Computed-Tomography as First-line Diagnostic Procedure in Patients With Out-of-Hospital Cardiac Arrest

Rib fractures and other injuries after cardiopulmonary resuscitation for non-traumatic cardiac arrest: a systematic review and meta-analysis

PURPOSE

This study aims to ascertain the prevalence of rib fractures and other injuries resulting from CPR and to compare manual with mechanically assisted CPR. An additional aim was to summarize the literature on surgical treatment for rib fractures following CPR.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar.

REVIEW METHODS

The databases were searched to identify studies reporting on CPR-related injuries in patients who underwent chest compressions for a non-traumatic cardiopulmonary arrest. Subgroup analysis was conducted to compare the prevalence of CPR-related injuries in manual versus mechanically assisted chest compressions. Studies reporting on surgery for CPR-related rib fractures were also reviewed and summarized.

RESULTS

Seventy-four studies reporting CPR-related injuries were included encompassing a total of 16,629 patients. Any CPR-related injury was documented in 60% (95% confidence interval [95% CI] 49-71) patients. Rib fractures emerged as the most common injury, with a pooled prevalence of 55% (95% CI 48-62). Mechanically assisted CPR, when compared to manual CPR, was associated with a higher risk ratio for CPR-related injuries of 1.36 (95% CI 1.17-1.59). Eight studies provided information on surgical stabilization of CPR-related rib fractures. The primary indication for surgery was the inability to wean from mechanical ventilation in the presence of multiple rib fractures.

CONCLUSION

Rib fractures and other injuries frequently occur in patients who undergo CPR after a non-traumatic cardiopulmonary arrest, especially when mechanical CPR is administered. Surgical stabilization of CPR-related rib fractures remains relatively uncommon.

LEVEL OF EVIDENCE

Level III, systematic review and meta-analysis.

Management of Patients After Cardiac Arrest

Cardiac arrest remains a significant cause of morbidity and mortality, although contemporary care now enables potential survival with good neurologic outcome. The core acute management goals for survivors of cardiac arrest are to provide organ support, sustain adequate hemodynamics, and evaluate the underlying cause of the cardiac arrest. In this article, the authors review the current state of knowledge and clinical intensive care unit practice recommendations for patients after cardiac arrest, particularly focusing on important areas of uncertainty, such as targeted temperature management, neuroprognostication, coronary evaluation, and hemodynamic targets.

Opportunistic CT-derived analysis of fat and muscle tissue composition predicts mortality in patients with cardiogenic shock

Prognosis estimation in patients with cardiogenic shock (CS) is important to guide clinical decision making. Aim of this study was to investigate the predictive value of opportunistic CT-derived body composition analysis in CS patients. Amount and density of fat and muscle tissue of 152 CS patients were quantified from single-slice CT images at the level of the intervertebral disc space L3/L4. Multivariable Cox regression and Kaplan-Meier survival analyses were performed to evaluate the predictive value of opportunistically CT-derived body composition parameters on the primary endpoint of 30-day mortality. Within the 30-day follow-up, 90/152 (59.2%) patients died. On multivariable analyses, lactate (Hazard Ratio 1.10 [95% Confidence Interval 1.04-1.17]; p = 0.002) and patient age (HR 1.04 [95% CI 1.01-1.07], p = 0.017) as clinical prognosticators, as well as visceral adipose tissue (VAT) area (HR 1.004 [95% CI 1.002-1.007]; p = 0.001) and skeletal muscle (SM) area (HR 0.987 [95% CI 0.975-0.999]; p = 0.043) as imaging biomarkers remained as independent predictors of 30-day mortality. Kaplan-Meier survival analyses showed significantly increased 30-day mortality in patients with higher VAT area (p = 0.015) and lower SM area (p = 0.035). CT-derived VAT and SM area are independent predictors of dismal outcomes in CS patients and have the potential to emerge as new imaging biomarkers available from routine diagnostic CT.

Injury pattern and clinical outcome in patients with and without chest wall injury after cardiopulmonary resuscitation

BACKGROUND

Cardiopulmonary resuscitation (CPR), although lifesaving may cause chest wall injury (CWI) because of the physical force exerted on the thorax. The impact of CWI on clinical outcome in this patient group is unclear. The primary aim of this study was to investigate the incidence of CPR-related CWI and the secondary aim to study injury pattern, length of stay (LOS), and mortality in patients with and without CWI.

METHODS

This is a retrospective study of adult patients who were admitted to our hospital due to cardiac arrest (CA) during 2012 to 2020. Patients were identified in the Swedish CPR Registry and those undergoing CT of the thorax within 2 weeks after CPR were included. Patients with traumatic CA, chest wall surgery prior or after CA were excluded. Demographic data, type and length of CPR, type of CWI, LOS on mechanical ventilator (MV), in intensive care unit (ICU) and in hospital (H), and mortality were studied.

RESULTS

Of 1,715 CA patients, 245 met the criteria for inclusion. The majority (79%) of the patients suffered from CWI. Chondral injuries and rib fractures were more common than sternum fractures (95% vs. 57%), and 14% had a radiological flail segment. Patients with CWI were older (66.5 ± 15.4 vs. 52.5 ± 15.2, p < 0.001). No difference was seen in MV-LOS (3 [0-43] vs. 3 [0-22]; p = 0.430), ICU-LOS (3 [0-48] vs. 3 [0-24]; p = 0.427), and H-LOS (5.5 [0-85] vs. 9.0 [1-53]; p = 0.306) in patients with or without CWI. Overall mortality within 30 days was higher with CWI (68% vs. 47%, p = 0.007).

CONCLUSION

Chest wall injuries are common after CPR and 14% of patients had a flail segment on CT. Elderly patients have an increased risk of CWI, and a higher overall mortality is seen in patients with CWI.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Head-to-pelvis CT imaging after sudden cardiac arrest: Current status and future directions

Causes for sudden circulatory arrest (SCA) can vary widely making early treatment and triage decisions challenging. Additionally, cardiopulmonary resuscitation (CPR), while a life-saving link in the chain of survival, can be associated with traumatic injuries. Computed tomography (CT) can identify many causes of SCA as well as its sequelae. However, the diagnostic and therapeutic impact of CT in survivors of SCA has not been reviewed to date. This general review outlines the rationale and potential applications of focused head, chest, and abdomen/pelvis CT as well as comprehensive head-to-pelvis CT imaging after SCA. CT has a diagnostic yield approaching 30% to identify causes of SCA while the addition of ECG-gated chest CT provides further information about coronary anatomy and cardiac function. Risks of CT include radiation exposure, contrast-induced kidney injury, and incidental findings. This review's findings suggest that routine head-to-pelvis CT can yield clinically actional findings with the potential to improve clinical outcome after SCA that merits further investigation.

Both decreased and increased grey-to-white matter attenuation ratio in the putamen and caudate on early head computed tomography differentiate patients with favorable and unfavorable outcomes after prolonged cardiac arrest-secondary analysis of the Prague OHCA study

Background

Neurological damage remains the leading cause of death in cardiac arrest victims with early neuroprognostication being the cornerstone of the decision-making process to continue or discontinue advanced treatments. In this study, we aimed to find markers of favorable and unfavorable outcome on early brain computed tomography (CT) in patients after prolonged out-of-hospital cardiac arrest (OHCA) treated both by conventional and extracorporeal cardiopulmonary resuscitation (ECPR).

Methods

In a secondary analysis of the Prague OHCA study, patients who underwent brain CT within 36 hours after cardiac arrest were identified. Qualitative findings (brain edema, hemorrhage) and quantitative measurements [attenuation of grey matter structures and grey-to-white matter attenuation ratio (GWR)] between patients with cerebral performance category (CPC) of 1-2 (favorable outcome) and 3-5 (unfavorable outcome) within 180 days after the event were compared.

Results

In 45 eligible patients, intracranial edema (n=16, 50%) was present in patients with CPC 3-5 only (n=32, 71%). Attenuation of brain structures and GWR did not differ between patients with favorable and unfavorable outcomes. However, the GWR in the caudate and putamen of most CPC 1-2 patients was within a narrow range of values (1.18 to 1.30 and 1.20 to 1.33) that separated patients with CPC 1-2 from CPC 3-5 with a sensitivity of 78% and 66% a specificity of 85% and 100%, and area under the curve （AUC） of 0.86 (P=0.0001) and 0.77 (P=0.0053), respectively. Patients treated by ECPR had lower attenuation in the centrum semiovale (28.3±2.7) compared to those who were not (31.0±2.8, P=0.003). The most common causes of death in CPC 3-5 patients were brain death in 13 (41%) patients, multiorgan failure in 12 (38%), and cardiac rearrest in 4 (13%).

Conclusions

Both decreased and increased grey-to-white matter differentiation in the putamen and caudate on early non-contrast brain CT after prolonged OHCA indicate poor neurological outcome within 180 days after cardiac arrest.

Diagnostic Yield, Safety, and Outcomes of Head-to-Pelvis Sudden Death CT Imaging in Post Arrest Care: The CT FIRST Cohort Study

AIM

Our aim was to test whether a head-to-pelvis CT scan improves diagnostic yield and speed to identify causes for out of hospital circulatory arrest (OHCA).

METHODS

CT FIRST was a prospective observational pre-/post-cohort study of patients successfully resuscitated from OHCA. Inclusion criteria included unknown cause for arrest, age>18 years, stability to undergo CT, and no known cardiomyopathy or obstructive coronary artery disease. A head-to-pelvis sudden death CT (SDCT) scan within 6 hours of hospital arrival was added to the standard of care for patients resuscitated from OHCA (post-cohort) and compared to standard of care (SOC) alone (pre-cohort). The primary outcome was SDCT diagnostic yield. Secondary outcomes included time to identifying OHCA cause and time-critical diagnoses, SDCT safety, and survival to hospital discharge.

RESULTS

Baseline characteristics between the SDCT (N=104) and the SOC (N=143) cohorts were similar. CT scans (either head, chest, and/or abdomen) were ordered in 74 (52%) of SOC patients. Adding SDCT scanning identified 92% of causes for arrest compared to 75% (SOC-cohort; p value <0.001) and reduced the time to diagnosis by 78% (SDCT 3.1 hours, SOC alone 14.1 hours, p <0.0001). Identification of critical diagnoses was similar between cohorts, but SDCT reduced delayed (>6 hours) identification of critical diagnoses by 81% (p<0.001). SDCT safety endpoints were similar including acute kidney injury. Patient survival to discharge was similar between cohorts.

DISCUSSION

SDCT scanning early after OHCA resuscitation safely improved the efficiency and diagnostic yield for causes of arrest compared to the standard of care alone.

CLINICAL TRIALS NUMBER

NCT03111043.