% of patients experience rearrest after ROSC, which is associated with significantly reduced survival. Preventable physiologic factors related to prehospital care - including hypoxia, hypotension, and hyperventilation - are frequently identified prior to rearrest. Evidence-based post-ROSC clinical bundles exist mainly for in-hospital settings, while structured prehospital post-resuscitation care protocols are limited, particularly in resource-constrained environments. The RE-ARREST project aims to develop, implement, and evaluate an evidence-based prehospital post-resuscitation care protocol designed for paramedic-led Emergency Medical Services. The intervention includes structured monitoring, tailored oxygenation and ventilation targets, vasopressor use criteria (norepinephrine), fluid management decision support, teamwork communication, and operational training workshops using simulation. This is a quasi-experimental pre-post interventional study conducted at the Siriraj Emergency Medical Service (SiEMS), Thailand. The study compares outcomes from retrospective pre-implementation cases with prospective post-implementation cases, including both patient-centered outcomes and provider compliance. Adult OHCA patients with ROSC achieved prehospital and transported to Siriraj Hospital are eligible. The estimated sample size is 318 participants (pre-intervention 212; post-intervention 106) over two years. The primary outcome is the incidence of rearrest within 1 hour after ROSC during prehospital care and initial emergency department management. Secondary outcomes include protocol compliance, survival-to-admission, and survival-to-hospital-discharge. The protocol emphasizes feasibility, safety, and replicability to inform scalable EMS clinical practice guidelines. This research is expected to provide novel evidence on targeted prehospital post-ROSC care and has the potential to reduce rearrest, improve neurologically favorable survival, and strengthen EMS system quality improvement efforts in Thailand and other low-to-middle-resource settings.

Conditions

Out-of-hospital Cardiac Arrest (OHCA)

Keywords

Post cardiac arrest care; Out-of-hospital cardiac arrest; Prehospital care

Outcome Measures

Primary Outcomes (1)

• Rearrest rate

  patient who has return of spontaneous circulation and then has no pulse again

  From return of spontaneous circulation to first 1 hour in emergency room

Secondary Outcomes (1)

• Survival to dischrage

  30 days after admission

Study Arms (2)

No intervention

NO INTERVENTION

Conventional post cardiac arrest care by ALS unit in Bangkok Thailand

Prehospital post cardiac arrest care protocol

EXPERIMENTAL

Prehospital post cardiac arrest care protocol

Drug: Prehospital post cardiac arrest care protocol

Interventions

Prehospital post cardiac arrest care protocol DRUG

Prehospital post cardiac arrest care including: 1. Fluid assessment and resuscitation in prehospital phase 2. Early vasopressor in prehospital phase 3. Regular monitoriny end-tidal CO2 in prehospital phase

Prehospital post cardiac arrest care protocol

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Adults aged 18 years or older.
• Patients with out-of-hospital cardiac arrest (OHCA) who received resuscitative care from the Siriraj Emergency Medical Services Center (SiEMS).
• Patients who achieved return of spontaneous circulation (ROSC) prior to hospital arrival.
• \- Patients subsequently transported to the Emergency Department of Siriraj Hospital for further treatment.

You may not qualify if:

• Suspected traumatic cardiac arrest.
• ROSC patients whose legally authorized representative declined vasopressor administration, despite clinical indication according to the prehospital post-resuscitation care protocol.
• ROSC patients who had not undergone endotracheal intubation, and whose legally authorized representative declined endotracheal intubation, despite protocol-based indication.
• ROSC patients without rearrest whose legally authorized representative declined further blood investigations or additional procedures after arrival at the Emergency Department.
• Patients whose legally authorized representative declined participation in the study.
• Patients without an available legally authorized representative to provide consent for study participation.

Sponsors & Collaborators

• Siriraj Hospital: lead

Study Sites (1)

Faculty of Medicine Siriraj Hospital, Mahidol University

Bangkok Noi, Bangkok, 10700, Thailand

RECRUITING

Related Publications (11)

• Vos IA, Lucassen FG, Bens BWJ, Dercksen B, Postma R, Jorna EMF, Ter Maaten JC, Struys MMRF, Ter Avest E. Pre-hospital care after return of spontaneous circulation: Are we achieving our targets? Resusc Plus. 2024 Jun 21;19:100691. doi: 10.1016/j.resplu.2024.100691. eCollection 2024 Sep.

  PMID: 39006133 BACKGROUND

• Dillon DG, Montoy JCC, Bosson N, Toy J, Kidane S, Ballard DW, Gausche-Hill M, Donofrio-Odmann J, Schlesinger SA, Staats K, Kazan C, Morr B, Thompson K, Mackey K, Brown J, Menegazzi JJ; California Resuscitation Outcomes Consortium. Rationale and development of a prehospital goal-directed bundle of care to prevent rearrest after return of spontaneous circulation. J Am Coll Emerg Physicians Open. 2024 Nov 5;5(6):e13321. doi: 10.1002/emp2.13321. eCollection 2024 Dec.

  PMID: 39503017 BACKGROUND

• Toy J, Tolles J, Bosson N, Hauck A, Abramson T, Sanko S, Kazan C, Eckstein M, Gausche-Hill M, Schlesinger SA. Association between a Post-Resuscitation Care Bundle and the Odds of Field Rearrest after Successful Resuscitation from Out-of-Hospital Cardiac Arrest: A Pre/Post Study. Prehosp Emerg Care. 2024;28(1):98-106. doi: 10.1080/10903127.2023.2172633. Epub 2023 Feb 13.

  PMID: 36692410 BACKGROUND

• Smida T, Price BS, Mizener A, Crowe RP, Bardes JM. Prehospital Post-Resuscitation Vital Sign Phenotypes are Associated with Outcomes Following Out-of-Hospital Cardiac Arrest. Prehosp Emerg Care. 2025;29(2):138-145. doi: 10.1080/10903127.2024.2386445. Epub 2024 Aug 15.

  PMID: 39088816 BACKGROUND

• Smida T, Menegazzi JJ, Crowe RP, Weiss LS, Salcido DD. Association of prehospital hypotension depth and dose with survival following out-of-hospital cardiac arrest. Resuscitation. 2022 Nov;180:99-107. doi: 10.1016/j.resuscitation.2022.09.018. Epub 2022 Sep 30.

  PMID: 36191809 BACKGROUND

• Salcido DD, Sundermann ML, Koller AC, Menegazzi JJ. Incidence and outcomes of rearrest following out-of-hospital cardiac arrest. Resuscitation. 2015 Jan;86:19-24. doi: 10.1016/j.resuscitation.2014.10.011. Epub 2014 Oct 23.

  PMID: 25447433 BACKGROUND

• Salcido DD, Stephenson AM, Condle JP, Callaway CW, Menegazzi JJ. Incidence of rearrest after return of spontaneous circulation in out-of-hospital cardiac arrest. Prehosp Emerg Care. 2010 Oct-Dec;14(4):413-8. doi: 10.3109/10903127.2010.497902.

  PMID: 20809686 BACKGROUND

• Lerner EB, O'Connell M, Pirrallo RG. Rearrest after prehospital resuscitation. Prehosp Emerg Care. 2011 Jan-Mar;15(1):50-4. doi: 10.3109/10903127.2010.519820. Epub 2010 Nov 5.

  PMID: 21054177 BACKGROUND

• Chestnut JM, Kuklinski AA, Stephens SW, Wang HE. Cardiovascular collapse after return of spontaneous circulation in human out-of-hospital cardiopulmonary arrest. Emerg Med J. 2012 Feb;29(2):129-32. doi: 10.1136/emj.2010.108340. Epub 2011 Feb 18.

  PMID: 21335581 BACKGROUND

• Woo JH, Cho JS, Lee CA, Kim GW, Kim YJ, Moon HJ, Park YJ, Lee KM, Jeong WJ, Choi IK, Choi HJ, Choi HJ. Survival and Rearrest in out-of-Hospital Cardiac Arrest Patients with Prehospital Return of Spontaneous Circulation: A Prospective Multi-Regional Observational Study. Prehosp Emerg Care. 2021 Jan-Feb;25(1):59-66. doi: 10.1080/10903127.2020.1733716. Epub 2020 Mar 20.

  PMID: 32091295 BACKGROUND

• Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies. Resuscitation. 2010 Nov;81(11):1479-87. doi: 10.1016/j.resuscitation.2010.08.006. Epub 2010 Sep 9.

  PMID: 20828914 BACKGROUND

MeSH Terms

Conditions

Out-of-Hospital Cardiac Arrest

Condition Hierarchy (Ancestors)

Heart Arrest; Heart Diseases; Cardiovascular Diseases

Study Officials

• Sattha Riyapan, MD MPH

  Mahidol University

  PRINCIPAL INVESTIGATOR

Central Study Contacts

Sattha Riyapan, MD MPH

CONTACT

+66994489090; sattha.riy@mahidol.ac.th

Bongkot Somboonkul, BS

CONTACT

+6624141672; bongkot.somboonkul.work@gmail.com

Study Design

• Study Type: interventional
• Phase: phase 2
• Allocation: NON RANDOMIZED
• Masking: NONE
• Purpose: TREATMENT
• Intervention Model: SEQUENTIAL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Assistant professor

Model Details: Prehospital post cardiac arrest care protocol for advanced life support ambulance

Study Record Dates

• First Submitted: November 16, 2025
• First Posted: November 20, 2025
• Study Start: December 1, 2025
• Primary Completion (Estimated): December 31, 2027
• Study Completion (Estimated): December 1, 2028
• Last Updated: April 21, 2026

Record last verified: 2026-04

Data Sharing

• IPD Sharing: Will share
• Shared Documents: STUDY PROTOCOL

Locations

TH (1)