scholarly journals LO018: The utility of ECG characteristics as prognostic markers in pulseless electrical activity arrests: a retrospective observational cohort study

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S36-S36
Author(s):  
M. Ho ◽  
M. Gatien ◽  
C. Vaillancourt ◽  
V. Whitham ◽  
I.G. Stiell
Keyword(s):  
Electrical Activity ◽  
Pulseless Electrical Activity ◽  
Multivariate Regression Analysis ◽  
Spontaneous Circulation ◽  
Qrs Complex ◽  
P Waves ◽  
Initial Rhythm ◽  
Observational Cohort ◽  
Kappa Agreement ◽  
The Impact

Introduction: Compared to pseudo-pulseless electrical activity (PEA with myocardial contractions present), true PEA is hypothesized to carry a poorer prognosis and to show bradycardia and a wide QRS complex on ECG. Our objective was to study the predictive potential of ECG characteristics on survival to hospital discharge (SHD) for out-of-hospital cardiac arrest (OHCA) patients with PEA initial rhythm. Methods: We studied a cohort of OHCA patients prospectively enrolled between Sept. 2007 and Oct. 2009 at the Ottawa/OPALS site (13 cities, 7 EMS, and 6 Fire services) of the ROC PRIMED study. We included adult (≥ 18) non-traumatic OHCA with PEA initial rhythm where resuscitation was attempted, and for which ECG characteristics were available. We measured mean heart rate (HR), mean QRS interval, and presence of P waves (each with kappa agreement) using the first six QRS complex available. We report patient and system characteristics using descriptive statistics and determined the impact of ECG characteristics (HR, QRS width, P waves) on return of spontaneous circulation (ROSC) and SHD using multivariate regression analysis. Results: Demographics of 332 included cases were: mean age 71.7; male 58.4%; home residence 76.5%; bystander witnessed 56.3%; bystander CPR 28.5%; interval from dispatch to paramedic arrival 6min:24sec; ROSC at ED arrival 26.5%; SHD 5.4%. Survivors had higher mean HR (66.1 vs. 52.0 bpm, p=0.83; kappa=0.69) and shorter mean QRS intervals (108.3 vs. 129.6 ms, p=0.01; kappa=0.74) compared to non-survivors. Presence of p waves could not reliably be ascertained (kappa=0.35). Predictors of ROSC were: ALS paramedic on scene (AdjOR=8.90, 95%CI 1.11-71.41; p=0.04), successful intubation (AdjOR=3.35, 1.75-6.39; p=0.0002), and use of atropine (AdjOR=0.27, 0.14 - 0.50; p<0.0001). Predictors of survival were: location of arrest (AdjOR=1.49, 1.11 - 1.99; p=0.007), and use of atropine (AdjOR=0.06, 0.02-0.22; p<0.0001). Despite various cutoff explorations, ECG characteristics were not predictive of ROSC or survival in multivariate analyses. Survivors had HR as low as 6 bpm and QRS as wide as 357 ms. Conclusion: Early ECG characteristics could not predict ROSC or SHD in a population of OHCA PEA victims, and should not be used to terminate resuscitation efforts. Atropine administration was consistently associated with decreased likelihood of ROSC and survival.

Utility of prehospital electrocardiogram characteristics as prognostic markers in out-of-hospital pulseless electrical activity arrests

2017 ◽  
Vol 35 (2) ◽  
pp. 89-95 ◽  
Author(s):  
Michael L Ho ◽  
Mathieu Gatien ◽  
Christian Vaillancourt ◽  
Veronica Whitham ◽  
Ian G Stiell
Keyword(s):  
Survival Rate ◽  
Electrical Activity ◽  
Life Support ◽  
Pulseless Electrical Activity ◽  
Advanced Life Support ◽  
Multivariate Regression Analysis ◽  
Spontaneous Circulation ◽  
Successful Intubation ◽  
P Waves ◽  
Negative Predictor

BackgroundIt is unclear if there are predictors of survival, including ECG characteristics, that can guide resuscitative efforts in pulseless electrical activity (PEA) cardiac arrests. We studied the predictive potential of presenting prehospital ECGs on survival for patients with out-of-hospital cardiac arrest (OHCA) with PEA.MethodsWe studied prehospital ECGs of patients with OHCA prospectively enrolled between June 2007 and November 2009 at the Ottawa/OPALS (Ontario Prehospital Advanced Life Support Study) site of the Resuscitation Outcomes Consortium PRIMED study (Prehospital Resuscitation using an IMpedance valve and Early versus Delayed analysis). We included adult non-traumatic OHCA with PEA rhythm where resuscitation was attempted. We measured HR, QRS interval and presence of P waves, and determined their impact on return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD) using multivariate regression analysis.ResultsThe demographic characteristics of the 332 included cases were the following: mean age 71.8, male 58.4%, SHD 5.4% and ROSC at ED arrival 26.5%. Survivors had similar HR (56.8 vs 52.0 beats per minute (bpm), p=0.53) and QRS intervals (128.7 vs 129.6 ms, p=0.95) compared with non-survivors. Prehospital ECG characteristics did not predict SHD or ROSC on multivariate analyses. Patients with initial HR <30 bpm had a 3.8% survival rate; those with both HR <30 bpm and QRS≥120 ms had a 3.7% survival rate. Location of arrest predicted SHD (adjusted OR (AdjOR)=1.49, 1.11 to 1.99; p=0.007). Atropine use negatively predicted SHD (AdjOR=0.06, 0.02 to 0.22; p<0.001). Predictors of ROSC ALS paramedic on scene (AdjOR=8.90, 1.11 to 71.41; p=0.04) and successful intubation (AdjOR=3.35, 1.75 to 6.39; p<0.001). Atropine use negatively predicted ROSC (AdjOR=0.27, 0.14 to 0.50; p<0.001).ConclusionsPresenting prehospital ECG characteristics did not predict SHD or ROSC in OHCA PEA victims and should not be used to guide termination of resuscitation. Location of arrest was a positive predictor for SHD; atropine use was a negative predictor. ALS paramedic on scene and successful intubation were positive predictors of ROSC; atropine use was a negative predictor.Trial registration numberNCT00394706; post-results.

Abstract 150: Impact of Epinephrine on ECG Changes During Resuscitation From Out-of-Hospital Cardiac Arrest With Initial Pulseless Electrical Activity

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Gunnar W Skjeflo ◽  
Eirik Skogvoll ◽  
Jan Pål Loennechen ◽  
Theresa M Olasveengen ◽  
Lars Wik ◽  
...  
Keyword(s):  
Heart Rate ◽  
Cardiac Arrest ◽  
Electrical Activity ◽  
Multivariate Regression ◽  
Life Support ◽  
Controlled Trial ◽  
Pulseless Electrical Activity ◽  
Qrs Complex ◽  
Epinephrine Administration ◽  
Hospital Cardiac Arrest

Introduction: Presence of electrocardiographic rhythm, documented by the electrocardiogram (ECG), in the absence of palpable pulses defines pulseless electrical activity (PEA). Our aims were to examine the development of ECG characteristics during advanced life support (ALS) from Out-of-Hospital-Cardiac-Arrest (OHCA) with initial PEA, and to explore the effects of epinephrine on these characteristics. Methods: Patients with OHCA and initial PEA in a randomized controlled trial of ALS with or without intravenous access and medications were included. QRS widths and heart-rates were measured in recorded ECG signals during pauses in compressions. Statistical analysis was carried out by multivariate regression (MANOVA). Results: Defibrillator recordings from 170 episodes of cardiac arrest were analyzed, 4840 combined measurements of QRS complex width and heart rate were made. By the multivariate regression model both whether epinephrine was administered and whether return of spontaneous circulation (ROSC) was obtained were significantly associated with changes in QRS width and heart rate. For both control and epinephrine groups, ROSC was preceded by decreasing QRS width and increasing rate, but in the epinephrine group an increase in rate without a decrease in QRS width was associated with poor outcome (fig). Conclusion: The QRS complex characteristics are affected by epinephrine administration during ALS, but still yields valuable prognostic information.

Abstract 143: Electrocardiographic Changes Preceding In-Hospital Cardiac Arrests From Pulseless Electrical Activity / Asystole Provide Insights into Underlying Cause and Pathophysiology

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Jason J Yang ◽  
Duc H Do ◽  
Xiao Hu ◽  
Noel G Boyle
Keyword(s):  
Electrical Activity ◽  
Real Time ◽  
Tertiary Care ◽  
Pulseless Electrical Activity ◽  
Spontaneous Circulation ◽  
Care Hospital ◽  
Right Ventricular Strain ◽  
Wave Morphology ◽  
Electrocardiographic Changes ◽  
Ecg Data

Introduction: Survival from in-hospital cardiac arrests (IHCA) due to pulseless electrical activity (PEA) or asystole remains extremely poor. Our understanding of the pathophysiology of PEA is limited, and management of IHCA largely follows a “one size fits all” approach due to the lack of reliable methods to determine underlying cause in real-time. Hypothesis: Changes on continuous electrocardiogram (ECG) preceding IHCA reflect the underlying cause and pathophysiology of IHCA. Methods: We evaluated adult patients with IHCA from PEA/asystole at a tertiary care hospital between 3/2010 - 8/2014 with at least 3 hours of continuous ECG data preceding IHCA. We determined the likely cause of IHCA by reviewing of clinical, lab, imaging, and autopsy data. We analyzed up to 24 hours of continuous ECG data evaluating for changes in rhythm, PR interval, QRS and ST/T wave morphology leading up to IHCA. Results: Eighty-nine patients were studied (mean age 62 ± 18 years, 54% male). Return of spontaneous circulation was obtained in 65 (73%) and 24 (27%) survived to discharge. We found 5 distinct patterns of ECG changes leading up to and including the arrest rhythm (Table). Causes of cardiac arrest were significantly different between the group (Fischer’s exact p<0.001). Notably, a severe right ventricular strain ECG pattern was found preceding PEA caused by pulmonary embolism, asphyxia from large mucus plugs or massive aspiration, acute respiratory distress syndrome, and cardiogenic shock with biventricular failure. Conclusion: Distinct patterns of changes in rhythm and ECG morphology which reflect different underlying causes and pathophysiology of IHCA were identified. Recognition of these patterns may provide an opportunity for better understanding of PEA mechanisms and outcomes, and allow for real-time prediction of IHCA cause to help direct management.

scholarly journals How senior paramedics decide to cease resuscitation in pulseless electrical activity out of hospital cardiac arrest: a mixed methods study

2021 ◽  
Vol 29 (1) ◽  
Author(s):  
Ali Coppola ◽  
Sarah Black ◽  
Ruth Endacott
Keyword(s):  
Cardiac Arrest ◽  
Electrical Activity ◽  
Pulseless Electrical Activity ◽  
Structured Interview ◽  
Ambulance Service ◽  
Local Context ◽  
Clinical Judgement ◽  
Framework Analysis ◽  
Senior Clinician ◽  
The Impact

Abstract Background Evidenced-based guidelines on when to cease resuscitation for pulseless electrical activity are limited and support for paramedics typically defaults to the senior clinician. Senior clinicians include paramedics employed to work beyond the scope of clinical guidelines as there may be a point at which it is reasonable to cease resuscitation. To support these decisions, one ambulance service has applied a locally derived cessation of resuscitation checklist. This study aimed to describe the patient, clinical and system factors and examine senior clinician experiences when ceasing resuscitation for pulseless electrical activity. Design and methods An explanatory sequential mixed method study was conducted in one ambulance service in the South West of England. A consecutive sample of checklist data for adult pulseless electrical activity were retrieved from 1st December 2015 to 31st December 2018. Unexpected results which required exploration were identified and developed into semi-structured interview questions. A purposive sample of senior clinicians who ceased resuscitation and applied the checklist were interviewed. Content framework analysis was applied to the qualitative findings. Results Senior clinicians ceased resuscitation for 50 patients in the presence of factors known to optimise survival: Witnessed cardiac arrest (n = 37, 74%), bystander resuscitation (n = 30, 60%), defibrillation (n = 22, 44%), return of spontaneous circulation (n = 8, 16%). Significant association was found between witnessed cardiac arrest and bystander resuscitation (p = .00). Six senior clinicians were interviewed, and analysis resulted in four themes: defining resuscitation futility, the impact of ceasing resuscitation, conflicting views and clinical decision tools. In the local context, senior clinicians applied their clinical judgement to balance survivability. Multiple factors were considered as the decision to cease resuscitation was not always clear. Senior clinicians deviated from the checklist when the patient was perceived as non-survivable. Conclusion Senior clinicians applied clinical judgement to assess patients as non-survivable or when continued resuscitation was considered harmful with no patient benefit. Senior clinicians perceived pre-existing factors with duration of resuscitation and clinical factors known to optimise patient survival. Future practice could look beyond a set criteria in which to cease resuscitation, however, it would be helpful to investigate the value or threshold of factors associated with patient outcome.

QRS complex characteristics and patient outcomes in out-of-hospital pulseless electrical activity cardiac arrest

2020 ◽  
Vol 38 (1) ◽  
pp. 53-58
Author(s):  
Jung Ho Kim ◽  
Hyun Wook Ryoo ◽  
Jong-yeon Kim ◽  
Jae Yun Ahn ◽  
Sungbae Moon ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Electrical Activity ◽  
Hospital Discharge ◽  
Neurological Outcome ◽  
Prospective Observational Study ◽  
Pulseless Electrical Activity ◽  
Secondary Outcome ◽  
Qrs Complex ◽  
The Relationship ◽  
Hospital Cardiac Arrest

BackgroundPulseless 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).MethodsThis 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.ResultsOf 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.ConclusionOHCA-P outcomes were better when the initial QRS complex showed a higher amplitude or narrower width.

Abstract 19131: The Advanced Life Support Termination of Resuscitation Rule: A Local Evaluation of the Impact on Termination Rates

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Joris Nas ◽  
Judith L Bonnes ◽  
Dominique V Verhaert ◽  
Wessel Keuper ◽  
Pierre van Grunsven ◽  
...  
Keyword(s):  
Life Support ◽  
Response Times ◽  
Advanced Life Support ◽  
Spontaneous Circulation ◽  
Shock Delivery ◽  
Bystander Cardiopulmonary Resuscitation ◽  
Initial Rhythm ◽  
Bystander Cpr ◽  
The Impact ◽  
Termination Decisions

Introduction: Termination of Resuscitation (TOR) rules have been designed to guide in-field termination decisions and reduce futile hospital transportations. The impact of such a rule may depend on regional infrastructure, arrest characteristics and pre-existent termination rates. Our region is characterized by high rates of bystander cardiopulmonary resuscitation (CPR), and Advanced Life Support (ALS) trained rescuers authorized to make termination decisions. We aim to investigate the actual in-field termination rates and the termination rates as recommended by the ALS-TOR rule. Furthermore, we studied factors associated with the actual termination decisions. Methods: Cohort of out-of-hospital cardiac arrest patients who were resuscitated in the Nijmegen area, the Netherlands (2008-2011). The ALS-TOR rule recommends termination in case all following criteria are met: unwitnessed arrest, no bystander CPR, no shock delivery, no return of spontaneous circulation (ROSC). Results: The observed percentage of in-field termination was 46% (275/598), while the ALS-TOR rule recommended termination in only 6% (35/588), owing to high percentages of witnessed arrests (73%) and bystander CPR (54%) in our region. Factors independently associated with the actual decisions to terminate resuscitation were absence of ROSC [aOR 35.6 (95% CI 18.3-69.3)], non-shockable initial rhythm [aOR 6.0 (95% CI 3.2-11.0)], unwitnessed arrest [aOR 2.7 (95% CI 1.4-5.2)], non-public arrest [aOR 2.5 (95% CI 1.2-5.0)] and longer EMS-response times [aOR 1.1 per minute increase (95% CI 1.0-1.2)]. Conclusions: Contrary to previous studies, implementation of the ALS-TOR rule in our region would have decreased termination rates from almost half to less than 10% due to the favourable arrest characteristics. In light of the prognosis after OHCA, this finding suggests that adherence to this set of criteria does not contribute to efficient triage in our population. Therefore it seems prudent to locally evaluate the utility of the ALS-TOR rule prior to implementation.

P4167Non-shockable rhythm related sudden cardiac arrest in the community

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
A Sharifzadehgan ◽  
J Rischard ◽  
W Bougouin ◽  
F Dumas ◽  
V Waldmann ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Heart Disease ◽  
Sudden Cardiac Arrest ◽  
Pulseless Electrical Activity ◽  
Structural Heart Disease ◽  
Population Based ◽  
Spontaneous Circulation ◽  
Coronary Syndrome ◽  
Shockable Rhythm ◽  
Initial Rhythm

Abstract Introduction A significant increase in the prevalence of sudden cardiac arrest (SCA) with non-shockable rhythm has been reported, related to asystole and pulseless electrical activity (PEA). Factors associated with non-shockable rhythm and the mode to the return of spontaneous circulation (ROSC) may help for a better understanding. Purpose We aimed to describe the frequency, characteristics and outcome of SCA related to non-shockable versus shockable rhythm in the community. Methods In this prospective ongoing, multicentre population-based registry (6.7 million inhabitants), data from all SCA over a 5-year period were analyzed. Initial rhythm was obtained from the EMS report and the initial recorded rhythm strip when available. Medical records for each SCA were reviewed by cardiologists to identify underlying aetiology and associated conditions. Results Among the 3,028 SCAs admitted alive out of a total of 18,622 out-of-hospital cardiac arrests from May 2011 to May 2016, 2,904 patients had available information regarding initial rhythm at the time of EMS arrival. Among them, 1,314 patients (45.3%) presented with non-shockable rhythm: 1,109 (38.2%) cases with asystole, 197 (6.8%) with PEA and 8 (0.3%) with high degree atrioventricular block. Cases with non-shockable rhythm were older (60.6 vs. 57.4 years, P<0.001), with greater proportion of females (34.9 vs. 19.2%, P<0.001) and less proportion of family history of coronary artery disease or SCA. Proportion of warning symptoms prior to the SCA was higher among patients with non-shockable rhythm (74.3 vs. 64.9%, P<0.001) but the proportion of chest pain was lower (24.0 vs. 43.3%, P<0.001). Survival rate was much lower in non-shockable rhythm cases (7.2 vs. 42.3%, P<0.001). Among the 1,314 non-shockable cases eventually admitted alive to hospital, 1,022 (77.8%) did not require external defibrillation prior to ROSC, and a majority (91.7%) received adrenaline during resuscitation. In this subgroup, the main identified cardiac cause was acute coronary syndrome (45.3%), followed by chronic CAD (27.1%), structural non-ischemic heart disease (22.4%), and non-structural heart disease (5.2%). Conclusions Initial non-shockable rhythm is encountered in almost half of SCA cases admitted alive; mostly occurs in older patients with higher proportion of females. Over three quarters of these cases did not require external defibrillation prior to ROSC.

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