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Holmstrom L, Chugh H, Uy-Evanado A, Jui J, Reinier K, Chugh SS. Temporal Trends in Incidence and Survival From Sudden Cardiac Arrest Manifesting With Shockable and Nonshockable Rhythms: A 16-Year Prospective Study in a Large US Community. Ann Emerg Med 2023; 82:463-471. [PMID: 37204349 PMCID: PMC10523906 DOI: 10.1016/j.annemergmed.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 05/20/2023]
Abstract
STUDY OBJECTIVE The proportion of nonshockable sudden cardiac arrests (pulseless electrical activity and asystole) continues to rise. Survival is lower than shockable (ventricular fibrillation [VF]) sudden cardiac arrests, but there is little community-based information on temporal trends in the incidence and survival from sudden cardiac arrests based on presenting rhythms. We investigated community-based temporal trends in sudden cardiac arrest incidence and survival by presenting rhythm. METHODS We prospectively evaluated the incidence of each presenting sudden cardiac arrest rhythm and survival outcomes for out-of-hospital events in the Portland, Oregon metro area (population of approximately 1 million, 2002 to 2017). We limited inclusion to cases of likely cardiac cause with resuscitation attempted by emergency medical services. RESULTS Out of 3,723 overall sudden cardiac arrest cases, 908 (24%) presented with pulseless electrical activity, 1,513 (41%) with VF, and 1,302 (35%) with asystole. The incidence of pulseless electrical activity-sudden cardiac arrest remained stable over 4-year periods (9.6/100,000 in 2002 to 2005, 7.4/100,000 in 2006 to 2009, 5.7/100,000 in 2010 to 2013, and 8.3/100,000 in 2014 to 2017; unadjusted beta [β] -0.56; 95% confidence interval [CI], -3.98 to 2.85). The incidence of VF-sudden cardiac arrests decreased over time (14.6/100,000 in 2002 to 2005, 13.4/100,000 in 2006 to 2009, 12.0/100,000 in 2010 to 2013, and 11.6/100,000 in 2014 to 2017; unadjusted β -1.05; 95% CI, -1.68 to -0.42) and asystole-sudden cardiac arrests (8.6/100,000 in 2002 to 2005, 9.0/100,000 in 2006 to 2009, 10.3/100,000 in 2010 to 2013, and 15.7/100,000 in 2014 to 2017; unadjusted β 2.25; 95% CI -1.24 to 5.73) did not change significantly over time. Survival increased over time for pulseless electrical activity-sudden cardiac arrests (5.7%, 4.3%, 9.6%, 13.6%; unadjusted β 2.8%; 95% CI 1.3 to 4.4) and VF-sudden cardiac arrests (27.5%, 29.8%, 37.9%, 36.6%; unadjusted β 3.5%; 95% CI 1.4 to 5.6), but not for asystole-sudden cardiac arrests (1.7%, 1.6%, 4.0%, 2.4%; unadjusted β 0.3%; 95% CI, -0.4 to 1.1). Enhancements in the emergency medical services system's pulseless electrical activity-sudden cardiac arrest management were temporally associated with the increasing pulseless electrical activity survival rates. CONCLUSIONS Over a 16-year period, the incidence of VF/ventricular tachycardia decreased over time, but pulseless electrical activity incidence remained stable. Survival from both VF-sudden cardiac arrests and pulseless electrical activity-sudden cardiac arrests increased over time with a more than 2-fold increase for pulseless electrical activity-sudden cardiac arrests.
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Affiliation(s)
- Lauri Holmstrom
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA
| | - Harpriya Chugh
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA
| | - Audrey Uy-Evanado
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA
| | - Jonathan Jui
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kyndaron Reinier
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA
| | - Sumeet S Chugh
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA.
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Faldaas BO, Nielsen EW, Storm BS, Lappegård KT, How OJ, Nilsen BA, Kiss G, Skogvoll E, Torp H, Ingul C. Hands-free continuous carotid Doppler ultrasound for detection of the pulse during cardiac arrest in a porcine model. Resusc Plus 2023; 15:100412. [PMID: 37448689 PMCID: PMC10336194 DOI: 10.1016/j.resplu.2023.100412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/24/2023] [Accepted: 06/04/2023] [Indexed: 07/15/2023] Open
Abstract
Background/Purpose Pulse palpation is an unreliable method for diagnosing cardiac arrest. To address this limitation, continuous hemodynamic monitoring may be a viable solution. Therefore, we developed a novel, hands-free Doppler system, RescueDoppler, to detect the pulse continuously in the carotid artery. Methods In twelve pigs, we evaluated RescueDoppleŕs potential to measure blood flow velocity in three situations where pulse palpation of the carotid artery was insufficient: (1) systolic blood pressure below 60 mmHg, (2) ventricular fibrillation (VF) and (3) pulseless electrical activity (PEA). (1) Low blood pressure was induced using a Fogarty balloon catheter to occlude the inferior vena cava. (2) An implantable cardioverter-defibrillator induced VF. (3) Myocardial infarction after microembolization of the left coronary artery caused True-PEA. Invasive blood pressure was measured in the contralateral carotid artery. Time-averaged blood flow velocity (TAV) in the carotid artery was related to mean arterial pressure (MAP) in a linear mixed model. Results RescueDoppler identified pulsatile blood flow in 41/41 events with systolic blood pressure below 60 mmHg, with lowest blood pressure of 19 mmHg. In addition the absence of spontaneous circulation was identified in 21/21 VF events and true PEA in 2/2 events. The intraclass correlation coefficient within animals for TAV and MAP was 0.94 (95% CI. 0.85-0.98). Conclusions In a porcine model, RescueDoppler reliably identified pulsative blood flow with blood pressures below 60 mmHg. During VF and PEA, circulatory arrest was rapidly and accurately demonstrated. RescueDoppler could potentially replace unreliable pulse palpation during cardiac arrest and cardiopulmonary resuscitation.
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Affiliation(s)
- Bjørn Ove Faldaas
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Erik Waage Nielsen
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
- Department of Anesthesia, Surgical Clinic, Nordland Hospital Trust, Bodø, Norway
- Department of Immunology, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Benjamin Stage Storm
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
- Department of Anesthesia, Surgical Clinic, Nordland Hospital Trust, Bodø, Norway
- Research Laboratory, Nordland Hospital Trust, Bodø, Norway
| | - Knut Tore Lappegård
- Department of Clinical Medicine, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
- Department of Medicine, Nordland Hospital Trust, Bodø, Norway
| | - Ole-Jakob How
- Department of Medical Biology, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Bent Aksel Nilsen
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
- Department of Anesthesia, Surgical Clinic, Nordland Hospital Trust, Bodø, Norway
| | - Gabriel Kiss
- Department of Computer Science (IDI), Faculty of Information Technology and Electrical Engineering, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Eirik Skogvoll
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Anesthesia and Intensive Care Medicine, St Olav University Hospital, Trondheim, Norway
| | - Hans Torp
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Charlotte Ingul
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
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Andrea L, Shiloh AL, Colvin M, Rahmanian M, Bangar M, Grossestreuer AV, Berg KM, Gong MN, Moskowitz A. Pulseless electrical activity and asystole during in-hospital cardiac arrest: Disentangling the 'nonshockable' rhythms. Resuscitation 2023; 189:109857. [PMID: 37270088 PMCID: PMC10527285 DOI: 10.1016/j.resuscitation.2023.109857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Pulseless electrical activity (PEA) and asystole account for 81% of initial in-hospital cardiac arrest (IHCA) rhythms in the U.S.A. These "non-shockable" rhythms are often grouped together in resuscitation research and practice. We hypothesized that PEA and asystole are distinct initial IHCA rhythms with distinguishing features. METHODS This was an observational cohort study using the prospectively collected nationwide Get With The Guidelines®-Resuscitation registry. Adult patients with an index IHCA and an initial rhythm of PEA or asystole between the years of 2006 and 2019 were included. Patients with PEA vs. asystole were compared with respect to pre-arrest characteristics, resuscitation practice, and outcomes. RESULTS We identified 147,377 (64.9%) PEA and 79,720 (35.1%) asystolic IHCA. Asystole had more arrests in non-telemetry wards (20,530/147,377 [13.9%] PEA vs. 17,618/79,720 [22.1%] asystole). Asystole had 3% lower adjusted odds of ROSC (91,007 [61.8%] PEA vs. 44,957 [56.4%] asystole, aOR 0.97, 95%CI 0.96-0.97, P < 0.01); there was no statistically significant difference in survival to discharge (28,075 [19.1%] PEA vs. 14,891 [18.7%] asystole, aOR 1.00, 95%CI 1.00-1.01, P = 0.63). Duration of resuscitation for those without ROSC were shorter for asystole (29.8 [±22.5] minutes in PEA vs. 26.2 [±21.5] minutes in asystole, adjusted mean difference -3.05 95%CI -3.36--2.74, P < 0.01). INTERPRETATION Patients suffering IHCA with an initial PEA rhythm had patient and resuscitation level differences from those with asystole. PEA arrests were more common in monitored settings and received longer resuscitations. Even though PEA was associated with higher rates of ROSC, there was no difference in survival to discharge.
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Affiliation(s)
- Luke Andrea
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States.
| | - Ariel L Shiloh
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States
| | - Mai Colvin
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States
| | - Marjan Rahmanian
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States
| | - Maneesha Bangar
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States
| | - Anne V Grossestreuer
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 330 Brookline Ave, Boston, MA 02215, United States
| | - Katherine M Berg
- Beth Israel Deaconess Medical Center, Department of Pulmonary and Critical Care Medicine, Boston, MA, United States
| | - Michelle N Gong
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States
| | - Ari Moskowitz
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States
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Ho AFW, Lee KY, Nur S, Fook SC, Pek PP, Tanaka H, Sang DS, Chow PIK, Tan BYQ, Lim SL, Ma MHM, Ryoo HW, Lin CH, Kuo CW, Kajino K, Ong MEH. Association between Conversion to Shockable Rhythms and Survival with Favorable Neurological Outcomes for Out-of-Hospital Cardiac Arrests. PREHOSP EMERG CARE 2023; 28:126-134. [PMID: 37171870 DOI: 10.1080/10903127.2023.2212039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/05/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND The initial cardiac rhythm in out-of-hospital cardiac arrest (OHCA) portends different prognoses and affects treatment decisions. Initial shockable rhythms are associated with good survival and neurological outcomes but there is conflicting evidence for those who initially present with non-shockable rhythms. The aim of this study is to evaluate if OHCA with conversion from non-shockable (i.e., asystole and pulseless electrical activity) rhythms to shockable rhythms compared to OHCA remaining in non-shockable rhythms is associated with better survival and neurological outcomes. METHOD OHCA cases from the Pan-Asian Resuscitation Outcomes Study registry in 13 countries between January 2009 and February 2018 were retrospectively analyzed. Cases with missing initial rhythms, age <18 years, presumed non-medical cause of arrest, and not conveyed by emergency medical services were excluded. Multivariable logistic regression analysis was performed to evaluate the relationship between initial and subsequent shockable rhythm, survival to discharge, and survival with favorable neurological outcomes (cerebral performance category 1 or 2). RESULTS Of the 116,387 cases included. 11,153 (9.6%) had initial shockable rhythms and 9,765 (8.4%) subsequently converted to shockable rhythms. Japan had the lowest proportion of OHCA patients with initial shockable rhythms (7.3%). For OHCA with initial shockable rhythm, the adjusted odds ratios (aOR) for survival and good neurological outcomes were 8.11 (95% confidence interval [CI] 7.62-8.63) and 15.4 (95%CI 14.1-16.8) respectively. For OHCA that converted from initial non-shockable to shockable rhythms, the aORs for survival and good neurological outcomes were 1.23 (95%CI 1.10-1.37) and 1.61 (95%CI 1.35-1.91) respectively. The aORs for survival and good neurological outcomes were 1.48 (95%CI 1.22-1.79) and 1.92 (95%CI 1.3 - 2.84) respectively for initial asystole, while the aOR for survival in initial pulseless electrical activity patients was 0.83 (95%CI 0.71-0.98). Prehospital adrenaline administration had the highest aOR (2.05, 95%CI 1.93-2.18) for conversion to shockable rhythm. CONCLUSION In this ambidirectional cohort study, conversion from non-shockable to shockable rhythm was associated with improved survival and neurologic outcomes compared to rhythms that continued to be non-shockable. Continued advanced resuscitation may be beneficial for OHCA with subsequent conversion to shockable rhythms.
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Affiliation(s)
- Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore
| | - Kai Yi Lee
- Physicians, Ministry of Health Holdings, Singapore
| | - Shahidah Nur
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Pin Pin Pek
- Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore
| | - Hideharu Tanaka
- Department of Emergency Medical Services System, Graduate School, Kokushikan University, Tokyo, Japan
- Research institute, Disaster prevention, EMS and rescue, Kokushikan University, Tokyo, Japan
| | - Do Shin Sang
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical, Research Institute, Seoul, Republic of Korea
| | - Patrick In-Ko Chow
- Department of Emergency Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | - Shir Lynn Lim
- Department of Cardiology, National University Heart Center, Singapore
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Douliou, Taiwan
| | - Hyun Wook Ryoo
- Department of Emergency Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Chih-Hao Lin
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chan-Wei Kuo
- Department of Emergency Medicine, Chang-Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Kentaro Kajino
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Health Services & Systems Research, Duke-NUS Medical School, Singapore
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Holmstrom L, Chugh H, Uy-Evanado A, Salvucci A, Jui J, Reinier K, Chugh SS. Determinants of survival in sudden cardiac arrest manifesting with pulseless electrical activity. Resuscitation 2023; 187:109798. [PMID: 37080333 PMCID: PMC10202052 DOI: 10.1016/j.resuscitation.2023.109798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE The proportion of sudden cardiac arrests (SCA) manifesting with pulseless electrical activity (PEA) has increased significantly, and the survival rate remains lower than ventricular fibrillation (VF). However, a subgroup of PEA-SCA cases does survive and may yield key predictors of improved outcomes when compared to non-survivors. We aimed to identify key predictors of survival from PEA-SCA. METHODS Our study sample is drawn from two ongoing community-based, prospective studies of out-of-hospital SCA: Oregon SUDS from the Portland, OR metro area (Pop. approx. 1 million; 2002-2017) and Ventura PRESTO from Ventura County, CA (Pop. approx. 850,000, 2015-2021). For the present sub-study, we included SCA cases with PEA as the presenting rhythm where emergency medical services (EMS) personnel attempted resuscitation. RESULTS We identified 1,704 PEA-SCA cases, of which 173 (10.2%) were survivors and 1,531 (89.8%) non-survivors. Patients whose PEA-SCA occurred in a healthcare unit (16.9%) or public location (18.1%) had higher survival than those whose PEA-SCA occurred at home (9.3%) or in a care facility (5.7%). Young age, witness status, PEA-SCA location and pre-existing COPD/asthma were independent predictors of survival. Among witnessed cases the survival rate was 10% even if EMS response time was >10 minutes. CONCLUSIONS Key determinants for survival from PEA-SCA were young age, witnessed status, public location and pre-existing COPD/asthma. Survival outcomes in witnessed PEA cases were better than expected, even with delayed EMS response.
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Affiliation(s)
- L Holmstrom
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA, United States
| | - H Chugh
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA, United States
| | - A Uy-Evanado
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA, United States
| | - A Salvucci
- Ventura County Health Care Agency, Ventura, CA, United States
| | - J Jui
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States
| | - K Reinier
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA, United States
| | - S S Chugh
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, CA, United States.
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Holmstrom L, Salmasi S, Chugh H, Uy-Evanado A, Sorenson C, Bhanji Z, Seifer BM, Sargsyan A, Salvucci A, Jui J, Reinier K, Chugh SS. Survivors of Sudden Cardiac Arrest Presenting With Pulseless Electrical Activity: Clinical Substrate, Triggers, Long-Term Prognosis. JACC Clin Electrophysiol 2022; 8:1260-1270. [PMID: 36057529 DOI: 10.1016/j.jacep.2022.06.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/13/2022] [Accepted: 06/28/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The proportion of sudden cardiac arrest (SCA) presenting as pulseless electrical activity (PEA) is rising, and survival remains low. The pathophysiology of PEA-SCA is poorly understood, and current clinical practice lacks specific options for the management of survivors. OBJECTIVES In this study, the authors sought to investigate clinical profile, triggers, and long-term prognosis in survivors of SCA presenting with PEA. METHODS The community-based Oregon SUDS (Sudden Unexpected Death Study) (since 2002) and Ventura PRESTO (Prediction of Sudden Death in Multi-ethnic Communities) (since 2015) studies prospectively ascertain all out-of-hospital SCAs of likely cardiac etiology. Lifetime clinical history and detailed evaluation of SCA events is available. We evaluated all SCA survivors with PEA as the presenting rhythm. RESULTS The study population included 201 PEA-SCA survivors. Of these, 97 could be contacted for access to their clinical records. Among the latter, the mean age was 67 ± 17 years and 58 (60%) were male. After in-hospital examinations, 29 events (30%) were associated with acute myocardial infarction, and 5 (5%) had bradyarrhythmias. Among the remaining 63 patients (65%), specific triggers remained undetermined, although 31 (49%) had a previous history of heart failure. Of the 201 overall survivors, 91 (45%) were deceased after a mean follow-up of 4.2 ± 4.0 years. Survivors under the age of 40 years had an excellent long-term prognosis. CONCLUSIONS Survivors of PEA-SCA are a heterogeneous group with high prevalence of multiple comorbidities, especially heart failure. Surprisingly good long-term survival was observed in young individuals. Acute myocardial infarction as the precipitating event was common, but triggers remained undetermined in the majority. Provision of individualized care to PEA survivors requires a renewed investigative focus on PEA-SCA.
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Affiliation(s)
- Lauri Holmstrom
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA; Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Shiva Salmasi
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Harpriya Chugh
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Audrey Uy-Evanado
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Chad Sorenson
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Ziana Bhanji
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Bai Madison Seifer
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Ariik Sargsyan
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | | | - Jonathan Jui
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Kyndaron Reinier
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Sumeet S Chugh
- Center for Cardiac Arrest Prevention, Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA; Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Health System, Los Angeles, California, USA.
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Enzan N, Hiasa KI, Ichimura K, Nishihara M, Iyonaga T, Shono Y, Tohyama T, Funakoshi K, Kitazono T, Tsutsui H. Delayed administration of epinephrine is associated with worse neurological outcomes in patients with out-of-hospital cardiac arrest and initial pulseless electrical activity: insight from the nationwide multicentre observational JAAM-OHCA (Japan Association for Acute Medicine) registry. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:389-396. [PMID: 35238895 PMCID: PMC9197427 DOI: 10.1093/ehjacc/zuac026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/04/2022] [Accepted: 02/20/2022] [Indexed: 11/16/2022]
Abstract
Aims The delayed administration of epinephrine has been proven to worsen the neurological outcomes of patients with out-of-hospital cardiac arrest (OHCA) and shockable rhythm or asystole. We aimed to investigate whether the delayed administration of epinephrine might also worsen the neurological outcomes of patients with witnessed OHCA and initial pulseless electrical activity (PEA). Methods and results The JAAM-OHCA Registry is a multicentre registry including OHCA patients between 2014 and 2017. Patients with emergency medical services (EMS)-treated OHCA and initial PEA rhythm were included. The primary exposure was the time from the EMS call to the administration of epinephrine. The secondary exposure was the time to epinephrine dichotomized as early (≤15 min) or delayed (>15 min). The primary outcome was the achievement of a favourable neurological outcome, defined as Cerebral Performance Categories Scale 1–2 at 30 days after OHCA. Out of 34 754 patients with OHCA, 3050 patients were included in the present study. After adjusting for potential confounders, the delayed administration of the epinephrine was associated with a lower likelihood of achieving a favourable neurological outcome [adjusted odds ratio (OR) 0.96; 95% confidence interval (CI) 0.93–0.99; P = 0.016]. The percentage of patients who achieved a favourable neurological outcome in the delayed epinephrine group was lower than that in the early epinephrine group (1.3% vs. 4.7%; adjusted OR 0.33; 95% CI 0.15–0.72; P = 0.005). A restricted cubic spline analysis demonstrated that delayed epinephrine administration could decrease the likelihood of achieving a favourable neurological outcome; this was significant within the first 10 min. Conclusions The delayed administration of epinephrine was associated with worse neurological outcomes in patients with witnessed OHCA patients with initial PEA.
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Affiliation(s)
- Nobuyuki Enzan
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University , 3-1-1 Maidashi, Higashi-ku , Fukuoka 812-8582, Japan
| | - Ken ichi Hiasa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University , 3-1-1 Maidashi, Higashi-ku , Fukuoka 812-8582, Japan
| | - Kenzo Ichimura
- School of Medicine, Pulmonary, Allergy and Critical Care Medicine, Stanford University , 300 Pasteur Drive, Grand Bld Rm S126B , Stanford, CA 94305 USA
| | - Masaaki Nishihara
- Emergency and Critical Care Center, Kyushu University Hospital , 3-1-1 Maidashi, Higashi-ku , Fukuoka 812-8582, Japan
| | - Takeshi Iyonaga
- Emergency and Critical Care Center, Kyushu University Hospital , 3-1-1 Maidashi, Higashi-ku , Fukuoka 812-8582, Japan
| | - Yuji Shono
- Emergency and Critical Care Center, Kyushu University Hospital , 3-1-1 Maidashi, Higashi-ku , Fukuoka 812-8582, Japan
| | - Takeshi Tohyama
- Center for Clinical and Translational Research, Kyushu University Hospital , 3-1-1 Maidashi, Higashi-ku , Fukuoka 812-8582, Japan
| | - Kouta Funakoshi
- Center for Clinical and Translational Research, Kyushu University Hospital , 3-1-1 Maidashi, Higashi-ku , Fukuoka 812-8582, Japan
| | - Takanari Kitazono
- Emergency and Critical Care Center, Kyushu University Hospital , 3-1-1 Maidashi, Higashi-ku , Fukuoka 812-8582, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University , 3-1-1 Maidashi, Higashi-ku , Fukuoka 812-8582, Japan
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Influence of advanced life support response time on out-of-hospital cardiac arrest patient outcomes in Taipei. PLoS One 2022; 17:e0266969. [PMID: 35421162 PMCID: PMC9009650 DOI: 10.1371/journal.pone.0266969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/30/2022] [Indexed: 11/19/2022] Open
Abstract
Background The association between out-of-hospital cardiac arrest patient survival and advanced life support response time remained controversial. We aimed to test the hypothesis that for adult, non-traumatic, out-of-hospital cardiac arrest patients, a shorter advanced life support response time is associated with a better chance of survival. We analyzed Utstein-based registry data on adult, non-traumatic, out-of-hospital cardiac arrest patients in Taipei from 2011 to 2015. Methods Patients without complete data, witnessed by emergency medical technicians, or with response times of ≥ 15 minutes, were excluded. We used logistic regression with an exposure of advanced life support response time. Primary and secondary outcomes were survival to hospital discharge and favorable neurological outcomes (cerebral performance category ≤ 2), respectively. Subgroup analyses were based on presenting rhythms of out-of-hospital cardiac arrest, bystander cardiopulmonary resuscitation, and witness status. Results A total of 4,278 cases were included in the final analysis. The median advanced life support response time was 9 minutes. For every minute delayed in advanced life support response time, the chance of survival to hospital discharge would reduce by 7% and chance of favorable neurological outcome by 9%. Subgroup analysis showed that a longer advanced life support response time was negatively associated with the chance of survival to hospital discharge among out-of-hospital cardiac arrest patients with shockable rhythm and pulse electrical activity groups. Conclusions In non-traumatic, adult, out-of-hospital cardiac arrest patients in Taipei, a longer advanced life support response time was associated with declining odds of survival to hospital discharge and favorable neurologic outcomes, especially in patients presenting with shockable rhythm and pulse electrical activity.
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Successful Pre-Rewarming Resuscitation after Cardiac Arrest in Severe Hypothermia: A Retrospective Cohort Study from the International Hypothermia Registry. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074059. [PMID: 35409749 PMCID: PMC8997874 DOI: 10.3390/ijerph19074059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 12/02/2022]
Abstract
The aim of our study is to investigate successful pre-rewarming resuscitation after hypothermic cardiac arrest (HCA). The hypothermic heart may be insensitive to defibrillation when core temperature is below 30 °C and after successful defibrillation, sinus rhythm often returns into ventricular fibrillation. Recurrent defibrillation attempts may induce myocardial injury. Discrepancy exists concerning pre-rewarming defibrillation between the guidelines of the European Resuscitation Council and American Heart Association. The International Hypothermia Registry (IHR) gathers hypothermia cases. The primary outcome was survival. Secondary outcomes were the characteristics of defibrillation, the effect of Adrenaline administration under 30 °C, and the duration of CPR. Of the 239 patients, eighty-eight were in cardiac arrest at arrival of the rescue team. Successful pre-rewarming resuscitation was obtained in 14 patients. The outcome showed: seven deaths, one vegetative state, two patients with reversible damage, and four patients with full recovery. A total of five patients had a shockable rhythm, and defibrillation was successful in four patients. The response rate to Adrenaline was reported as normal in six patients. There were no statistically significant differences in the presence of a shockable rhythm, the success of defibrillation, and the effect on Adrenaline administration between the survivors and non-survivors. Successful resuscitation in severe hypothermia is possible before active rewarming and arrival in the hospital, thus improving the chance of survival.
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Okada Y, Komukai S, Kitamura T, Kiguchi T, Irisawa T, Yamada T, Yoshiya K, Park C, Nishimura T, Ishibe T, Yagi Y, Kishimoto M, Inoue T, Hayashi Y, Sogabe T, Morooka T, Sakamoto H, Suzuki K, Nakamura F, Matsuyama T, Nishioka N, Kobayashi D, Matsui S, Hirayama A, Yoshimura S, Kimata S, Shimazu T, Ohtsuru S, Iwami T. Clustering out‐of‐hospital cardiac arrest patients with non‐shockable rhythm by machine learning latent class analysis. Acute Med Surg 2022; 9:e760. [PMID: 35664809 PMCID: PMC9136939 DOI: 10.1002/ams2.760] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/11/2022] [Indexed: 11/26/2022] Open
Abstract
Aim We aimed to identify subphenotypes among patients with out‐of‐hospital cardiac arrest (OHCA) with initial non‐shockable rhythm by applying machine learning latent class analysis and examining the associations between subphenotypes and neurological outcomes. Methods This study was a retrospective analysis within a multi‐institutional prospective observational cohort study of OHCA patients in Osaka, Japan (the CRITICAL study). The data of adult OHCA patients with medical causes and initial non‐shockable rhythm presenting with OHCA between 2012 and 2016 were included in machine learning latent class analysis models, which identified subphenotypes, and patients who presented in 2017 were included in a dataset validating the subphenotypes. We investigated associations between subphenotypes and 30‐day neurological outcomes. Results Among the 12,594 patients in the CRITICAL study database, 4,849 were included in the dataset used to classify subphenotypes (median age: 75 years, 60.2% male), and 1,465 were included in the validation dataset (median age: 76 years, 59.0% male). Latent class analysis identified four subphenotypes. Odds ratios and 95% confidence intervals for a favorable 30‐day neurological outcome among patients with these subphenotypes, using group 4 for comparison, were as follows; group 1, 0.01 (0.001–0.046); group 2, 0.097 (0.051–0.171); and group 3, 0.175 (0.073–0.358). Associations between subphenotypes and 30‐day neurological outcomes were validated using the validation dataset. Conclusion We identified four subphenotypes of OHCA patients with initial non‐shockable rhythm. These patient subgroups presented with different characteristics associated with 30‐day survival and neurological outcomes.
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Affiliation(s)
- Yohei Okada
- Department of Preventive Services, School of Public Health Kyoto University Kyoto Japan
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine Kyoto University Kyoto Japan
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Graduate School of Medicine Osaka University Suita Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine Osaka University Osaka Japan
| | - Takeyuki Kiguchi
- Critical Care and Trauma Center Osaka General Medical Center Osaka Japan
| | - Taro Irisawa
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Tomoki Yamada
- Emergency and Critical Care Medical Center Osaka Police Hospital Osaka Japan
| | - Kazuhisa Yoshiya
- Department of Emergency and Critical Care Medicine Takii Hospital, Kansai Medical University Moriguchi Japan
| | - Changhwi Park
- Department of Emergency Medicine Tane General Hospital Osaka Japan
| | - Tetsuro Nishimura
- Department of Critical Care Medicine Osaka City University Osaka Japan
| | - Takuya Ishibe
- Department of Emergency and Critical Care Medicine Kindai University School of Medicine Osaka‐Sayama Japan
| | - Yoshiki Yagi
- Osaka Mishima Emergency Critical Care Center Takatsuki Japan
| | - Masafumi Kishimoto
- Osaka Prefectural Nakakawachi Medical Center of Acute Medicine Higashi‐Osaka Japan
| | | | - Yasuyuki Hayashi
- Senri Critical Care Medical Center Saiseikai Senri Hospital Suita Japan
| | - Taku Sogabe
- Traumatology and Critical Care Medical Center National Hospital Organization Osaka National Hospital Osaka Japan
| | - Takaya Morooka
- Emergency and Critical Care Medical Center Osaka City General Hospital Osaka Japan
| | - Haruko Sakamoto
- Department of Pediatrics Osaka Red Cross Hospital Osaka Japan
| | - Keitaro Suzuki
- Emergency and Critical Care Medical Center Kishiwada Tokushukai Hospital Osaka Japan
| | - Fumiko Nakamura
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine Kyoto Prefectural University of Medicine Kyoto Japan
| | - Norihiro Nishioka
- Department of Preventive Services, School of Public Health Kyoto University Kyoto Japan
| | - Daisuke Kobayashi
- Department of Preventive Services, School of Public Health Kyoto University Kyoto Japan
| | - Satoshi Matsui
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine Osaka University Osaka Japan
| | - Atsushi Hirayama
- Public Health, Department of Social and Environmental Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Satoshi Yoshimura
- Department of Preventive Services, School of Public Health Kyoto University Kyoto Japan
| | - Shunsuke Kimata
- Department of Preventive Services, School of Public Health Kyoto University Kyoto Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine Kyoto University Kyoto Japan
| | - Taku Iwami
- Department of Preventive Services, School of Public Health Kyoto University Kyoto Japan
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Outcomes of Out-of-hospital Cardiac Arrests After a Decade of System-wide Initiatives Optimising Community Chain of Survival in Taipei City. Resuscitation 2021; 172:149-158. [PMID: 34971722 DOI: 10.1016/j.resuscitation.2021.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/02/2021] [Accepted: 12/21/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE A strengthened chain of survival benefits patient outcomes after out-of-hospital cardiac arrest (OHCA).2 Over the past decade, the Taipei Fire Department (TFD) has continuously implemented system-wide initiatives on this issue.We hypothesised that for adult, non-trauma OHCA patients, the bundle of these system-wide initiatives are associated with better outcomes. METHODS We conducted a registry-based, retrospective study to examine the association between consecutive system-level initiatives and OHCA survival on a two-yearly basis using trend analysis and multivariable logistic regression. The primary outcome was survival to hospital discharge (STHD) and favourable neurological status. RESULTS We analysed 18,076 cases from 2008 to 2017. The numbers of two-yearly cases of OHCA with resuscitation attempts from 2008 to 2017 were 3,576, 3,456, 3,822, 3,811, and 3,411. There was a significant trend of improved STHD (Two-fold) and favourable neurological outcome (Six-fold) over the past decade. Similar trends were observed in the shockable and non-shockable groups. Considering the first 2 years as baseline, the odds of STHD and favourable neurological status in the end of the initiatives increased significantly after adjusting for universally recognised predictors for OHCA survival. CONCLUSION For non-trauma adult OHCA in Taipei, continuous, multifaceted system-wide initiatives on the community chain of survival were associated with improved odds of STHD and favourable neurologic outcomes.
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Scquizzato T, D'Amico F, Rocchi M, Saracino M, Stella F, Landoni G, Zangrillo A. Impact of COVID-19 Pandemic on Out-of-Hospital Cardiac Arrest System-of-Care: A Systematic Review and Meta-Analysis. PREHOSP EMERG CARE 2021:1-12. [PMID: 34382909 DOI: 10.1080/10903127.2021.1967535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/02/2021] [Accepted: 08/09/2021] [Indexed: 01/08/2023]
Abstract
Introduction: COVID-19 pandemic overwhelmed healthcare systems and diverted resources allocated for other conditions. This systematic review and meta-analysis aimed to analyse how the pandemic impacted the system-of-care of out-of-hospital cardiac arrest.Methods: We searched PubMed and Embase up to May 31, 2021, for studies comparing out-of-hospital cardiac arrests that occurred during the COVID-19 pandemic versus a non-pandemic period. Survival at hospital discharge or at 30 days was the primary outcome.Results: We included 24 studies for a total of 75,952 patients. Out-of-hospital cardiac arrests during COVID-19 pandemic had lower survival (19 studies; 603/11,666 [5.2%] vs. 1320/17,174 [7.7%]; OR = 0.54; 95% CI, 0.44-0.65; P = 0.001) and return of spontaneous circulation (4370/24353 [18%] vs. 7401/34510 [21%]; OR = 0.64; 95% CI, 0.55-0.75; P < 0.001) compared with non-pandemic periods. Ambulance response times (10.1 vs 9.0 minutes, MD = 1.01; 95% CI, 0.59-1.42; P < 0.001) and non-shockable rhythms (18,242/21,665 [84%] vs. 19,971/24,817 [81%]; OR = 1.27; 95% CI, 1.10-1.46; P < 0.001) increased. Use of supraglottic airways devices increased (2853/7645 [37%] vs. 2043/17521 [12%]; OR = 1.97; 95% CI, 1.42-2.74; P < 0.001).Conclusions: The COVID-19 pandemic affected the system-of-care of out-of-hospital cardiac arrest, and patients had worse short-term outcomes compared to pre-pandemic periods. Advanced airway management strategy shifted from endotracheal intubation to supraglottic airway devices. REVIEW REGISTRATION PROSPERO CRD42021250339.
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Affiliation(s)
- Tommaso Scquizzato
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (TS, FDA, MR, MS, GL, AZ); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (GL, AZ); Emergency Medical Services (SUEM 118), Venice, Italy (FS)
| | - Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (TS, FDA, MR, MS, GL, AZ); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (GL, AZ); Emergency Medical Services (SUEM 118), Venice, Italy (FS)
| | - Margherita Rocchi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (TS, FDA, MR, MS, GL, AZ); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (GL, AZ); Emergency Medical Services (SUEM 118), Venice, Italy (FS)
| | - Marco Saracino
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (TS, FDA, MR, MS, GL, AZ); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (GL, AZ); Emergency Medical Services (SUEM 118), Venice, Italy (FS)
| | - Federica Stella
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (TS, FDA, MR, MS, GL, AZ); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (GL, AZ); Emergency Medical Services (SUEM 118), Venice, Italy (FS)
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (TS, FDA, MR, MS, GL, AZ); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (GL, AZ); Emergency Medical Services (SUEM 118), Venice, Italy (FS)
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (TS, FDA, MR, MS, GL, AZ); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (GL, AZ); Emergency Medical Services (SUEM 118), Venice, Italy (FS)
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13
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Pulseless electrical activity vs. asystole in adult in-hospital cardiac arrest: Predictors and outcomes. Resuscitation 2021; 165:50-57. [PMID: 34126134 DOI: 10.1016/j.resuscitation.2021.05.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/20/2021] [Accepted: 05/31/2021] [Indexed: 12/26/2022]
Abstract
AIM This observational cohort study aimed to identify factors associated with pulseless electrical activity (PEA) and asystole in in-hospital cardiac arrest (IHCA) patients and to determine whether differences in outcome based on the initial rhythm were explained by patient- and cardiac arrest characteristics. METHODS Adults with IHCA from 2017 to 2018 were included from the Danish IHCA Registry (DANARREST). Additional data came from population-based registries. Unadjusted (RRs) and adjusted risk ratios (aRRs) were estimated for predictors of initial rhythm, return of spontaneous circulation (ROSC), and survival. RESULTS We included 1495 PEA and 1285 asystole patients. The patients did not differ substantially in patient characteristics. Female sex, age>90 years, pulmonary disease, and obesity were associated with initial asystole. Ischemic heart disease and witnessed and monitored cardiac arrest were associated with initial PEA. In unadjusted and adjusted analyses, PEA was associated with increased ROSC (aRR = 1.21, 95% confidence interval [CI] 1.10; 1.33). PEA was also associated with increased 30-day and 1-year survival in the unadjusted analysis, while there was no clear association between the initial rhythm and 30-day (aRR = 0.88, 95% CI 0.71; 1.11) and 1-year (aRR = 0.85, 95% CI 0.69; 1.04) survival when patient- and cardiac arrest characteristics were adjusted for. CONCLUSION In patients with IHCA presenting with PEA or asystole, there were no major differences in patient demographics and comorbidities. The patients differed substantially in cardiac arrest characteristics. Initial PEA was associated with higher risk of ROSC, but there was no difference in 30-day and 1-year survival.
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Kim YM, Park JE, Hwang SY, Lee SU, Kim T, Yoon H, Sim MS, Jo IJ, Lee GT, Shin TG. Association between wide QRS pulseless electrical activity and hyperkalemia in cardiac arrest patients. Am J Emerg Med 2021; 45:86-91. [PMID: 33677265 DOI: 10.1016/j.ajem.2021.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 01/14/2023] Open
Abstract
AIM We evaluated the relationship between hyperkalemia and wide QRS complex in patients with pulseless electrical activity (PEA) cardiac arrest. METHODS This was a single-center, retrospective observational study of patients over the age of 18 treated for cardiac arrest at a tertiary referral hospital whose initial electrocardiogram rhythm was PEA from February 2010 to December 2019. Wide QRS PEA was defined as a QRS interval of 120 ms or more. Hyperkalemia was defined as serum potassium level > 5.5 mmol/L. The primary outcome was hyperkalemia. Multivariable logistic regression analysis was used to evaluate the relationship between wide QRS and hyperkalemia. RESULTS Among 617 patients, we analyzed 111 episodes in the wide QRS group and 506 episodes in the narrow QRS group. The potassium level in the wide QRS group was significantly higher than in the narrow QRS group (5.4 mmol/L, IQR 4.4-6.7 vs. 4.6 mmol/L, IQR 4.0-5.6, P < 0.001). Among all patients, 49.6% (n = 55/111) in the wide QRS group had hyperkalemia, which was significantly higher than the 26.7% (n = 135/506) in the narrow QRS group (P < 0.001). In multivariable logistic regression analysis, wide QRS PEA was significantly associated with hyperkalemia (odds ratio = 2.86, 95% confidence interval: 1.80-4.53, P < 0.001). CONCLUSIONS Wide QRS PEA as an initial cardiac rhythm was significantly associated with hyperkalemia in cardiac arrest patients.
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Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungbuk National University, Cheongju, Chungcheongbuk-do, Republic of Korea.
| | - Jong Eun Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Gangwon-do, Republic of Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Se Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taerim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Min Seob Sim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ik Joon Jo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gun Tak Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Gangwon-do, Republic of Korea.
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Van den Bempt S, Wauters L, Dewolf P. Pulseless Electrical Activity: Detection of Underlying Causes in a Prehospital Setting. Med Princ Pract 2021; 30:212-222. [PMID: 33254164 PMCID: PMC8280430 DOI: 10.1159/000513431] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/26/2020] [Indexed: 01/30/2023] Open
Abstract
The proportion of out-of-hospital cardiac arrests (OHCAs) with pulseless electrical activity (PEA) as initial rhythm is increasing. PEA should be managed by identifying the underlying cause of the arrest and treating it accordingly. This often poses a challenge in the chaotic prehospital environment with only limited resources available. The aim of this study was to review the diagnostic tools available in a prehospital setting, and their interpretation during cardiac arrest (CA) with PEA as initial rhythm. A systematic literature search of the PubMed database was performed. Articles were assessed for eligibility by title, abstract, and full text. Ultrasonography has become a great asset in detecting underlying causes, and a variety of protocols have been proposed. There are currently no studies comparing these protocols regarding their feasibility and their effect on patient survival. Further research concerning the relationship between electrocardiogram characteristics and underlying causes is required. Limited evidence suggests a role for point-of-care testing in detecting hyperkalemia and a role for capnography in the diagnosis of asphyxia CA. Multiple studies describe a prognostic potential. Although evidence about the prognostic potential of cerebral oximetry in OHCA is accumulating, its diagnostic potential is still unknown. In the management of OHCA, anamnestic and clinical information remains the initial source of information in search for an underlying cause. Ultrasonographic evaluation should be performed subsequently, both for detecting an underlying cause and discriminating between true PEA and pseudo PEA. Comparative studies are required to identify the best ultrasonographic protocol, which can be included in resuscitation guidelines.
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Affiliation(s)
- Senne Van den Bempt
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - Lina Wauters
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - Philippe Dewolf
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium,
- Department of Public Health and Primary Care, KU Leuven - University, Leuven, Belgium,
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Leong YC, Cheskes S, Drennan IR, Buick JE, Latchmansingh RG, Verbeek PR. Clinical considerations for out-of-hospital cardiac arrest management during COVID-19. Resusc Plus 2020; 4:100027. [PMID: 33403363 PMCID: PMC7489886 DOI: 10.1016/j.resplu.2020.100027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/20/2020] [Accepted: 09/07/2020] [Indexed: 12/14/2022] Open
Abstract
Managing out-of-hospital cardiac arrest requires paramedics to perform multiple aerosol generating medical procedures in an uncontrolled setting. This increases the risk of cross infection during the COVID-19 pandemic. Modifications to conventional protocols are required to balance paramedic safety with optimal patient care and potential stresses on the capacity of critical care resources. Despite this, little specific advice has been published to guide paramedic practice. In this commentary, we highlight challenges and controversies regarding critical decision making around initiation of resuscitation, airway management, mechanical chest compression, and termination of resuscitation. We also discuss suggested triggers for implementation and revocation of recommended protocol changes and present an accompanying paramedic-specific algorithm.
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Affiliation(s)
- Yuen Chin Leong
- Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sheldon Cheskes
- Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Ian R. Drennan
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Jason E. Buick
- Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - P. Richard Verbeek
- Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
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17
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Kim JH, Ryoo HW, Kim JY, Ahn JY, Moon S, Lee DE, Mun YH, Son JW. QRS complex characteristics and patient outcomes in out-of-hospital pulseless electrical activity cardiac arrest. Emerg Med J 2020; 38:53-58. [PMID: 33106288 DOI: 10.1136/emermed-2020-209623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 09/12/2020] [Accepted: 09/15/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pulseless electrical activity (PEA) is increasingly observed in out-of-hospital cardiac arrest (OHCA), but outcomes are still poor. We aimed to assess the relationship between QRS characteristics and outcomes of patients with OHCA with initial PEA (OHCA-P). METHODS This prospective observational study included patients aged at least 18 years who developed OHCA-P between 1 January 2016 and 31 December 2018, and were enrolled in the Daegu Emergency Medical Services registry, South Korea. We performed multivariable logistic regression analyses to identify the associations between QRS characteristics and OHCA-P outcomes, in which QRS complexes were considered separately (model 1) and simultaneously (model 2). The primary outcome was survival to hospital discharge and the secondary outcome was a favourable neurological outcome. RESULTS Of the 3659 patients with OHCA, 576 were enrolled (median age 73 years; 334 men). A higher QRS amplitude was associated with survival to hospital discharge and a favourable neurological outcome in model 1 (adjusted OR (aOR) 1.077 and 1.106, respectively; 95% CI 1.021 to 0.136 and 1.029 to 1.190, respectively) and model 2 (aOR 1.084 and 1.123, respectively; 95% CI 1.026 to 1.145 and 1.036 to 1.216, respectively). A QRS width of <120 ms was associated with survival to hospital discharge and a favourable neurological outcome in model 1 (aOR 3.371 and 4.634, respectively; 95% CI 1.633 to 6.960 and 1.562 to 13.144, respectively) and model 2 (aOR 3.213 and 5.103, respectively; 95% CI 1.568 to 6.584 and 1.682 to 15.482, respectively). Survival to hospital discharge and neurological outcome were not associated with QRS frequency. CONCLUSION OHCA-P outcomes were better when the initial QRS complex showed a higher amplitude or narrower width.
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Affiliation(s)
- Jung Ho Kim
- Department of Emergency Medicine, Yeungnam University School of Medicine and College of Medicine, Daegu, Korea
| | - Hyun Wook Ryoo
- Department of Emergency Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jong-Yeon Kim
- Department of Public Health, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jae Yun Ahn
- Department of Emergency Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sungbae Moon
- Department of Emergency Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dong Eun Lee
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - You Ho Mun
- Department of Emergency Medicine, Yeungnam University School of Medicine and College of Medicine, Daegu, Korea
| | - Jang Won Son
- Division of Cardiology, Internal Medicine, Yeungnam University School of Medicine and College of Medicine, Daegu, Korea
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18
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Kauppila JP, Hantula A, Pakanen L, Perkiömäki JS, Martikainen M, Huikuri HV, Junttila MJ. Association of non-shockable initial rhythm and psychotropic medication in sudden cardiac arrest. IJC HEART & VASCULATURE 2020; 28:100518. [PMID: 32346603 PMCID: PMC7182673 DOI: 10.1016/j.ijcha.2020.100518] [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: 12/28/2019] [Revised: 04/03/2020] [Accepted: 04/14/2020] [Indexed: 11/17/2022]
Abstract
Background Asystole (ASY) and pulseless electrical activity (PEA) have a poor outcome during sudden cardiac arrest (SCA). Psychotropic medication has been associated with a risk for sudden cardiac death (SCD). Our aim was to study the association of psychotropic medication with ASY/PEA during SCA. Methods and results A total of 659 SCA subjects were derived from the emergency data of Oulu University Hospital (2007-2012). Subjects with non-cardiac origin of SCA and over 30-minute delay to rhythm recording were excluded. Population included 222 subjects after exclusions (mean age 64 ± 14 years, 78% males). Initial rhythm was ventricular fibrillation (VF) or ventricular tachycardia (VT) in 123 (55%), ASY in 67 (30%) and PEA in 32 (14%) subjects. The delay (collapse to rhythm recording) was similar in VF/VT and ASY/PEA subjects (median 8 min [1st-3rd quartile 3-12 min] versus 10 [0-14] minutes, p = 0.780). Among VF/VT subjects underlying cardiac disease was more often ischemic compared to ASY/PEA subjects (85% versus 68%, p = 0.003). Psychotropic medication was associated with ASY/PEA rhythm (OR 3.18, 95%CI 1.40-7.23, p = 0.006) after adjustment for gender, age and underlying cardiac disease. Subsequently, antipsychotics (OR 4.27, 95%CI 1.28-14.25, p = 0.018) were more common in the ASY/PEA group. Benzodiazepines and antidepressants were not associated with ASY/PEA. Conclusion Psychotropic medication and especially antipsychotics are associated with non-shockable rhythm during SCA and may lower the possibility of survival from the event. This might partly explain the risk of SCD related to psychotropic medication.
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Affiliation(s)
- Janna P. Kauppila
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Finland
- Corresponding author at: Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 5000, 90114 Oulu, Finland.
| | - Antti Hantula
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Finland
| | - Lasse Pakanen
- Forensic Medicine Unit, National Institute for Health and Welfare, and Department of Forensic Medicine, Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Juha S. Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Finland
| | - Matti Martikainen
- Center for Pre-hospital Emergency Care, Oulu University Hospital, Oulu, Finland
| | - Heikki V. Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Finland
| | - M. Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Finland
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19
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Hosseini M, Wilson RH, Crouzet C, Amirhekmat A, Wei KS, Akbari Y. Resuscitating the Globally Ischemic Brain: TTM and Beyond. Neurotherapeutics 2020; 17:539-562. [PMID: 32367476 PMCID: PMC7283450 DOI: 10.1007/s13311-020-00856-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cardiac arrest (CA) afflicts ~ 550,000 people each year in the USA. A small fraction of CA sufferers survive with a majority of these survivors emerging in a comatose state. Many CA survivors suffer devastating global brain injury with some remaining indefinitely in a comatose state. The pathogenesis of global brain injury secondary to CA is complex. Mechanisms of CA-induced brain injury include ischemia, hypoxia, cytotoxicity, inflammation, and ultimately, irreversible neuronal damage. Due to this complexity, it is critical for clinicians to have access as early as possible to quantitative metrics for diagnosing injury severity, accurately predicting outcome, and informing patient care. Current recommendations involve using multiple modalities including clinical exam, electrophysiology, brain imaging, and molecular biomarkers. This multi-faceted approach is designed to improve prognostication to avoid "self-fulfilling" prophecy and early withdrawal of life-sustaining treatments. Incorporation of emerging dynamic monitoring tools such as diffuse optical technologies may provide improved diagnosis and early prognostication to better inform treatment. Currently, targeted temperature management (TTM) is the leading treatment, with the number of patients needed to treat being ~ 6 in order to improve outcome for one patient. Future avenues of treatment, which may potentially be combined with TTM, include pharmacotherapy, perfusion/oxygenation targets, and pre/postconditioning. In this review, we provide a bench to bedside approach to delineate the pathophysiology, prognostication methods, current targeted therapies, and future directions of research surrounding hypoxic-ischemic brain injury (HIBI) secondary to CA.
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Affiliation(s)
- Melika Hosseini
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Robert H Wilson
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Christian Crouzet
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Arya Amirhekmat
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Kevin S Wei
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Yama Akbari
- Department of Neurology, School of Medicine, University of California, Irvine, USA.
- Beckman Laser Institute, University of California, Irvine, USA.
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20
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Lundin A, Karlsson T, Herlitz J, Lundgren P, Rylander C. The association between duration of mechanical ventilation and survival in post cardiac arrest patients. Resuscitation 2020; 148:145-151. [PMID: 32004666 DOI: 10.1016/j.resuscitation.2020.01.013] [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: 09/16/2019] [Revised: 12/17/2019] [Accepted: 01/13/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE To assess the association between the duration of mechanical ventilation during post resuscitation care and 30-day survival after cardiac arrest. METHODS We conducted a retrospective observational study using data from two national registries. Comatose cardiac arrest patients admitted to general intensive care in Swedish hospitals between 2011 and 2016 were eligible. Based on the median duration of mechanical ventilation for patients who did not survive to hospital discharge, used as a proxy for the endurance of post resuscitation care, the hospitals were divided into four ordered groups for which association with 30-day survival was analyzed. RESULTS In total, 5.113 patients in 56 hospitals were included. Median duration of mechanical ventilation for patients who did not survive to hospital discharge ranged from 17 h in hospital group 1-51 hours in hospital group 4. After adjustment for baseline characteristics, 30-day survival in the entire cohort was positively and independently associated with ordered hospital group: (adjusted odds ratio (95%CI); 1.12 (1.02,1.23); p = 0.02). Thus, hospitals with a longer duration of mechanical ventilation among non-survivors had better survival rate among patients admitted to ICU after a cardiac arrest. However, in a secondary analysis restricted to patients with length of stay in the intensive care unit ≥ 48 h, there was no significant association between 30-day survival and ordered hospital group. CONCLUSION A tendency for longer duration of post resuscitation care in the ICU was associated with higher 30-day survival in comatose patients admitted to intensive care after cardiac arrest.
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Affiliation(s)
- Andreas Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Thomas Karlsson
- Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Herlitz
- Prehospen - Centre for Prehospital Research, University of Borås and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Lundgren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg and Prehospen - Centre for Prehospital Research, University of Borås, Sweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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21
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Nas J, Kleinnibbelink G, Hannink G, Navarese EP, van Royen N, de Boer MJ, Wik L, Bonnes JL, Brouwer MA. Diagnostic performance of the basic and advanced life support termination of resuscitation rules: A systematic review and diagnostic meta-analysis. Resuscitation 2019; 148:3-13. [PMID: 31887367 DOI: 10.1016/j.resuscitation.2019.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/14/2019] [Accepted: 12/18/2019] [Indexed: 01/22/2023]
Abstract
AIM To minimize termination of resuscitation (TOR) in potential survivors, the desired positive predictive value (PPV) for mortality and specificity of universal TOR-rules are ≥99%. In lack of a quantitative summary of the collective evidence, we performed a diagnostic meta-analysis to provide an overall estimate of the performance of the basic and advanced life support (BLS and ALS) termination rules. DATA SOURCES We searched PubMed/EMBASE/Web-of-Science/CINAHL and Cochrane (until September 2019) for studies on either or both TOR-rules in non-traumatic, adult cardiac arrest. PRISMA-DTA-guidelines were followed. RESULTS There were 19 studies: 16 reported on the BLS-rule (205.073 patients, TOR-advice in 57%), 11 on the ALS-rule (161.850 patients, TOR-advice in 24%). Pooled specificities were 0.95 (0.89-0.98) and 0.98 (0.95-1.00) respectively, with a PPV of 0.99 (0.99-1.00) and 1.00 (0.99-1.00). Specificities were significantly lower in non-Western than Western regions: 0.84 (0.73-0.92) vs. 0.99 (0.97-0.99), p < 0.001 for the BLS rule. For the ALS-rule, specificities were 0.94 (0.87-0.97) vs. 1.00 (0.99-1.00), p < 0.001. For non-Western regions, 16 (BLS) or 6 (ALS) out of 100 potential survivors met the TOR-criteria. Meta-regression demonstrated decreasing performance in settings with lower rates of in-field shocks. CONCLUSIONS Despite an overall high PPV, this meta-analysis highlights a clinically important variation in diagnostic performance of the BLS and ALS TOR-rules. Lower specificity and PPV were seen in non-Western regions, and populations with lower rates of in-field defibrillation. Improved insight in the varying diagnostic performance is highly needed, and local validation of the rules is warranted to prevent in-field termination of potential survivors.
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Affiliation(s)
- Joris Nas
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands.
| | - Geert Kleinnibbelink
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands; Institute for Sport and Exercise Sciences, Liverpool John Moores University, 3 Byrom Street, L3 3AF Liverpool, UK
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Cardiovascular Institute Mater Dei Hospital, Bari, Italy; SIRIO MEDICINE Cardiovascular Network, Italy; Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Niels van Royen
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - Menko-Jan de Boer
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - Lars Wik
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS), Oslo University Hospital, Oslo, Norway
| | - Judith L Bonnes
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - Marc A Brouwer
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
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22
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Long-term trends in the epidemiology of out-of-hospital cardiac arrest precipitated by suspected drug overdose. Resuscitation 2019; 144:17-24. [DOI: 10.1016/j.resuscitation.2019.08.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 08/12/2019] [Accepted: 08/25/2019] [Indexed: 11/21/2022]
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23
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Polsinelli VB, Wang NC, Kancharla K, Bhonsale A, Jain SK, Saba S. Implications of Initial Recorded Rhythm on Cardioverter-Defibrillator Insertion and Subsequent All-Cause Mortality in Sudden Cardiac Arrest Survivors. Am J Cardiol 2019; 124:709-714. [PMID: 31279406 DOI: 10.1016/j.amjcard.2019.05.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/11/2019] [Accepted: 05/16/2019] [Indexed: 10/26/2022]
Abstract
Sudden cardiac arrest (SCA) rhythms have been traditionally divided into shockable [ventricular tachycardia (VT)/ventricular fibrillation (VF)] and nonshockable [(asystole (ASY)/pulseless electrical activity (PEA)] rhythms. It is unclear if the specific rhythm has implications on patient management and outcomes. We evaluated 1,433 patients who were admitted with SCA from 2000 to 2012 and were discharged alive. Of those, 1,123 patients had a recorded initial SCA rhythm. Subjects included were >18 years of age, and without an implantable cardioverter-defibrillator (ICD) in place at the time of the event. The likelihood of receiving an ICD for each SCA rhythm and the time to death were analyzed. Of the overall cohort of 1,123 SCA survivors (age of 62 ± 15 years; 39.2% women; 56.3% in-hospital SCA; 83% white; 67% coronary artery disease), 355 (31.6%) received an ICD, and 493 (43.9%) died over a mean follow-up of 3.8 ± 3.2 years. Patients with VF (n = 254, 43.6%) or VT (n = 83, 43.9%) were more likely to receive ICD therapy compared with those with ASY (n = 9, 5.3%) or PEA (n = 9, 4.8%; p <0.001). All-cause mortality was lower in VF patients compared with the other groups (p <0.0001). ICD therapy was associated with lower risk of death in the VF group (hazard ratio [HR] 0.61 [0.45 to 0.83]; p = 0.002) and strong trends toward less mortality in patients with VT (HR 0.64 [0.40 to 1.03]; p = 0.07) and ASY (HR 0.39 [0.12 to 1.31]; p = 0.13) but not in those with PEA (HR 0.93 [0.39 to 2.23]; p = 0.88). In conclusion, long-term survival in post-SCA patients is influenced by initial SCA rhythm. Although SCA survivors with shockable rhythms were more likely to receive ICDs, the ICD was associated with lower risk of death in most patients, including those with ASY. In conclusion, our data suggest that a more detailed SCA rhythm classification has important implications to patient management and long-term survival in this population.
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Affiliation(s)
- Vincenzo B Polsinelli
- The Heart and Vascular Institute and the Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Norman C Wang
- The Heart and Vascular Institute and the Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Krishna Kancharla
- The Heart and Vascular Institute and the Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Aditya Bhonsale
- The Heart and Vascular Institute and the Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sandeep K Jain
- The Heart and Vascular Institute and the Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samir Saba
- The Heart and Vascular Institute and the Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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