PP10  How senior paramedics determine a futile resuscitation in pulseless electrical activity out of hospital cardiac arrest: a mixed methods study

2020 ◽  
Vol 37 (10) ◽  
pp. e6.1-e6
Author(s):  
Ali Coppola ◽  
Sarah Black ◽  
Ruth Endacott
Keyword(s):  
Decision Making ◽  
Cardiac Arrest ◽  
Electrical Activity ◽  
Pulseless Electrical Activity ◽  
Ambulance Service ◽  
Clinical Factors ◽  
Patient Demographics ◽  
System Factors ◽  
The Impact ◽  
Hospital Cardiac Arrest

BackgroundPulseless electrical activity, a non-shockable cardiac arrest, is treated using advanced life support resuscitation. When resuscitation fails, evidenced-based guidelines are limited on when to stop resuscitation. This led to one UK Ambulance Service developing a local guideline for senior paramedics to cease resuscitation when considered futile. The aim of this study was to examine clinical, patient and system factors of a futile resuscitation for pulseless electrical activity and how senior paramedics apply these factors to the decision-making process.Design and MethodsAn explanatory sequential mixed method design conducted in a single UK Ambulance Service. Cessation of resuscitation data was retrieved for all adult patients suffering an Out of Hospital Cardiac Arrest from 1st December 2015 to 31st December 2018. Cases subject to a coronial or police investigation were excluded. Senior paramedics made decisions to cease resuscitation for 50 patients at the scene and these were reviewed in detail. Interviews were conducted with six senior paramedics, who provide telephone clinical support to on-scene paramedics.ResultsThe mean patient age was 78 years, the majority were male (n=30, 60%) had a witnessed collapse (n=37, 74%) and had a PEA rate below 50 (n=46, 92%). There were no significant associations between patient demographics and clinical or system factors. Themes arising from paramedic interviews included concepts that defined futility, the impact of decision-making, conflicting views and supportive clinical decision tools.ConclusionWhilst there were no significant associations between variables, senior paramedics balanced patient survival with resuscitation futility by interpreting key factors, such as patient demographics and clinical factors. This multifactorial approach questions termination of resuscitation based on clinical factors alone. It identifies a group of PEA patients, when resuscitation is not successful, may be considered for termination of resuscitation. Research using a larger sample is warranted to explore the validity of these criteria.AcknowledgementsThe authors would like to thank Professor Jonathan Benger for his valuable input and guidance as the educational supervisor for this study. J. Lynde and H. Trebilcock for quantitative data extraction. L. Tremayne and E. Freeman, qualitative data coding. Thank you to all the paramedics who participated.

scholarly journals Cessation of Resuscitation in Pulseless Electrical Activity Out of Hospital Cardiac Arrest: A Mixed Methods Study of Senior Paramedic Decision Making

2020 ◽  
Author(s):  
Alison Coppola ◽  
Sarah Black ◽  
Ruth Endacott
Keyword(s):  
Decision Making ◽  
Cardiac Arrest ◽  
Electrical Activity ◽  
Clinical Features ◽  
Life Support ◽  
Pulseless Electrical Activity ◽  
Advanced Life Support ◽  
Patient Characteristics ◽  
System Factors ◽  
Hospital Cardiac Arrest

Abstract BackgroundPulseless electrical activity, a non-shockable cardiac arrest, is treated using advanced life support resuscitation. Typically, survival rates are poor and there is a paucity of evidenced-based guidelines for paramedics on when to cease resuscitation. This led to one UK Ambulance Service developing a local guideline to support senior paramedics when making cessation decisions. This study aimed to describe the patient characteristics, clinical features and system factors of pulseless electrical activity and explore the experiences of senior paramedics making autonomous cessation decisions. Design and MethodsAn explanatory sequential mixed method design conducted in a single UK Ambulance Service. Data was retrieved for all adult Out of Hospital Cardiac Arrest patients from 1st December 2015 to 31st December 2018. Cases subject to a coronial or police investigation were excluded. Senior paramedics ceased resuscitation for 50 PEA patients, a consecutive sample, which was reviewed in detail using descriptive statistics. Independent t-test and Chi Square examined associations between variables known to prognosticate survival. Interviews were conducted with six senior paramedics who remotely supported on-scene paramedics and findings were analysed using content framework analysis. ResultsPatient characteristics: Mean age 78 years, male (n=30, 60%), co-morbidities (n=40, 80%), witnessed collapse (n=37, 74%), bystander BLS (n=30, 60%). Clinical features: defibrillation (n=22, 44%), ROSC (n=8, 16%), heart rate< 50 (n=46, 92%), mean ETCO2 2.3kPa. System factors: Advanced life support duration 59mins. A significant association between witnessed cardiac arrest and bystander basic life support was found (95% p=.00). Themes arising from interviews were defining resuscitation futility, the impact of ceasing resuscitation, conflicting views and clinical decision tools. ConclusionSenior paramedics interpreted and applied a multifactorial approach to ceasing resuscitation for patients with PEA. Patient characteristics, clinical features and system factors were balanced using clinical judgement, found to be vital to the decision-making process. This finding questions the appropriateness of paramedics making cessation decisions based on clinical features alone. As prognostic factors for survival were present, further investigation to identify the difference between an unsuccessful or futile resuscitation is required.

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.

scholarly journals UK ambulance service resuscitation management of pulseless electrical activity: a systematic review protocol of text and opinion

2020 ◽  
Vol 5 (1) ◽  
pp. 20-25
Author(s):  
Alison Coppola ◽  
Sarah Black ◽  
Sasha Johnston ◽  
Ruth Endacott
Keyword(s):  
Systematic Review ◽  
Cardiac Arrest ◽  
Electrical Activity ◽  
Life Support ◽  
Guideline Implementation ◽  
Pulseless Electrical Activity ◽  
Ambulance Service ◽  
Synthesis Process ◽  
Reference List ◽  
Hospital Cardiac Arrest

Background: Out-of-hospital cardiac arrest patients with pulseless electrical activity are treated by paramedics using basic and advanced life support resuscitation. When resuscitation fails to achieve return of spontaneous circulation, there are limited evidence and national guidelines on when to continue or stop resuscitation. This has led to ambulance services in the United Kingdom developing local guidelines to support paramedics in the resuscitative management of pulseless electrical activity. The content of each guideline is unknown, as is any association between guideline implementation and patient survival. We aim to identify and synthesise local ambulance service guidelines to help improve the consistency of paramedic-led decision-making for the resuscitation of pulseless electrical activity in out-of-hospital cardiac arrest.Methods: A systematic review of text and opinion will be conducted on ambulance service guidelines for resuscitating adult cardiac arrest patients with pulseless electrical activity. Data will be gathered direct from the ambulance service website. The review will be guided by the methods of the Joanna Briggs Institute (JBI). The search strategy will be conducted in three stages: 1) a website search of the 14 ambulance services; 2) a search of the evidence listed in support of the guideline; and 3) an examination of the reference list of documents found in the first and second stages and reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Each document will be assessed against the inclusion criteria, and quality of evidence will be assessed using the JBI Critical Appraisal Checklist for Text and Opinion. Data will be extracted using the JBI methods of textual data extraction and a three-stage data synthesis process: 1) extraction of opinion statements; 2) categorisation of statements according to similarity of meaning; and 3) meta-synthesis of statements to create a new collection of findings. Confidence of findings will be assessed using the graded ConQual approach.

Abstract 232: Delayed Administration of Epinephrine is Associated with Worse Neurological Outcomes in Patients with Out-of-hospital Cardiac Arrest and Initial Pulseless Electrical Activity

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Nobuyuki Enzan ◽  
Ken-ichi Hiasa ◽  
Kenzo Ichimura ◽  
Masaaki Nishihara ◽  
Takeshi Iyonaga ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Electrical Activity ◽  
Odds Ratio ◽  
Primary Outcome ◽  
Pulseless Electrical Activity ◽  
Cubic Spline ◽  
Epinephrine Administration ◽  
Neurological Outcomes ◽  
The Impact ◽  
Hospital Cardiac Arrest

Background: Delayed administration of epinephrine has been proven to worsen the neurological outcomes of patients with out-of-hospital cardiac arrest (OHCA) and initial shockable rhythm. We aimed to investigate whether delayed administration of epinephrine might also worsen the neurological outcomes of patients with witnessed OHCA and initial pulseless electrical activity (PEA). Methods: The Japanese Association for Acute Medicine - out-of-hospital cardiac arrest (JAAM-OHCA) Registry is a multicenter, prospective, observational registry including 34,754 OHCA patients between 2014 and 2017. The present study assessed the impact of the time to epinephrine administration on neurological outcomes in patients with witnessed non-traumatic OHCA with initial rhythm of PEA. The primary outcome was defined as Cerebral Performance Categories (CPC) Scale 1-2 at 30 days after OHCA. The association between the odds ratio for the primary outcome and the time from witnessed OHCA to epinephrine administration was assessed with a restricted cubic spline analysis. Results: Out of 34,754 patients with OHCA, 3,050 patients with OHCA and initial PEA who received epinephrine were included in the present study. Mean age was 73.7 years and 1836 (60.2%) was male. After adjusting for potential confounders, the time from witnessed OHCA to epinephrine administration was associated with lower likelihood of favorable neurological outcomes (odds ratio [OR] 0.92; 95% confidence interval [CI] 0.89-0.96; P&lt;0.001). The restricted cubic spline analysis demonstrated that delayed epinephrine administration could decrease the likelihood of a favorable neurological outcome; this was significant within the first 10 minutes. Conclusions: Delayed administration of epinephrine was associated with worse neurological outcomes in patients with witnessed OHCA patients with initial PEA.

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.

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.

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