Regional cerebral oxygen saturation monitoring for predicting interventional outcomes in patients following out-of-hospital cardiac arrest of presumed cardiac cause: A prospective,observational, multicentre study

AimThis study investigated the value of regional cerebral oxygen saturation (rSO₂) monitoring upon arrival at the hospital for predicting post-cardiac arrest intervention outcomes.MethodsWe enrolled 1195 patients with out-of-hospital cardiac arrest of presumed cardiac cause from the Japan-Prediction of Neurological Outcomes in Patients Post-cardiac Arrest Registry. The primary endpoint was a good neurologic outcome (cerebral performance categories 1 or 2 [CPC1/2]) 90 days post-event.ResultsA total of 68 patients (6%) had good neurologic outcomes. We found a mean rSO₂ of 21% ± 13%. A receiver operating characteristic curve analysis indicated an optimal rSO₂ cut-off of ≥40% for good neurologic outcomes (area under the curve 0.92, sensitivity 0.81, specificity 0.96). Good neurologic outcomes were observed in 53% (55/103) and 1% (13/1092) of patients with high (≥40%) and low (<40%) rSO₂, respectively. Even without return of spontaneous circulation (ROSC) upon arrival at the hospital, 30% (9/30) of patients with high rSO₂ had good neurologic outcomes. Furthermore, 16 patients demonstrating ROSC upon arrival at the hospital and low rSO₂ had poor neurologic outcomes. Multivariate analyses indicated that high rSO₂ was independently associated with good neurologic outcomes (odds ratio = 14.07, P < 0.001). Patients with high rSO₂ showed favourable neurologic prognoses if they had undergone therapeutic hypothermia or coronary angiography (CPC1/2, 69% [54/78]). However, 24% (25/103) of those with high rSO₂ did not undergo these procedures and exhibited unfavourable neurologic prognoses (CPC1/2, 4% [1/25]).ConclusionrSO₂ is a good indicator of 90-day neurologic outcomes for post-cardiac arrest intervention patients.     

Esophageal temperature after out-of-hospital cardiac arrest: An observational study

Introduction

Out-of-hospital cardiac arrest (OHCA) is a significant cause of death and severe neurological disability. The only post-return of spontaneous circulation (ROSC) therapy shown to increase survival is mild therapeutic hypothermia (MTH). The relationship between esophageal temperature post OHCA and outcome is still poorly defined.

Methods

Prospective observational study of all OHCA patients admitted to a single centre for a 14-month period (1/08/2008 to 31/09/2009). Esophageal temperature was measured in the Emergency Department and Intensive Care Unit (ICU). Selected patients had pre-hospital temperature monitoring. Time taken to reach target temperature after ROSC was recorded, together with time to admission to the Emergency Department and ICU.

Results

164 OHCA patients were included in the study. 105 (64.0%) were pronounced dead in the Emergency Department. 59 (36.0%) were admitted to ICU for cooling; 40 (24.4%) died in ICU and 19 (11.6%) survived to hospital discharge. Patients who achieved ROSC and had esophageal temperature measured pre-hospital (n = 29) had a mean pre-hospital temperature of 33.9 °C (95% CI 33.2-34.5). All patients arriving in the ED post OHCA had a relatively low esophageal temperature (34.3 °C, 95% CI 34.1-34.6). Patients surviving to hospital discharge were warmer on admission to ICU than patients who died in hospital (35.7 °C vs 34.3 °C, p < 0.05). Patients surviving to hospital discharge also took longer to reach T_targ than non-survivors (2 h 48 min vs 1 h 32 min, p < 0.05).

Conclusions

Following OHCA all patients have esophageal temperatures below normal in the pre-hospital phase and on arrival in the Emergency Department. Patients who achieve ROSC following OHCA and survive to hospital discharge are warmer on arrival in ICU and take longer to reach target MTH temperatures compared to patients who die in hospital. The mechanisms of action underlying esophageal temperature and survival from OHCA remain unclear and further research is warranted to clarify this relationship.     

The effect of carbon dioxide on near-death experiences in out-of-hospital cardiac arrest survivors: a prospective observational study

Introduction  

Near-death experiences (NDEs) are reported by 11-23% of cardiac arrest survivors. Several theories concerning the mechanisms of NDEs exist - including physical, psychological, and transcendental reasons - but so far none of these has satisfactorily explained this phenomenon. In this study, we investigated the effect of partial pressures of O₂ and CO₂, and serum levels of Na and K on the occurrence of NDEs in out-of-hospital cardiac arrest survivors.     

Epidemiology and outcomes from non-traumatic out-of-hospital cardiac arrest in Korea: A nationwide observational study

Objectives

We aimed to describe the epidemiological features and to determine the predictors for survival to discharge of non-traumatic out-of-hospital cardiac arrest (OHCA) in Korea.

Subjects and methods

A nationwide Utstein style OHCA database (2006-2007) was constructed from ambulance records and hospital medical record review. Cases were enrolled when they were non-traumatic OHCA with presumed cardiac aetiology. Using the population census (2005), we calculated age-gender standardized incidence rates (SIR) and mortality (SMR). We modelled a multivariate logistic regression analysis to determine the effect of risk factors on hospital outcomes.

Results

The total number of EMS-assessed non-traumatic OHCA patients was 19 045. The SIR was 20.9 (2006) and 22.2 (2007) per 100 000 and survival-to-discharge rate was 2.3% for EMS-assessed non-traumatic OHCA, and was 3.5% for the resuscitation-attempted group. From a multivariate logistic regression analysis, witnessed arrest, and shorter basic life support (BLS) and EMS intervals turned out to be significant predictors of good outcome in the resuscitation-attempted group.

Conclusion

From a nationwide OHCA cohort, the incidence of EMS-assessed non-traumatic OHCA was found to be low. Survival-to-discharge rate in the resuscitation-attempted group was 3.5%, which was significantly associated with witnessed arrest, and shorter BLS and EMS intervals.     

The duration of cardiopulmonary resuscitation in emergency departments after out-of-hospital cardiac arrest is associated with the outcome: A nationwide observational study

Aim of the studyThe appropriate duration of cardiopulmonary resuscitation (CPR) for patients who experience out-of-hospital cardiac arrest (OHCA) remains unknown. This study aimed to evaluate the duration of CPR in emergency departments (EDs) and to determine whether the institutions’ median duration of CPR was associated with survival-to-discharge rate.MethodsA cohort of adult patients from a nationwide OHCA registry was retrospectively evaluated. The main variable was the median duration of CPR for each ED (institutional duration), and the main outcome was survival to discharge. Multivariable logistic regression analysis was performed to adjust for individual and aggregated confounders.ResultsAmong the 107,736 patients who experienced OHCA between 2006 and 2010, 30,716 (28.5%) were selected for analysis. The median age was 65 years, and 67.1% were men. The median duration of CPR for all EDs was 28 min, ranging from 11 to 45 min. EDs were categorized into 3 groups according to their institutional duration of CPR: groups A (<20 min), B (20–29 min), C (≥30 min). The observed survival rates of the 3 groups were 2.11%, 5.20%, and 5.62%, respectively. Compared with group B, the adjusted difference (95% confidence interval) for survival to discharge was 3.01% (1.90–4.11, P < 0.001) for group A, and 0.33% (−0.64 to 1.30, P = 0.51) for group C.ConclusionThe duration of CPR varied widely among hospitals. The institutional duration of CPR less than 20 min was significantly associated with lower survival-to-discharge rate.     

Subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest: A prospective computed tomography study

Aim

Aneurysmal subarachnoid haemorrhage (SAH) is a relatively common cause of out-of-hospital cardiac arrest (OHCA). Early identification of SAH-induced OHCA with the use of brain computed tomography (CT) scan obtained immediately after resuscitation may help emergency physicians make therapeutic decision as quickly as they can.

Methods

During the 4-year observation period, brain CT scan was obtained prospectively in 142 witnessed non-traumatic OHCA survivors who remained haemodynamically stable after resuscitation. Demographics and clinical characteristics of SAH-induced OHCA survivors were compared with those with “negative” CT finding.

Results

Brain CT scan was feasible with an average door-to-CT time of 40.0 min. SAH was found in 16.2% of the 142 OHCA survivors. Compared with 116 survivors who were negative for SAH, SAH-induced OHCA survivors were significantly more likely to be female, to have experienced a sudden headache, and trended to have achieved return of spontaneous circulation (ROSC) prior to arrival in the emergency department less frequently. Ventricular fibrillation (VF) was significantly less likely to be seen in SAH-induced than SAH-negative OHCA (OR, 0.06; 95% CI, 0.01–0.46). Similarly, Cardiac Trop-T assay was significantly less likely to be positive in SAH-induced OHCA (OR, 0.08; 95% CI, 0.01–0.61).

Conclusion

Aneurysmal SAH causes OHCA more frequently than had been believed. Immediate brain CT scan may particularly be useful in excluding SAH-induced OHCA from thrombolytic trial enrollment, for whom the use of thrombolytics is contraindicated. The low VF incidence suggests that VF by itself may not be a common cause of SAH-induced OHCA.     

Neuropsychological outcome of survivors of out-of-hospital cardiac arrest

Thirty patients resuscitated from out-of-hospital cardiac arrest (15 with and 15 without postanoxic coma on admission) underwent a clinical examination and neuropsychological testing. In order to assess quality of life, they were compared to two matched control groups; 15 patients with previous myocardial infarction and 15 healthy subjects. None of the survivors showed severe neurologic impairment, and all had returned to self-sufficient physical activity. However, the behavior rating scale scores were significantly worse in patients with postanoxic coma. The processing ability linked to memory was significantly worse in the postanoxic coma group. Mood disorders were also observed in this group, but they did not have pathological significance. The remarkably low incidence of neurologic and psychological sequelae in these resuscitated patients, particularly in those with early clinical evidence of severe cerebral damage, is an encouraging result that supports the therapeutic systems development and efforts in the management of out-of-hospital cardiac arrest.     

Active compression-decompression cardiopulmonary resuscitation: a population-based, prospective randomised clinical trial in out-of-hospital cardiac arrest

Different mechanical devices have been developed to improve cardiopulmonary resuscitation (CPR). The aim of this study was to evaluate active compression-decompression (ACD) CPR applied by Emergency Medical Service (EMS) in a defined population. The Trondheim region EMS (population 154,000) employs simultaneous paramedic and physician response. Upon decision to treat, patients with cardiac arrest of presumed cardiac origin were allocated to ACD CPR (CardioPump) or standard CPR by drawing a random number tag. Outcome in each patient was determined on a 5 point ordinal scale (no clinical improvement = 1, survival to discharge = 5). In 4 years, CPR was attempted in a total of 431 cardiac arrests, 54 patients (13%) survived to discharge; 302 patients with similar baseline characteristics were randomised. The prevalence of bystander CPR was 57% and the median call-arrival interval 9 min. By intention to treat, the mean score in the standard CPR group was 2.51 and 17/145 patients (12%) survived. The mean score in the ACD CPR group was 2.53 (P = 0.9) and 20/157 patients (13%) survived. Cerebral outcome was similar in the two groups. Among the 145 ACD patients, the technique was successfully applied in 110, found inapplicable in 35 and in seven patients chest compressions were unnecessary. This is the largest, single-centre, randomised, population based study of ACD CPR in out-of-hospital cardiac arrest to date. Even when considering a wider outcome spectrum than crude survival, we found no evidence of clinical benefit. In a quarter of cases ACD CPR was inapplicable, further limiting its potential usefulness.     

An outcome study of out-of-hospital cardiac arrest using the Utstein template--a Japanese experience

Publication of the Utstein style template has made it possible to evaluate and compare national, regional, and hospital based Emergency Medical Services. This research was a national investigation to present outcome data for out-of-hospital cardiac arrest (OHCA) patients in Japan. 3029 OHCA patients who were transported to 10 Emergency and Critical Care Medical Center from November 1997 to April 1999 were recorded according to the Utstein style and the outcome evaluated by logistic regression analysis. Among 3029 OHCA patients, 109 were found dead. The remaining 2920 patients who underwent cardiopulmonary resuscitation (CPR) by emergency medical technicians (EMT) were included in this study. Among these patients, 1294 were considered of primary cardiac origin patients by the EMT and 722 of these patients suffered a witnessed cardiac arrest. Bystander CPR were performed in 28.4% of these witnessed patients and the discharge rate was 3.5% overall and 11.4% in witnessed VF/VT. Outcome analysis showed that a discharge rate in witnessed primary cardiac arrest was 30% in prehospital resuscitation which was 7.5 times higher than in-hospital emergency room resuscitation groups (4.0%). The longer the interval between an emergency telephone call and defibrillation, the lower the 1 month survival rate, which reached almost 0% at 30 min. Follow up evaluation after discharge revealed that the survival rate rapidly decreased from 24 h to 3 months, then became a plateau in primary cardiac patients was rapidly decreased from 24 h to 1 month, then became a near plateau in non-cardiac origin group. To improve the resuscitation rate in the prehospital phase, a prehospital medical control system should be developed with expansion of on scene techniques by Japanese paramedics such as tracheal intubation, administration of emergency drugs and early defibrillation with standing orders. Education and motivation of first responders will be needed and every effort should be concentrated on improving bystander CPR rate.     

Prehospital care and outcome of pediatric out-of-hospital cardiac arrest

Cardiac arrest in children outside the hospital is associated with high mortality rates. Recent investigations have suggested that the use of advanced life support (ALS) measures by emergency medical services (EMS) personnel may decrease survival. These studies have used the pediatric Utstein style of defining ALS and basic life support (BLS) measures. The pediatric Utstein style defines BLS as “an attempt to restore effective ventilation and circulation” using noninvasive means to open the airway but specifically excludes the use of bag-valve-mask devices. Advanced life support is defined as the “addition of invasive maneuvers to restore effective ventilation and circulation.” The authors of the study described below believe that using this definition would categorize some patients into an ALS group who would otherwise be categorized as having received BLS (i.E., “bag-valve-mask only”). Objective: To compare survival rates among children receiving BLS or ALS following out-of-hospital cardiac arrest using amended definitions of prehospital life support measures. Specifically, the definition of BLS was expanded to include the use of bag-valve-mask devices only. Methods: This was a retrospective chart review in an urban, pediatric emergency department. Patients included all children presenting to the emergency department between January 1, 1986, and December 31, 1999, following out-of-hospital cardiac arrest. The main outcome measure was survival to hospital discharge. Results: Two hundred ten children were identified. Twenty-one patients were excluded from further analysis because of absent or incomplete medical records. One hundred eighty-nine patients were studied. Five children (2.6%) survived to discharge from the hospital. Of 189 children, 39 (20.6%) were provided BLS measures by prehospital personnel; 150 (79.4%) received ALS. There was no significant difference between groups in survival to hospital discharge. Patients who survived to hospital discharge were more likely to be in sinus rhythm upon arrival in the emergency department (p < 0.001) and to have received fewer doses of standard-dose epinephrine in the emergency department (p < 0.001). Conclusion: The use of ALS by prehospital personnel for children with out-of-hospital cardiac arrest did not improve survival to discharge from the hospital when compared with the use of BLS. PREHOSPITAL EMERGENCY CARE 2002;6:283-290     

Changes in S-100 protein serum levels in survivors of out-of-hospital cardiac arrest treated with mild therapeutic hypothermia: a prospective, observational study

Introduction  

Knowledge about the influence of current neuroprotective interventions on prognostic markers after survival from cardiac arrest is lacking. This study aimed to investigate the effects of mild therapeutic hypothermia on the release of the astroglial protein S-100 after cardiopulmonary resuscitation (CPR) in survivors of out-of-hospital cardiac arrest.     

VF recurrence: characteristics and patient outcome in out-of-hospital cardiac arrest

BACKGROUND: Refibrillation after successful defibrillation in out-of-hospital cardiac arrest is a frequent event. Little is known of factors that predispose to the occurrence of refibrillation. The effect of recurrence of ventricular fibrillation (VF) on survival is not known. METHODS: Data of patients in out-of-hospital cardiac arrest were collected in a combined first responder and paramedic programme in Amsterdam, the Netherlands. Continuous recorded rhythm data of 322 patients covering the entire out-of-hospital resuscitation attempt was included in the analysis. Recurrence of VF was recorded, the patient and process characteristics were analysed in relation to the occurrence of refibrillation. The number of refibrillations was related to survival. RESULTS AND CONCLUSION: Of the studied patients 79% had at least one recurrence of VF, and a median number of two times 25-75%; one to four times). The median time from successful first shock to VF recurrence was 45 s (25-75%: 23-115 s). A significant inverse relation was found between the number of refibrillations and survival of out-of-hospital cardiac arrest. The recurrence of VF was independent of the underlying cardiac disorder, the time to defibrillation, the defibrillation waveform and other characteristics of the patient and the process. Anti-arrhythmics should be considered in all patients found in VF to reduce the number of recurrences.     

The effect of hydrocortisone on the outcome of out-of-hospital cardiac arrest patients: a pilot study

OBJECTIVE: Several studies have disclosed the importance of serum adrenocorticotropic hormone and cortisol levels in resuscitation. The objective of this study was to observe the effect of hydrocortisone on the outcome of out-of-hospital cardiac arrest (OHCA) patients. DESIGN: Prospective, nonrandomized, open-labeled clinical trial. SETTING: Emergency department (ED) of National Taiwan University Hospital. PATIENTS AND PARTICIPANTS: Ninety-seven nontraumatic adult OHCA victims. INTERVENTIONS: Serum adrenocorticotropic hormone and total cortisol levels were examined in all patients. The hydrocortisone group (n = 36) received 100 mg intravenous hydrocortisone during resuscitation, and the nonhydrocortisone group (n = 61) received 0.9% saline as placebo. MEASUREMENTS AND RESULTS: Comparison of return of the spontaneous circulation (ROSC) rates between the 2 groups was analyzed. The hydrocortisone group had a significantly higher ROSC rate than the nonhydrocortisone group (61% vs 39%, P = .038). Hydrocortisone administration within 6 minutes after ED arrival led to an increased ROSC rate (90% vs 50%, P = .045). The hydrocortisone and nonhydrocortisone groups did not differ in the development of electrolyte disturbances, gastrointestinal tract bleeding, or infection during early postresuscitation period (gastrointestinal bleeding: 41% vs 46%, P = .89; infection: 50% vs 75%, P = .335). There was no significant difference between the hydrocortisone and nonhydrocortisone groups in terms of 1- and 7-day survival and hospital discharge rates. CONCLUSIONS: Hydrocortisone treatment during resuscitation, particularly when administrated within 6 minutes of ED arrival, may be associated with an improved ROSC rate in OHCA patients.     

Cardiopulmonary resuscitation outcome of out-of-hospital cardiac arrest in low-volume versus high-volume emergency departments: An observational study and propensity score matching analysis

Objective

This study aimed to determine whether cardiopulmonary resuscitation (CPR) volume is associated with survival to discharge rate for out-of hospital cardiac arrest (OHCA) victims.

Methods

This study was performed in an emergency medical service (EMS) system with single-tiered basic to intermediate service level. A nationwide OHCA cohort database from January 2006 to December 2007 was used and composed of hospital chart review and ambulance run sheet data. We enrolled data from the 410 emergency departments and excluded cases without available hospital outcome data. From sensitivity analysis, we decided cut-off value for the high volume (HV) versus low volume (LV) EDs. A matching process based on propensity score was used to equalize potential prognostic factors in both groups. The adjusted odds ratio (OR) and its 95% confidence interval (95% CI) for survival to admission and to discharge were calculated.

Results

Of the 34,408 patients with OHCA, 20,457 (59.5%) were included except cases with unknown outcome (n = 1284), traumatic cause (n = 4894), no CPR attempt by EMS (n = 7779), and cases transferred to non-ED facilities (n = 3885). Overall survival to admission and to discharge was 10.9% and 3.4%, respectively. When we performed the sensitivity analysis for deciding the cut-off value for HV versus LV, the number was 68 per two years (sensitivity 67.0%, specificity 67.0%). Using propensity score matching, 3533 cases were randomly assigned to HV and LV group, respectively. The unadjusted and adjusted OR for survival to admission in HV was 1.35 (95% CI 1.19-1.54) and 1.44 (95% CI 1.24-1.66), respectively. The unadjusted and adjusted OR for survival to discharge was 1.71 (95% CI 1.36-2.14) and 1.81 (95% 1.43-2.30), respectively.

Conclusions

Emergency departments with high volumes of CPR cases showed significantly better outcomes for OHCA patients than those with low volumes in an EMS system with single-tiered basic to intermediate service level.     

Pediatric out-of-hospital cardiac arrest in Korea: A nationwide population-based study

Study objectives

Our objective was to describe the incidence and demographics of pediatric out-of-hospital cardiac arrest (OHCA) in Korea.

Methods

We identified non-traumatic OHCA patients aged less than 20 years from a Korean nationwide OHCA registry (2006-2007). Data from emergency medical service (EMS) run-sheets and hospital records were reviewed. We excluded cases with unknown hospital outcomes. Patient characteristics, treatment by EMS, and outcomes were compared by age groups: infant (<1 year), children (1-11 years), and adolescents (12-19 years).

Results

A total of 971 patients including infants (n = 299, 30.8%), children (n = 305, 31.4%), and adolescents (n = 367, 37.8%) met inclusion criteria. The incidence of pediatric OHCA was 4.2 per 100,000 person-years (67.1 in infants, 2.5 in children, and 3.5 in adolescents). The rate of cardiopulmonary resuscitation administered was 82.1% (infants 80.6%, children 82.0%, and adolescent 83.4%). The rate of applying automated external defibrillators and advanced airway management (endotracheal intubation or laryngeal mask airway), was only 4.1% and 2.5%, respectively. 7.4% showed ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in the initial ECG. Survival to hospital discharge for all pediatric OHCA was 4.9% (2.9% for infants, 4.7% for children, and 7.2% of adolescents). For EMS-treated pediatric OHCA or patients with VF or pulseless VT, the rate was 5.0% and 31.6%, respectively.

Conclusion

Incidence and hospital outcomes in pediatric OHCA in Korea were comparable to other population-based nationwide reports.     

Termination-of-resuscitation rule for emergency department physicians treating out-of-hospital cardiac arrest patients: an observational cohort study

Introduction

The 2010 cardiopulmonary resuscitation guidelines recommend emergency medical services (EMS) personnel consider prehospital termination-of-resuscitation (TOR) rules for out-of-hospital cardiac arrest (OHCA) following basic life support and/or advanced life support efforts in the field. However, the rate of implementation of international TOR rules is still low. Here, we aimed to develop and validate a new TOR rule for emergency department physicians to replace the international TOR rules for EMS personnel in the field. This rule aims to guide physicians in deciding whether to withhold further resuscitation attempts or terminate on-going resuscitation immediately after patient arrival.

Methods

We analyzed data prospectively collected in a nationwide Utstein-style Japanese database between 2005 and 2009, from 495,607 adult patients with OHCA. Patients were divided into development (n = 390,577) and validation (n = 105,030) groups. The main outcome measures were specificity, positive predictive value (PPV), and area under the receiver operating characteristic (ROC) curve for the newly developed TOR rule.

Results

We developed a new TOR rule that includes 3 criteria based on the results of multivariate logistic regression analysis for predicting a 1-month death after OHCA: no prehospital return of spontaneous circulation (adjusted odds ratio [OR], 25.8; 95% confidence interval [CI], 24.7–26.9), unshockable initial rhythm (adjusted OR, 2.76; 95% CI, 2.54–3.01), and unwitnessed by bystanders (adjusted OR, 2.18; 95% CI, 2.09–2.28). The specificity, PPV, and area under the ROC curve for this new TOR rule for predicting 1-month death in the validation group were 0.903 (95% CI, 0.894–0.911), 0.993 (95% CI, 0.992–0.993), and 0.874 (95% CI, 0.872–0.876), respectively.

Conclusions

We developed and validated a new TOR rule for emergency department physicians consisting of 3 prehospital variables (no prehospital ROSC, unshockable initial rhythm, and unwitnessed by bystanders) that is a >99% predictor of very poor outcome. However, the implementation of this new rule in other countries or EMS systems requires further validation studies.