264 Survival to Hospital Discharge After Cardiac Arrest Is Rare Without Out-of-Hospital Return of Spontaneous Circulation

Background: Time to ROSC has been shown to be an important and independent predictor of mortality and adverse neurological outcome. In resource limited situations judicious deployment of resources is crucial. Prognostication of arrest victims may aid in better resource allocation. This study aimed to assess the time to Return of Spontaneous Circulation (ROSC) in cardiac arrest victims and its relationship with opening rhythms.Methods: Consecutive victims of cardiopulmonary arrest who presented to a single center were included in this study if they met the inclusion and exclusion criteria. Time at which opening rhythm was analyzed and time at which ROSC was achieved was noted. This was done for all cases and mean time to ROSC was calculated for each opening rhythm. All those patients who achieved ROSC were followed up till hospital discharge or death. Primary outcome measured was achievement of ROSC and the secondary outcome was the survival to hospital discharge.Results: A sample size of 100 was calculated to yield a significance criterion of 0.05 and a power of 0.80 based on prior studies. Out of 100 patients studied. 58% had shockable rhythms and 42% had non-shockable rhythms. Mean time to ROSC for shockable rhythm was 5.55±3.51 minutes, and for non-shockable rhythm is 17.29±4.18 minutes. There was a statistically significant difference between opening rhythms in terms of survival to hospital discharge (p=0.0329).Conclusions: Cardiac arrests with shockable rhythms attained ROSC faster when compared to nonshockable rhythms. Shockable rhythms have a better survival to hospital discharge when compared to shockable rhythms. Opening rhythms may aid the clinician in better utility of resources in a resource constrained setting.

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Abstract 12258: Out-of-hospital Cardiac Arrest With Initially Shockable Rhythm: What Are the Outcomes if No Shock is Given?

Circulation ◽

10.1161/circ.132.suppl_3.12258 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Yan Xiong ◽

Ahamed H Idris

Keyword(s):

Cardiac Arrest ◽

Hospital Discharge ◽

Spontaneous Circulation ◽

Shock Delivery ◽

Return Of Spontaneous Circulation ◽

Shockable Rhythm ◽

Multiple Variable ◽

Multiple Variable Regression ◽

Hospital Cardiac Arrest ◽

Resuscitation Attempt

Background: Prompt defibrillation is critical for termination of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in out-of-hospital cardiac arrest (OHCA). For ethical reasons, the real impact of not shocking OHCA patients with a shockable rhythm is unlikely to be investigated in clinical trials and thus remains unknown. Objectives: To describe demographics, pre-hospital characteristics, interventions, and outcomes in OHCA patients with an initially shockable rhythm who did and did not get shocked in the field in DFW ROC site. Methods: We included all non-traumatic OHCA cases ≥18 years old with VF or VT as first known rhythms, who were treated and transported to a hospital within the DFW ROC site between 2006 - 2011. We report return of spontaneous circulation (ROSC) in the field and survival to hospital discharge for victims with and without shock delivered in the field. Multiple variable regression analysis assessed the association between shock delivery and ROSC in the field as well as survival. Results: Included were 882 adult non-traumatic OHCA cases with VF or VT as first known rhythms; mean (±SD) age was 60 ± 15 years, 71% male, bystander witnessed 56%, bystander resuscitation attempt 43%, public arrest location 26%, EMS response time 4.7 ± 2.3 min, 26.9% (237) had ROSC in the field, 14.9% (131) survived to hospital discharge; 93.4% (824) of all patients were shocked, while 6.6% (58) were not shocked. Of the 6.6% (58) who were not shocked, 12.1% (7) achieved ROSC in the field and 8.6% (5) survived to hospital discharge. For those not shocked in the field, the unadjusted and adjusted odds ratios for ROSC were 0.354 (95% CI 0.158-0.791, p=0.011) and 0.189 (95% CI 0.039-0.911, p=0.038), respectively; and for survival to hospital discharge they were 0.522 (95% CI 0.205-1.331, p=0.173) and 0.498 (95% CI 0.088-2.810, p=0.430), respectively. Conclusions: In the DFW ROC site, 6.6% of OHCA victims with an initially shockable rhythm did not receive a shock, which was significantly associated with decreased ROSC in the field. More patients survived who were shocked in the field, but this difference was not significant after adjustment for Utstein variables.

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Abstract 418: Categorization of Post-Cardiac Arrest Patients According to the Pattern of Amplitude-Integrated Electroencephalography After Return of Spontaneous Circulation: Analysis of Long-Term Prognosis

Circulation ◽

10.1161/circ.140.suppl_2.418 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Kazuhiro Sugiyama ◽

Kazuki Miyazaki ◽

Yuichi Hamabe

Keyword(s):

Cardiac Arrest ◽

Hospital Discharge ◽

Spontaneous Circulation ◽

Neurological Function ◽

Temperature Management ◽

Return Of Spontaneous Circulation ◽

Good Outcome ◽

Long Term Prognosis ◽

One Year

Introduction: Amplitude-integrated electroencephalography (aEEG) is a type of quantitative EEG easily interpreted by emergency physicians and intensivists at the bedside. We previously reported that categorizing post-cardiac arrest patients according to the pattern of aEEG, after return of spontaneous circulation (ROSC), could help predict the neurological function at hospital discharge (Critical Care. 2018;20:226). In post-cardiac arrest patients, increasing importance is being placed on long-term prognosis. In this study we evaluated the neurological outcome of patients in each category from our previous study, one year after cardiac arrest. Methods: We assessed the outcomes of patients who received post-cardiac arrest care, including targeted temperature management (TTM) and aEEG monitoring, in our tertiary emergency center, between March 2013 and April 2017. The patients were divided into four categories: C1 included those who displayed continuous normal voltage (CNV), within 12 hours of ROSC, and the best aEEG pattern in post-cardiac arrest patients; C2 included those who recovered CNV between 12 and 36 hours after ROSC; C3 included those with no CNV up to 36 hours after ROSC; and C4 included those who revealed burst suppression any time after ROSC. A good outcome was defined as a cerebral performance category (CPC) of 1 or 2, one year after cardiac arrest. Results: A total of 60 patients, with a median age of 60 years, were assessed; of them, 41 (68%) had an initial shockable rhythm. A good outcome was recorded in 18/19 (95%) C1 patients, 8/14 (57%) C2 patients, 1/10 (10%) C3 patients, and 0/14 C4 patients. Three patients could not be categorized because the recording period was too short. Conclusion: The categorization of post-cardiac arrest patients according to the pattern of aEEG after ROSC may be useful to predict long-term neurological function. C1 patients had excellent prognosis, while C3 and C4 patients had poor prognosis. However, one patient in the C3 group had CPC 3 at hospital discharge and then recovered to CPC 2 within one year. Withdrawal of care should be considered cautiously, using a multimodal approach, for patients in this category. C2 patients have borderline prognosis and are targets for intensive post-cardiac neurological care.

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Abstract 10559: Association of Intra-Arrest Transport versus Continued On-scene Resuscitation with Survival to Hospital Discharge Among Pediatric Patients with Out-of-Hospital Cardiac Arrest

Circulation ◽

10.1161/circ.144.suppl_2.10559 ◽

2021 ◽

Vol 144 (Suppl_2) ◽

Author(s):

Masashi Okubo ◽

Sho Komukai ◽

Junichi Izawa ◽

Ian Drennan ◽

Brian Grunau ◽

...

Keyword(s):

Cardiac Arrest ◽

Hospital Discharge ◽

Pediatric Patients ◽

Secondary Analysis ◽

Spontaneous Circulation ◽

Time Dependent ◽

Matched Cohort ◽

Return Of Spontaneous Circulation ◽

Patient Demographics ◽

Hospital Cardiac Arrest

Introduction: For pediatric patients with out-of-hospital cardiac arrest (OHCA) who do not achieve return of spontaneous circulation (ROSC), it remains unclear whether patients should be transported to a hospital with ongoing resuscitation or remain on-scene for further resuscitation. We therefore evaluated: (1) the association between intra-arrest transport, with reference to continued on-scene resuscitation, and survival to hospital discharge; and, (2) whether the association differs across the timing of intra-arrest transport. Methods: We conducted a secondary analysis of the Resuscitation Outcomes Consortium Epidemiologic Registry. We included pediatrics (<18 years) with emergency medical services (EMS)-treated OHCA between 2005 and 2015. Our exposure of interest was intra-arrest transport, defined as transport to a hospital prior to ROSC. Patients who had intra-arrest transport at any minute after EMS arrival underwent risk-set matching with patients who had continued on-scene resuscitation within the same minute using time-dependent propensity score calculated from patient demographics, arrest characteristics, and EMS interventions. We repeated the main analysis with 5-minute strata by the time of matching. Results: Of 2,854 included patients, the median age was 1 year (IQR, 0-9), 59.3% were male, 9.8% were public location, 22.1% were bystander witnessed, 6.0% had initial shockable rhythms, and 66.3% underwent intra-arrest transport at a median of 15 minutes (IQR 9-22) after EMS arrival. In the propensity-matched cohort including 2,080 patients, 5.5 % (57/1040) in intra-arrest transport group and 5.9% (61/1040) in continued on-scene resuscitation group had survival to hospital discharge (risk ratio [RR]=0.94, 95% CI 0.65-1.37). We did not detect an association within the time-based strata: 0-5 minutes (RR=0.74, 95% CI 0.19-2.85), 5-10 minutes (RR=0.52, 95% CI 0.23-1.16), 10-15 minutes (RR=1.13, 95% CI 0.58-2.22), 15-20 minutes, (RR=1.70, 95% CI 0.78-3.71), or >20 minutes (RR=0.73, 95% CI 0.32-1.63) after EMS arrival. Conclusions: Among pediatric patients with OHCA, intra-arrest transport was not associated with survival to hospital discharge. The findings persisted across the timing of intra-arrest transport.

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Clinical case review: out-of-hospital cardiac arrest following thyroid storm

Journal of Paramedic Practice ◽

10.12968/jpar.2021.13.4.144 ◽

2021 ◽

Vol 13 (4) ◽

pp. 144-150

Author(s):

Matthew Hale ◽

Jo Mildenhall ◽

Christopher Hook ◽

James Burt

Keyword(s):

Cardiac Arrest ◽

Ventricular Fibrillation ◽

Hospital Discharge ◽

Clinical Case ◽

Spontaneous Circulation ◽

Thyroid Storm ◽

Case Review ◽

Return Of Spontaneous Circulation ◽

Good Outcome ◽

Hospital Cardiac Arrest

Acute thyrotoxicosis (thyroid storm) caused by hyperthyroidism is a rare but severe endocrine imbalance which, in extreme cases, may lead to ventricular fibrillation and ultimately, without intervention, death. The authors attended such an incident and, following clinical interventions, achieved return of spontaneous circulation with a good outcome for the patient and subsequent hospital discharge.

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Ability of neuron-specific enolase to predict survival to hospital discharge after successful cardiopulmonary resuscitation

CJEM ◽

10.1017/s1481803500013324 ◽

2006 ◽

Vol 8 (01) ◽

pp. 13-18 ◽

Cited By ~ 15

Author(s):

Johann Auer ◽

Robert Berent ◽

Thomas Weber ◽

Michael Porodko ◽

Gudrun Lamm ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Hospital Discharge ◽

Time Course ◽

Clinical Decision Making ◽

Neuron Specific Enolase ◽

High Specificity ◽

Spontaneous Circulation ◽

Return Of Spontaneous Circulation ◽

Prediction Of Survival

ABSTRACT Background: Accurate prediction of survival to hospital discharge in patients who achieve return of spontaneous circulation after cardiopulmonary resuscitation (CPR) has significant ethical and socioeconomic implications. We investigated the prognostic performance of serum neuron-specific enolase (NSE), a biochemical marker of ischemic brain injury, after successful CPR. Methods: In-hospital or out-of-hospital patients with nontraumatic normothermic cardiac arrest who achieved return of spontaneous circulation (ROSC) following at least 5 minutes of CPR were eligible. Neuron-specific enolase levels were assessed immediately, 6 hours, 12 hours and 2 days after ROSC. Subjects were followed to death or hospital discharge. Results: Seventeen patients (7 men, 10 women) were enrolled during a 1-year period. Median (range) NSE levels in survivors and non-survivors respectively were as follows: immediately after ROSC: 14.0 μg/L (9.1–51.4 μg/L) versus 25.9 μg/L (10.2–57.5 μg/L); 6 hours after ROSC: 15.2 μg/L (9.7–30.8 μg/L) versus 25.6 μg/L (12.7–38.2 μg/L); 12 hours after ROSC: 14.0 μg/L (8.6–32.4 μg/L) versus 28.5 μg/L (11.0–50.7 μg/L); and 48 hours after ROSC: 13.1 μg/L (7.8–29.5 μg/L) versus 52.0 μg/L (29.1–254.0 μg/L). Non-survivors had significantly higher NSE levels 48 hours after ROSC than surivors (p = 0.04) and showed a trend toward higher values during the entire time course following ROSC. An NSE concentration of >30 μg/L 48 hours after ROSC predicted death with a high specificity (100%: 95% confidence interval [CI] 85%–100%), and a level of 29 μg/L or less at 48 hours predicted survival with a high specificity (100%: 95% CI 83%–100%). Conclusions: Serum NSE levels may have clinical utility for the prediction of survival to hospital discharge in patients after ROSC following CPR over 5 minutes in duration. This study is small, and our results are limited by wide confidence intervals. Further research on ability of NSE to facilitate prediction and clinical decision-making after cardiac arrest is warranted.

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Incidence, Mechanism, and Outcomes of On‐Plane Versus Off‐Plane Cardiac Arrest in Air Travelers

Journal of the American Heart Association ◽

10.1161/jaha.120.021360 ◽

2021 ◽

Vol 10 (18) ◽

Author(s):

Neal A. Chatterjee ◽

Kosuke Kume ◽

Christopher Drucker ◽

Peter J. Kudenchuk ◽

Thomas D. Rea

Keyword(s):

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Hospital Discharge ◽

The United States ◽

Spontaneous Circulation ◽

Air Travel ◽

Common Mechanism ◽

Study Cohort ◽

Automated External Defibrillators ◽

Return Of Spontaneous Circulation

Background Air travel affords an opportunity to evaluate resuscitation performance and outcome in a setting where automated external defibrillators (AEDs) are readily available. Methods and Results The study cohort included people aged ≥18 years with out of hospital cardiac arrest (OHCA) traveling through Seattle‐Tacoma International Airport between January 1, 2004 and December 31, 2019 treated by emergency medical services (EMS). The primary outcomes were pre‐EMS therapies (cardiopulmonary resuscitation, application of AED), return of spontaneous circulation, and survival to hospital discharge. Over the 16‐year study period, there were 143 OHCA occurring before EMS arrival, 34 (24%) on‐plane and 109 (76%) off‐plane. Cardiac etiology (81%) was the most common mechanism of arrest. The majority of arrests were bystander‐witnessed and presented with a shockable rhythm; these characteristics were more common in off‐plane OHCA compared with on‐plane (witnessed: 89% versus 74% and shockable: 72% versus 50%). Pre‐EMS therapies including cardiopulmonary resuscitation and AED application were common regardless of arrest location. Compared with on‐plane OHCA, off‐plane OHCA was associated with greater rates of return of spontaneous circulation (68% versus 44%) and 3‐fold higher rate of survival to hospital discharge (44% versus 15%). All survivors of on‐plane OHCA had AED application with defibrillation before EMS arrival. Conclusions When applied to air travel volumes, we estimate 350 air travel‐associated OHCA occur in the United States and 2000 OHCA worldwide each year, nearly a quarter of which happen on‐plane. These events are survivable when early arrest interventions including rapid arrest recognition, AED application, and CPR are deployed.

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Improved neurologic outcomes after cardiac arrest with combined administration of vasopressin, steroids, and epinephrine compared to epinephrine alone

CJEM ◽

10.2310/8000.2014.141394 ◽

2015 ◽

Vol 17 (2) ◽

pp. 202-205 ◽

Cited By ~ 1

Author(s):

Tudor Botnaru ◽

Tawfeeq Altherwi ◽

Jerrald Dankoff

Keyword(s):

Cardiac Arrest ◽

Hospital Discharge ◽

Spontaneous Circulation ◽

Neurologic Outcome ◽

Clinical Question ◽

Return Of Spontaneous Circulation ◽

Neurologic Outcomes ◽

Combined Administration ◽

Hydrocortisone Administration ◽

Hospital Cardiac Arrest

Clinical questionIs a vasopressin, steroid, and epinephrine (VSE) protocol for in-hospital cardiac arrest resuscitation associated with better survival to hospital discharge with favourable neurologic outcome compared to epinephrine alone?Article chosenMentzelopoulos S, Malachias S, Konstantopoulos D, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA 2013;310:270-9.ObjectiveTo determine if a VSE protocol during cardiopulmonary resuscitation with hydrocortisone administration in patients with postresuscitative shock at 4 hours after return of spontaneous circulation would improve survival to hospital discharge with favourable neurologic outcome.

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Abstract 124: Chest Compression Pause Duration is Associated with Worse Survival Outcomes Following Pediatric In-hospital Cardiac Arrest

Circulation ◽

10.1161/circ.142.suppl_4.124 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

Kasper Glerup Lauridsen ◽

Ryan W Morgan ◽

Robert A Berg ◽

Dana E Niles ◽

Monica E Kleinman ◽

...

Keyword(s):

Cardiac Arrest ◽

Hospital Discharge ◽

Neurological Outcome ◽

Pause Duration ◽

Spontaneous Circulation ◽

Survival Outcomes ◽

Lower Odds ◽

Return Of Spontaneous Circulation ◽

Favorable Neurological Outcome ◽

Hospital Cardiac Arrest

Introduction: The association between chest compression (CC) pause duration and pediatric in-hospital cardiac arrest (IHCA) survival outcomes is unknown. We hypothesized that longer maximum CC pause durations are associated with worse survival and neurological outcomes. Methods: Cohort study of all index pediatric IHCAs (<18 years of age) ≥1 min in the Pediatric Resuscitation Quality (PediRES-Q) Network from July 2015 through December 2019. We used multivariate logistic regression with mixed effects and robust standard errors to analyze association of 5-sec increments of longest CC pause duration with survival and neurologic outcomes. Favorable neurological outcome was defined as Pediatric Cerebral Performance Category (PCPC) at discharge ≤3 or no change from baseline. Results: We identified 371 index IHCAs: median [Q1,Q3] age 2.6 [0.6,9.4] years, female 46%, shockable rhythm 13%, CPR duration 23 [9,47] min. Median length of the longest pause was 17 [8,27] sec. Each 5 sec increase in longest CC pause duration was associated with 6% lower odds for survival with favorable neurological outcome, even after adjusting for age, defibrillation, intubation, extracorporeal CPR, illness category, hypotension as etiology for arrest, CC depth, and clustering by site (aOR 0.94 [95% CI:0.88-0.99], p=0.04). Analyses controlling for the same factors demonstrated an association of longest pause duration with lower odds for survival to hospital discharge (aOR 0.94 [95% CI: 0.90-0.99, p=0.02) and return of spontaneous circulation (aOR 0.91 [(95% CI: 0.86-0.96], p=0.001). Conclusions: Longest CC pause duration is associated with favorable neurological outcome, survival to hospital discharge, and return of spontaneous circulation following pediatric IHCA, even when controlling for known confounders and clustering by site. Each 5 sec. increment in longest CC pause duration was associated with 6% lower odds for survival with favorable neurological outcome.

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A Six-Year Prospective Study of Out-of-Hospital Cardiac Arrest Managed by a Voluntary Ambulance Organisation

Hong Kong Journal of Emergency Medicine ◽

10.1177/102490790501200303 ◽

2005 ◽

Vol 12 (3) ◽

pp. 140-147 ◽

Cited By ~ 6

Author(s):

CH Chung ◽

PCY Wong

Keyword(s):

Cardiac Arrest ◽

Hong Kong ◽

Prospective Study ◽

Hospital Discharge ◽

Pulseless Electrical Activity ◽

Spontaneous Circulation ◽

Ambulance Service ◽

Service Improvement ◽

Return Of Spontaneous Circulation ◽

At Home

Objective To obtain a database on the epidemiology of prehospital cardiac arrest and its management by a voluntary ambulance service, with the view for developing future strategies and service improvement. Design A 6-year prospective study from December 1998 to November 2004, using the Utstein-style template. Setting A voluntary ambulance service in Hong Kong. Subjects and methods Ambulance members had to complete and submit a specially designed data form after managing a cardiac arrest case, together with the ambulance run record and the automated external defibrillator (AED) computer printout, if appropriate. Main outcome measures Survival to hospital discharge and return of spontaneous circulation after resuscitation. Results A total of 72 cardiac arrests occurred during the period, with patients' age ranging from 29 to 106 years (mean 73.4). Most cardiac arrests occurred at home (46 or 63.9%). There were 58 witnessed cardiac arrests (80.5%), but bystander cardiopulmonary resuscitation (CPR) was started in only nine cases (15.5%) before the arrival of the ambulance crew. Six patients had evidence of rigor mortis or dependent lividity on ambulance arrival. For the 61 patients with electrocardiogram strips, the initial presenting rhythm on the AED was asystole in 45 (73.8%), pulseless electrical activity in 5 (8.2%), and ventricular fibrillation (VF) in 11 (18.0%). The median call-to-arrival time for VF cases (4.0 minutes) was significantly shorter than that of non-VF rhythms (8.5 minutes) [Mann-Whitney U test p=0.008]. Five patients had return of spontaneous circulation after resuscitation, but only one survived to hospital discharge. Conclusions Bystander CPR and ambulance response time are two areas requiring urgent improvement in our locality. As the majority of cardiac arrests occurred at home, the cost-effectiveness of public access defibrillation for Hong Kong is unclear. However, strategic placement of AED at high incidence' locations should be seriously considered.

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