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Kim JH, Lee J, Shin H, Lim TH, Jang BH, Cho Y, Kim W, Choi KS, Kim JG, Ahn C, Lee H, Namgung M, Na MK, Kwon SM. Association Between QRS Characteristics in Pulseless Electrical Activity and Survival Outcome in Cardiac Arrest Patients: A Systematic Review and Meta-Analysis. PREHOSP EMERG CARE 2024:1-8. [PMID: 38787646 DOI: 10.1080/10903127.2024.2360139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE Recent studies have shown inconsistent results regarding the association between QRS characteristics and survival outcomes in patients with cardiac arrest and pulseless electrical activity (PEA) rhythms. This meta-analysis aimed to identify the usefulness of QRS width and frequency as prognostic tools for outcomes in patients with cardiac arrest and PEA rhythm. METHODS Extensive searches were conducted using Medline, Embase, and the Cochrane Library to find articles published from database inception to 4 June 2023. Studies that assessed the association between the QRS characteristics of cardiac arrest patients with PEA rhythm and survival outcomes were included. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. RESULTS A total of 9727 patients from seven observational studies were included in this systematic review and meta-analysis. The wide QRS group (QRS ≥ 120 ms) was associated with significantly higher odds of mortality than the narrow QRS group (QRS < 120 ms) (odds ratio (OR) = 1.86, 95% confidence interval (CI) = 1.11-3.11, I2 = 58%). The pooled OR for mortality was significantly higher in patients with a QRS frequency of < 60/min than in those with a QRS frequency of ≥ 60/min (OR = 1.90, 95% CI = 1.19-3.02, I2 = 65%). CONCLUSIONS Wide QRS width or low QRS frequency is associated with increased odds of mortality in patients with PEA cardiac arrest. These findings may be beneficial to guide the disposition of cardiac arrest patients with PEA during resuscitation.
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Affiliation(s)
- Jae Hwan Kim
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Juncheol Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Hyungoo Shin
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Bo-Hyoung Jang
- Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Youngsuk Cho
- Department of Emergency Medicine, Hallym University, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Wonhee Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Jae Guk Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Heekyung Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Myeong Namgung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gyeonggi-do, Republic of Korea
| | - Min Kyun Na
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Sae Min Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
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Urteaga J, Elola A, Norvik A, Unneland E, Eftestøl TC, Bhardwaj A, Buckler D, Abella BS, Skogvoll E, Aramendi E. Machine learning model to predict evolution of pulseless electrical activity during in-hospital cardiac arrest. Resusc Plus 2024; 17:100598. [PMID: 38497047 PMCID: PMC10940985 DOI: 10.1016/j.resplu.2024.100598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 03/19/2024] Open
Abstract
Background During pulseless electrical activity (PEA) the cardiac mechanical and electrical functions are dissociated, a phenomenon occurring in 25-42% of in-hospital cardiac arrest (IHCA) cases. Accurate evaluation of the likelihood of a PEA patient transitioning to return of spontaneous circulation (ROSC) may be vital for the successful resuscitation. The aim We sought to develop a model to automatically discriminate between PEA rhythms with favorable and unfavorable evolution to ROSC. Methods A dataset of 190 patients, 120 with ROSC, were acquired with defibrillators from different vendors in three hospitals. The ECG and the transthoracic impedance (TTI) signal were processed to compute 16 waveform features. Logistic regression models where designed integrating both automated features and characteristics annotated in the QRS to identify PEAs with better prognosis leading to ROSC. Cross validation techniques were applied, both patient-specific and stratified, to evaluate the performance of the algorithm. Results The best model consisted in a three feature algorithm that exhibited median (interquartile range) Area Under the Curve/Balanced accuracy/Sensitivity/Specificity of 80.3(9.9)/75.6(8.0)/ 77.4(15.2)/72.3(16.4) %, respectively. Conclusions Information hidden in the waveforms of the ECG and TTI signals, along with QRS complex features, can predict the progression of PEA. Automated methods as the one proposed in this study, could contribute to assist in the targeted treatment of PEA in IHCA.
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Affiliation(s)
- Jon Urteaga
- Communications Engineering Department, University of the Basque Country (UPV/EHU), Plaza Ingeniero Torres Quevedo 1, 48013 Bilbao, Spain
| | - Andoni Elola
- Department of Electronic Technology, University of the Basque Country (UPV/EHU), Plaza Ingeniero Torres Quevedo 1, 48013 Bilbao, Spain
| | - Anders Norvik
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Prinsesse Kristinas gate 3, 7030 Trondheim, Norway
| | - Eirik Unneland
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Prinsesse Kristinas gate 3, 7030 Trondheim, Norway
| | - Trygve C. Eftestøl
- Department of Electrical Engineering and Computer Science, University of Stavanger (UiS), Kjell Arholms gate 41, 4021 Stavanger, Norway
| | - Abhishek Bhardwaj
- University of California, 900 University Ave, Riverside, CA 92521, United State
| | - David Buckler
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, United States
| | | | - Eirik Skogvoll
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Prinsesse Kristinas gate 3, 7030 Trondheim, Norway
| | - Elisabete Aramendi
- Communications Engineering Department, University of the Basque Country (UPV/EHU), Plaza Ingeniero Torres Quevedo 1, 48013 Bilbao, Spain
- Biocruces Bizkaia Health Research Institute, Cruces Plaza, 48903 Barakaldo, Spain
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Norvik A, Kvaløy JT, Skjeflo GW, Bergum D, Nordseth T, Loennechen JP, Unneland E, Buckler DG, Bhardwaj A, Eftestøl T, Aramendi E, Abella BS, Skogvoll E. Heart rate and QRS duration as biomarkers predict the immediate outcome from pulseless electrical activity. Resuscitation 2023; 185:109739. [PMID: 36806651 DOI: 10.1016/j.resuscitation.2023.109739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023]
Abstract
INTRODUCTION Pulseless electrical activity (PEA) is commonly observed in in-hospital cardiac arrest (IHCA). Universally available ECG characteristics such as QRS duration (QRSd) and heart rate (HR) may develop differently in patients who obtain ROSC or not. The aim of this study was to assess prospectively how QRSd and HR as biomarkers predict the immediate outcome of patients with PEA. METHOD We investigated 327 episodes of IHCA in 298 patients at two US and one Norwegian hospital. We assessed the ECG in 559 segments of PEA nested within episodes, measuring QRSd and HR during pauses of compressions, and noted the clinical state that immediately followed PEA. We investigated the development of HR, QRSd, and transitions to ROSC or no-ROSC (VF/VT, asystole or death) in a joint longitudinal and competing risks statistical model. RESULTS Higher HR, and a rising HR, reflect a higher transition intensity ("hazard") to ROSC (p < 0.001), but HR was not associated with the transition intensity to no-ROSC. A lower QRSd and a shrinking QRSd reflect an increased transition intensity to ROSC (p = 0.023) and a reduced transition intensity to no-ROSC (p = 0.002). CONCLUSION HR and QRSd convey information of the immediateoutcome during resuscitation from PEA. These universally available and promising biomarkers may guide the emergency team in tailoring individual treatment.
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Affiliation(s)
- A Norvik
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Anesthesia and Intensive Care Medicine, St Olav University Hospital, Trondheim, Norway
| | - J T Kvaløy
- Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway
| | - G W Skjeflo
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Surgery, Section for Anesthesiology, Nordland Hospital, Bodø, Norway
| | - D Bergum
- Department of Anesthesia and Intensive Care Medicine, St Olav University Hospital, Trondheim, Norway
| | - T Nordseth
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Anesthesia and Intensive Care Medicine, St Olav University Hospital, Trondheim, Norway
| | - J P Loennechen
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Clinic of Cardiology, St. Olav University Hospital, Trondheim, Norway
| | - E Unneland
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - D G Buckler
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, NY, USA
| | - A Bhardwaj
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - T Eftestøl
- Department of Electrical Engineering and Computer Science, University of Stavanger, Stavanger, Norway
| | - E Aramendi
- University of the Basque Country, Engineering School of Bilbao, Bilbao, Spain
| | - B S Abella
- Center for Resuscitation Science, University of Pennsylvania, Philadelphia, USA
| | - E Skogvoll
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Anesthesia and Intensive Care Medicine, St Olav University Hospital, Trondheim, Norway
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4
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The effect of intravenous adrenaline on electrocardiographic changes during resuscitation in patients with initial pulseless electrical activity in out of hospital cardiac arrest. Resuscitation 2019; 136:119-125. [DOI: 10.1016/j.resuscitation.2019.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 12/21/2018] [Accepted: 01/20/2019] [Indexed: 11/18/2022]
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Skjeflo GW, Nordseth T, Loennechen JP, Bergum D, Skogvoll E. ECG changes during resuscitation of patients with initial pulseless electrical activity are associated with return of spontaneous circulation. Resuscitation 2018; 127:31-36. [PMID: 29621571 DOI: 10.1016/j.resuscitation.2018.03.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/09/2018] [Accepted: 03/31/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pulseless electrical activity (PEA) is a frequent initial rhythm in cardiac arrest, and ECG characteristics have been linked to prognosis. The aim of this study was to examine the development of ECG characteristics during advanced life support (ALS) and cardiopulmonary resuscitation (CPR) in cardiac arrest with initial PEA, and to assess any association with survival. METHODS Patients with in-hospital cardiac arrest with initial PEA at St. Olav Hospital (Trondheim, Norway) over a three-year period were included. A total of 2187 combined observations of QRS complex rate (heart rate) and QRS complex width for the duration of ALS were determined from defibrillator recordings from 74 episodes of cardiac arrest. RESULTS Increasing heart rate and decreasing QRS complex width during ALS was significantly more prevalent in patients who obtained return of spontaneous circulation compared to patients who were declared dead. CONCLUSION Changes in ECG characteristics during ALS in cardiac arrest presenting as PEA are related to prognosis. An increase in heart rate was observed in the last 3-6 min before ROSC was obtained.
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Affiliation(s)
- Gunnar Waage Skjeflo
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway.
| | - Trond Nordseth
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway; St. Olav University Hospital, Department of Anesthesia and Intensive Care Medicine, NO-7006 Trondheim, Norway
| | - Jan Pål Loennechen
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway; St. Olav University Hospital, Department of Cardiology, NO-7006 Trondheim, Norway
| | - Daniel Bergum
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway; St. Olav University Hospital, Department of Anesthesia and Intensive Care Medicine, NO-7006 Trondheim, Norway
| | - Eirik Skogvoll
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway; St. Olav University Hospital, Department of Anesthesia and Intensive Care Medicine, NO-7006 Trondheim, Norway
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6
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Weiser C, Poppe M, Sterz F, Herkner H, Clodi C, Schriefl C, Warenits A, Vossen M, Schwameis M, Nürnberger A, Spiel A. Initial electrical frequency predicts survival and neurological outcome in out of hospital cardiac arrest patients with pulseless electrical activity. Resuscitation 2018; 125:34-38. [PMID: 29408228 DOI: 10.1016/j.resuscitation.2018.01.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/11/2018] [Accepted: 01/26/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Outcome is generally poor in out of hospital cardiac arrests (OHCA) with initial non-shockable rhythms. Termination of resuscitation rules facilitate early prognostication at the scene to cease resuscitation attempts in futile situations and to proceed advanced life support in promising conditions. As pulseless electrical activity (PEA) is present as first rhythm in every 4th OHCA we were interested if the initial electrical frequency in PEA predicts survival. METHODS All patients >18 years of age with non-traumatic OHCA and PEA as first rhythm between August 2013 and August 2015 from the Vienna Cardiac Arrest Registry were included in this retrospective observational study. Defibrillator and epidemiological data from the emergency medical system as survival data were processed considering the initial electrical activity in PEA and 30 days survival. RESULTS Out of 2149 OHCA patients, a total of 504 PEA patients were eligible for analyses. These patients were stratified into 4 groups according the initial electrical frequency in PEA: 10-24/min, 25-39/min, 40-59/min, >60/min. Compared to a frequency >60/min all other subgroups were associated with higher mortality especially those with an initial electrical frequency 10-24 (adjusted OR 0.56 (0.39-0.79) p = .001 for each category chance). QRS duration in PEA did not influence outcome. Patients in the >60/min group showed a 30-days-survival rate of 22% and a good neurological outcome in 15% of all patients - comparable to shockable cardiac arrest rhythms. CONCLUSION Regardless of other resuscitation factors, higher initial electrical frequency in PEA is associated with increased odds of survival and good neurological outcome.
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Affiliation(s)
- Christoph Weiser
- Department of Emergency Medicine, Medical University of Vienna, Austria.
| | - Michael Poppe
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Christian Clodi
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | | | | | - Mathias Vossen
- Department of Internal Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | | | - Alexander Spiel
- Department of Emergency Medicine, Medical University of Vienna, Austria
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Ho ML, Gatien M, Vaillancourt C, Whitham V, Stiell IG. Utility of prehospital electrocardiogram characteristics as prognostic markers in out-of-hospital pulseless electrical activity arrests. Emerg Med J 2017; 35:89-95. [DOI: 10.1136/emermed-2017-206878] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 09/20/2017] [Accepted: 10/03/2017] [Indexed: 11/03/2022]
Abstract
BackgroundIt is unclear if there are predictors of survival, including ECG characteristics, that can guide resuscitative efforts in pulseless electrical activity (PEA) cardiac arrests. We studied the predictive potential of presenting prehospital ECGs on survival for patients with out-of-hospital cardiac arrest (OHCA) with PEA.MethodsWe studied prehospital ECGs of patients with OHCA prospectively enrolled between June 2007 and November 2009 at the Ottawa/OPALS (Ontario Prehospital Advanced Life Support Study) site of the Resuscitation Outcomes Consortium PRIMED study (Prehospital Resuscitation using an IMpedance valve and Early versus Delayed analysis). We included adult non-traumatic OHCA with PEA rhythm where resuscitation was attempted. We measured HR, QRS interval and presence of P waves, and determined their impact on return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD) using multivariate regression analysis.ResultsThe demographic characteristics of the 332 included cases were the following: mean age 71.8, male 58.4%, SHD 5.4% and ROSC at ED arrival 26.5%. Survivors had similar HR (56.8 vs 52.0 beats per minute (bpm), p=0.53) and QRS intervals (128.7 vs 129.6 ms, p=0.95) compared with non-survivors. Prehospital ECG characteristics did not predict SHD or ROSC on multivariate analyses. Patients with initial HR <30 bpm had a 3.8% survival rate; those with both HR <30 bpm and QRS≥120 ms had a 3.7% survival rate. Location of arrest predicted SHD (adjusted OR (AdjOR)=1.49, 1.11 to 1.99; p=0.007). Atropine use negatively predicted SHD (AdjOR=0.06, 0.02 to 0.22; p<0.001). Predictors of ROSC ALS paramedic on scene (AdjOR=8.90, 1.11 to 71.41; p=0.04) and successful intubation (AdjOR=3.35, 1.75 to 6.39; p<0.001). Atropine use negatively predicted ROSC (AdjOR=0.27, 0.14 to 0.50; p<0.001).ConclusionsPresenting prehospital ECG characteristics did not predict SHD or ROSC in OHCA PEA victims and should not be used to guide termination of resuscitation. Location of arrest was a positive predictor for SHD; atropine use was a negative predictor. ALS paramedic on scene and successful intubation were positive predictors of ROSC; atropine use was a negative predictor.Trial registration numberNCT00394706; post-results.
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Bergum D, Skjeflo GW, Nordseth T, Mjølstad OC, Haugen BO, Skogvoll E, Loennechen JP. ECG patterns in early pulseless electrical activity-Associations with aetiology and survival of in-hospital cardiac arrest. Resuscitation 2016; 104:34-9. [PMID: 27143124 DOI: 10.1016/j.resuscitation.2016.03.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 01/21/2016] [Accepted: 03/04/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Pulseless electrical activity (PEA) is an increasingly common presentation in cardiac arrest. The aim of this study was to investigate possible associations between early ECG patterns in PEA and the underlying causes and survival of in-hospital cardiac arrest (IHCA). METHODS Prospectively observed episodes of IHCA presenting as PEA between January 2009 and august 2013, with a reliable cause of arrest and corresponding defibrillator ECG recordings, were analysed. QRS width, QT interval, Bazett's corrected QT interval, presence of P waves and heart rate (HR) was determined. QRS width and HR were considered to be normal below 120ms and within 60-100 cardiac cycles per minute, respectively. RESULTS Fifty-one episodes fulfilled the inclusion criteria. The defibrillator was attached after a median of one minute (75th percentile; 3min) after the onset of arrest. Ninety percent (46/51) had widened QRS complexes, 63% (32/51) were defined as 'wide-slow' due to QRS-widened bradycardia, and only 6% (3/51) episodes were categorized as normal. No unique cause-specific ECG pattern could be identified. Further 7 episodes with a corresponding defibrillator file, but without a reliable cause, were included in analysis of survival. Abnormal ECG patterns were seen in all survivors. None of the patients with 'normal' PEA survived. CONCLUSION Abnormal ECG patterns were frequent at the early stage of in-hospital PEA. No unique patterns were associated with the underlying causes or survival.
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Affiliation(s)
- Daniel Bergum
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; Department of Anaesthesia and Intensive Care Medicine, St. Olav University Hospital, Trondheim, Norway; Norwegian Air Ambulance Foundation, Norway.
| | - Gunnar Waage Skjeflo
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Trond Nordseth
- Department of Anaesthesia and Intensive Care Medicine, St. Olav University Hospital, Trondheim, Norway
| | - Ole Christian Mjølstad
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; Department of Cardiology, St. Olav University Hospital, Trondheim, Norway
| | - Bjørn Olav Haugen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; Department of Cardiology, St. Olav University Hospital, Trondheim, Norway
| | - Eirik Skogvoll
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; Department of Anaesthesia and Intensive Care Medicine, St. Olav University Hospital, Trondheim, Norway
| | - Jan Pål Loennechen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; Department of Cardiology, St. Olav University Hospital, Trondheim, Norway
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Cardiac arrest with initial arrest rhythm of pulseless electrical activity: do rhythm characteristics correlate with outcome? Am J Emerg Med 2015; 33:891-4. [PMID: 25943040 DOI: 10.1016/j.ajem.2015.03.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 03/21/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Cardiac arrest is a leading cause of death in the United States, with pulseless electrical activity (PEA) as a common initial arrest rhythm. We sought to determine if rate of electrical activity and QRS width correlate with survival in patients who present with PEA out-of-hospital cardiac arrest. METHODS AND RESULTS This is a retrospective review of patients with PEA out-of-hospital cardiac arrest with first documented cardiac rhythm of PEA from January 2010 to September 2013. Demographic, arrest and initial rhythm characteristics, and patient outcome were abstracted via systematic chart review. The initial 20 seconds of each rhythm strip were used to ascertain electrical rate and QRS width. Primary outcome was survival to hospital discharge. Four hundred fourteen patients were eligible for the study. One hundred fifty-two patients did not have sufficient data for analysis. Two hundred sixty-two patients were included in the final analysis with mean age, 66 years. There were 23 (8.8%) survivors and 17 (6.5%) neurologically intact survivors. Mean heart rate was 58 (confidence interval, 54-63) beats per minute, and mean QRS interval was 100 (confidence interval, 95-106) milliseconds. Twenty-nine point seven percent of patients had wide QRS complexes, and 70.3% were narrow. There was no difference in survival in patients based on heart rate (13.1% vs 7.4%, P = .16) or QRS interval (8.7% vs 7.7%, P = .79). CONCLUSIONS In this single emergency medical services agency study, neither PEA electrical rate nor QRS width correlated with survival or neurologic outcome.
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Littmann L, Bustin DJ, Haley MW. A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity. Med Princ Pract 2014; 23:1-6. [PMID: 23949188 PMCID: PMC5586830 DOI: 10.1159/000354195] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 07/02/2013] [Indexed: 12/03/2022] Open
Abstract
Cardiac arrest victims who present with pulseless electrical activity (PEA) usually have a grave prognosis. Several conditions, however, have cause-specific treatments which, if applied immediately, can lead to quick and sustained recovery. Current teaching focuses on recollection of numerous conditions that start with the letters H or T as potential causes of PEA. This teaching method is too complex, difficult to recall during resuscitation, and does not provide guidance to the most effective initial interventions. This review proposes a structured algorithm that is based on the differentiation of the PEA rhythm into narrow- or wide-complex subcategories, which simplifies the working differential and initial treatment approach. This, in conjunction with bedside ultrasound, can quickly point towards the most likely cause of PEA and thus guide resuscitation.
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Affiliation(s)
- Laszlo Littmann
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, N.C., USA
- *Laszlo Littmann, MD, PhD, Department of Internal Medicine, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232 (USA), E-Mail
| | - Devin J. Bustin
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, N.C., USA
| | - Michael W. Haley
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, N.C., USA
- Department of Pulmonary and Critical Care Consultants, Carolinas Medical Center, Charlotte, N.C., USA
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11
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Mehta C, Brady W. Pulseless electrical activity in cardiac arrest: electrocardiographic presentations and management considerations based on the electrocardiogram. Am J Emerg Med 2012; 30:236-9. [DOI: 10.1016/j.ajem.2010.08.017] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 08/11/2010] [Indexed: 01/24/2023] Open
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12
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Dynamic development of pulseless electrical activity in out-of-hospital cardiac arrest. Resuscitation 2010. [DOI: 10.1016/j.resuscitation.2010.09.308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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13
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Herlitz J, Svensson L, Engdahl J, Silfverstolpe J. Characteristics and outcome in out-of-hospital cardiac arrest when patients are found in a non-shockable rhythm. Resuscitation 2008; 76:31-6. [PMID: 17709164 DOI: 10.1016/j.resuscitation.2007.06.027] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2007] [Revised: 06/18/2007] [Accepted: 06/27/2007] [Indexed: 11/17/2022]
Abstract
AIM To define factors associated with an improved outcome among patients suffering out-of-hospital cardiac arrest (OHCA) who were found in a non-shockable rhythm. PATIENTS All the patients included in the Swedish OHCA registry between 1990 and 2005 in whom resuscitation was attempted, who were found in a non-shockable rhythm and where either the OHCA was witnessed by a bystander or was not witnessed. RESULTS In all, 22,465 patients fulfilled the inclusion criteria. Their mean age was 67 years, 32% were women, 57% were witnessed, 64% had a cardiac aetiology, 71% occurred at home and 34% received bystander cardiopulmonary resuscitation (CPR). Survival to 1 month was 1.3%. The following were independently associated with an increased chance of survival: 1/Decreasing age, 2/Witnessed arrest, 3/Bystander CPR, 4/Cardiac arrest outside home, 5/Shorter ambulance response time and 6/Need for defibrillatory shock. If these six criteria were fulfilled (age and ambulance response time below the median), survival to 1 month increased to 12.6%. If no criteria were fulfilled, survival was 0.15%. CONCLUSION The overall survival among patients with an OHCA found in a non-shockable rhythm is very low (1.3%). Six factors associated with survival can be defined. When they are taken into account, survival varies between 12.6 and 0.15%.
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Affiliation(s)
- J Herlitz
- Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, Göteborg, Sweden.
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14
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Fang X, Tang W, Sun S, Wang J, Huang L, Weil MH. The characteristics of postcountershock pulseless electrical activity may indicate the outcome of CPR. Resuscitation 2006; 69:303-9. [PMID: 16459008 DOI: 10.1016/j.resuscitation.2005.07.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2005] [Revised: 07/17/2005] [Accepted: 07/17/2005] [Indexed: 11/17/2022]
Abstract
OBJECTIVES When ventricular fibrillation is cardioverted to pulseless electrical activity (PEA), PEA has been regarded as a non-resuscitatable rhythm. Yet, recent reports and our earlier observations suggested otherwise. We therefore investigated outcomes after postcountershock PEA, and aimed to develop a scoring system for outcome classification at the onset of initial postcountershock PEA. METHODS Data from 215 domestic pigs were retrospectively reviewed. VF was induced and untreated for 7 min. Defibrillation was attempted with up to three 150 J biphasic shocks. Failing to restore spontaneous circulation (ROSC), 1 min of CPR preceded subsequent sequences of shocks until animals were resuscitated or for a total of 15 min. Fifty-nine instances of PEA followed defibrillation, including 29 animals that attained ROSC. RESULTS ROSC animals required a shorter interval between the first shock and the initial postcountershock PEA, fewer shocks prior to onset of initial postcountershock PEA, demonstrated a greater VF wavelet amplitude prior to onset of initial PEA, smaller QRS intervals, and higher heart rates. Using Fisher's linear discriminant analysis, 79.3% of the ROSC and 63.3% of non-ROSC cases were predicted correctly. A total of 71.2% of all cases were classified correctly. CONCLUSIONS Animals in which postcountershock PEA was converted to ROSC required shorter intervals from first shock to initial postcountershock PEA, fewer shocks prior to onset of initial postcountershock PEA, had greater VF wavelet amplitude prior to initial postcountershock PEA, small QRS intervals, and higher heart rates. Fisher's discriminant analysis is helpful in predicting the likelihood of ROSC for an individual animal presenting with postcountershock PEA.
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Affiliation(s)
- Xiangshao Fang
- Weil Institute of Critical Care Medicine, 35100 Bob Hope Drive, Rancho Mirage, CA, USA
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15
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Field JM. Update on cardiac resuscitation for sudden death: International Guidelines 2000 on Resuscitation and Emergency Cardiac Care. Curr Opin Cardiol 2003; 18:14-25. [PMID: 12496497 DOI: 10.1097/00001573-200301000-00003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiopulmonary resuscitation developed over the past one half century largely from empiric science and consensus opinions and recommendations. Treatment algorithms and protocols were originally developed to summarize existing recommendations for systematic and regimented use by a heterogenous group of health care providers. Now, resuscitation science and health care teams are focusing on major issues and continuing questions as sudden death rates remain undaunted and the population at risk is rapidly increasing. For the first time, the international resuscitation community has developed an international consensus on Guidelines for Resuscitation and Emergency Cardiac Care. More than 400 basic scientists, clinical trial investigators, and educators defined common priority and scientific areas during the Evidence Evaluation International Meeting in 1999. The science of resuscitation and emergency cardiac care was reviewed for evidence-based support in randomized clinical trials. In 2000, this review was used as a foundation to structure international guidelines. The participants from seven resuscitation councils and foundations realized that regional differences in systems may exist, but the underlying science should be the same. Presented in this article are some of the major issues and controversies discussed in adult advanced cardiac life support, primarily focusing on the major problem of prehospital adult cardiac arrest.
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Affiliation(s)
- John M Field
- Division of Cardiology, Penn State University College of Medicine, 500 University Drive, Hershey, PA 17033, USA.
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Engdahl J, Holmberg M, Karlson BW, Luepker R, Herlitz J. The epidemiology of out-of-hospital 'sudden' cardiac arrest. Resuscitation 2002; 52:235-45. [PMID: 11886728 DOI: 10.1016/s0300-9572(01)00464-6] [Citation(s) in RCA: 146] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
It is difficult to assemble data from an out-of-hospital cardiac arrest since there is often lack of objective information. The true incidence of sudden cardiac death out-of-hospital is not known since far from all of these patients are attended by emergency medical services. The incidence of out-of-hospital cardiac arrest increases with age and is more common among men. Among patients who die, the probability of having a fatal event outside hospital decreases with age; i. e. younger patients tend to more often die unexpectedly and outside hospital. Among the different initial arrhythmias, ventricular fibrillation is the most common among patients with cardiac aetiology. The true distribution of initial arrhythmias is not known since several minutes most often elapse between collapse and rhythm assessment. Most patients with out-of-hospital cardiac arrest have a cardiac aetiology. Out-of-hospital cardiac arrests most frequently occur in the patient's home, but the prognosis is shown to be better when they occur in a public place. Witnessed arrest, ventricular fibrillation as initial arrhythmia and cardiopulmonary resuscitation are important predictors for immediate survival. In the long-term perspective, cardiac arrest in connection with acute myocardial infarction, high left ventricular ejection fraction, moderate age, absence of other heart failure signs and no history of myocardial infarction promotes better prognosis. Still there is much to learn about time trends, the influence of patient characteristics, comorbidity and hospital treatment among patients with prehospital cardiac arrest.
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Affiliation(s)
- J Engdahl
- Division of Cardiology, Sahlgrenska University Hospital, Medicinmottagning II, S-413 435, Gothenburg, Sweden
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Engdahl J, Bång A, Lindqvist J, Herlitz J. Factors affecting short- and long-term prognosis among 1069 patients with out-of-hospital cardiac arrest and pulseless electrical activity. Resuscitation 2001; 51:17-25. [PMID: 11719169 DOI: 10.1016/s0300-9572(01)00377-x] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS To describe the epidemiology, resuscitation factors and prognosis among a consecutive population of patients suffering from out-of-hospital cardiac arrest (OHCA) where pulseless electrical activity (PEA) was the first arrhythmia recorded on emergency medical services (EMS) arrival. METHODS Analysis of data collected prospectively on all patients regardless of age succumbing to OHCA during 1980-1997 in the community of Gothenburg where EMS initiated resuscitative measures. RESULTS 4662 patients with OHCA were attended by the EMS during the study period. Of these, 1069 (23%) were judged as having PEA as the first recorded arrhythmia; 158 (15%) of these were admitted alive to hospital and 26 (2.4%) were discharged alive. Survivors to discharge had a significantly larger share of bystander cardiopulmonary resuscitation (CPR) (28 vs. 8%, P=0.008), significantly higher levels of consciousness (8% awake vs. 0%, P<0.001) and higher median systolic blood pressure (145 vs. 106 mmHg, P<0.001) on arrival at hospital. No patient with unwitnessed cardiac arrest and PEA over 80 years old survived. CONCLUSION Survival among patients suffering from OHCA and PEA is poor, especially among the elderly unwitnessed cases and those who do not receive bystander CPR. The latter seems to be of utmost importance among these patients.
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Affiliation(s)
- J Engdahl
- Division of Cardiology, Sahlgrenska University Hospital, SE-413 45, Gothenburg, Sweden
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Pernat A, Weil MH, Sun S, Tang W, Yamaguchi H, Bisera J. Atrial function during cardiac arrest caused by ventricular fibrillation. Chest 2000; 117:1118-23. [PMID: 10767250 DOI: 10.1378/chest.117.4.1118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES To report observations on preserved regular atrial electrical and mechanical systole during ventricular fibrillation (VF) and to quantitate blood flow generated by atrial contractions in this setting. METHODS In 10 rats, right atrial pressure pulses were continuously recorded before and for an interval of 8 min after inducing VF. In 3 isolated, perfused rat hearts, epicardial right atrial electrograms were recorded after inducing VF. In 15 pigs, transesophageal echo-Doppler measurements were obtained with pulsed and color-Doppler visualization of flow across the mitral valve after onset of VF. RESULTS In each rat, regular right atrial pressure pulses were documented during VF. These persisted over an average interval of 7.5 min. In isolated, perfused hearts, right atrial contractions were accompanied by regular atrial depolarizations. In pigs, regular atrial contractions generated atrial stroke volumes of approximately 12 mL, or 25% of prearrest values during the first minute after onset of VF, but those declined to approximately 6 mL after 10 min of untreated cardiac arrest. Blood flow from the left atrium into the left ventricle failed to advance significantly into the systemic circuit. During atrial diastole, we observed reversal of flow into the left atrium. CONCLUSIONS Atrial contractions are preserved during the initial 8 min or more after cardiac arrest due to VF. Substantial forward flow into the left ventricle failed to advance through the outflow tract but regurgitated into the atrium during atrial diastole.
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Affiliation(s)
- A Pernat
- Institute of Critical Care Medicine, Palm Springs, CA 92262-5309, USA
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19
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Abstract
This article reviews the critical resuscitations necessary during prehospital and emergency department treatment of cardiac arrest. Standard therapy for cardiac arrest rhythms is presented. Novel pharmacologic agents, types of cardiopulmonary resuscitation, and circulatory-assist devices are discussed.
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Affiliation(s)
- D J DeBehnke
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
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DeBehnke DJ, Swart GL, Spreng D, Aufderheide TP. Standard and higher doses of atropine in a canine model of pulseless electrical activity. Acad Emerg Med 1995; 2:1034-41. [PMID: 8597913 DOI: 10.1111/j.1553-2712.1995.tb03145.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine whether standard or increased doses of atropine improve the return of spontaneous circulation (ROSC) rate in a canine model of pulseless electrical activity (PEA). METHODS A prospective, controlled, blinded laboratory investigation was performed using an asphyxial canine cardiac arrest model. After the production of asphyxial PEA, 75 dogs remained in untreated PEA for 10 minutes and then were randomized to receive placebo (group 1) or one of four doses of atropine (group 2, 0.04 mg/kg; group 3, 0.1 mg/kg; group 4, 0.2 mg/kg; group 5, 0.4 mg/kg). All the animals received mechanical external CPR and epinephrine (0.02 mg/kg every 3 minutes) throughout resuscitation. RESULTS The ROSC rates were not significantly different between the groups (group 1, 73%; group 2, 67%; group 3, 40%; group 4, 47%; group 5, 27%; p = 0.06). The heart rates and hemodynamics during resuscitation were not significantly different between the groups. CONCLUSION In this canine model of asphyxial PEA cardiac arrest, standard-dose atropine did not improve ROSC rates, compared with placebo. Increasing doses of atropine tended to decrease ROSC rates, compared with placebo and standard-dose atropine.
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Affiliation(s)
- D J DeBehnke
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee 53226, USA
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DeBehnke DJ. Effects of vagal tone on resuscitation from experimental electromechanical dissociation. Ann Emerg Med 1993; 22:1789-94. [PMID: 8239096 DOI: 10.1016/s0196-0644(05)80401-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVE To determine if complete loss of vagal tone improves the return of spontaneous circulation rate in a canine model of electromechanical dissociation cardiac arrest. DESIGN Prospective, controlled laboratory investigation using an asphyxial canine cardiac arrest model randomized to receive bilateral cervical vagotomy or no vagotomy. INTERVENTIONS After the production of asphyxial electromechanical dissociation arrest, 16 mongrel dogs remained in untreated electromechanical dissociation for ten minutes and then were randomized to receive bilateral cervical vagotomy or no vagotomy. All animals received standard external CPR and epinephrine (0.02 mg/kg every five minutes) throughout resuscitation. MEASUREMENTS AND MAIN RESULTS Return of spontaneous circulation was achieved in 13% (one of eight) of no vagotomy and 75% (six of eight) of vagotomy animals (P = .02). Survival to one hour was achieved in 100% (one of one) of no vagotomy and 83% (five of six) of vagotomy animals (P = NS). The hemodynamic and arterial blood gas values at five, ten, and 15 minutes into resuscitation were not significantly different between groups. CONCLUSION In this canine model of asphyxial electromechanical dissociation cardiac arrest, surgical vagotomy and complete loss of vagal tone improved the rate of return of spontaneous circulation.
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Affiliation(s)
- D J DeBehnke
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee
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Paradis NA, Martin GB, Goetting MG, Rivers EP, Feingold M, Nowak RM. Aortic pressure during human cardiac arrest. Identification of pseudo-electromechanical dissociation. Chest 1992; 101:123-8. [PMID: 1729058 DOI: 10.1378/chest.101.1.123] [Citation(s) in RCA: 89] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
We measured aortic pressure during clinically apparent cardiac electromechanical dissociation (EMD). Patients with pulse pressures were designated as having pseudo-EMD; those without, as having true EMD. Of the 200 patients studied, 54 presented with EMD, and 40 others developed it during resuscitation. Of the 94 with EMD, 39 were found to have pseudo-EMD. We compared the two types of EMD for electrocardiographic duration, return of palpable pulses, and response to standard- and high-dose epinephrine. The mean resting aortic pressure was 18 +/- 11 mm Hg in patients with true EMD and 28 +/- 11 mm Hg in those with pseudo-EMD. The mean pulse pressure in patients with pseudo-EMD was 6.3 +/- 3.5 mm Hg. Patients with pseudo-EMD had a higher proportion of witnessed arrests, higher PaO2, and lower PaCO2 than patients with true EMD. Patients with pseudo-EMD had shorter QR and QRS durations than patients with true EMD. They had a better response to standard- and high-dose epinephrine than patients with true EMD. Many patients diagnosed clinically to be in EMD have mechanical cardiac activity; this should be considered when interpreting the results of cardiac arrest research.
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Affiliation(s)
- N A Paradis
- Department of Emergency Medical Services, Bellevue Hospital Center, New York University Medical Center, New York
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