Abstract 234: Validation of a Termination-of-resuscitation Rule for Patients with Refractory Out-of-hospital Cardiac Arrest at an Emergency Department in Japan

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Akira Funada ◽  
Yoshikazu Goto ◽  
Masayuki Takamura
Keyword(s):  
Emergency Department ◽  
Cardiac Arrest ◽  
Medical Service ◽  
Basic Life Support ◽  
Life Support ◽  
High Specificity ◽  
Spontaneous Circulation ◽  
Return Of Spontaneous Circulation ◽  
Using Data ◽  
Hospital Cardiac Arrest

Introduction: In Japan, emergency medical service (EMS) providers are prohibited from cardiopulmonary resuscitation (CPR) termination in the field and must transport all out-of-hospital cardiac arrest (OHCA) patients to a hospital, regardless of the return of spontaneous circulation (ROSC). We previously developed a termination of resuscitation (TOR) rule for emergency department physicians (ED-TOR) treating OHCA patients using data from the All-Japan Utstein Registry between 2005 and 2009, when CPR was performed according to the 2005 guidelines. The ED-TOR rule recommends CPR termination when patients in the emergency department meet all of the following criteria: initial unshockable rhythm, arrest unwitnessed by bystanders and no prehospital ROSC. Hypothesis: We aimed to validate the ED-TOR rule using more recent data, where CPR was performed according to the 2010 and 2015 guidelines, comparing the relevance of the ED-TOR rule with the universal basic life support TOR (BLS-TOR) rule, which consists of the following criteria: no prehospital ROSC, unwitnessed arrest by EMS providers and no shock received. Methods: We analysed 552,554 OHCA patients (age ≥ 18 years) treated by EMS providers. OHCA patients witnessed by EMS providers were excluded. Data were obtained from a prospectively recorded All-Japan Utstein Registry from 2013 to 2017. The study endpoints were specificity and a positive predictive value (PPV) for predicting 1-month mortality after OHCA with the ED-TOR and BLS-TOR rules. Results: The overall 1-month survival rate was 4.3% (23,733/552,554). The proportions of OHCA patients who fulfilled the ED-TOR and BLS-TOR criteria were 59.6% and 83.8%, respectively. The specificity and PPV of the ED-TOR and BLS-TOR rules for predicting 1-month mortality were 93.2% (95% confidence interval [CI], 92.8%-93.5%) and 99.5% (95% CI, 99.5%-99.5%) and 82.6% (95% CI, 82.1%-83.1%) and 99.1% (95% CI, 99.1%-99.1%), respectively. Conclusions: The ED-TOR rule was successfully validated using more recent data from a Japanese registry where CPR was performed according to the 2010 and 2015 guidelines. The ED-TOR rule was slightly superior to the BLS-TOR rule in Japanese EMS systems showing high specificity and PPV for predicting 1-month mortality.

P498External validation of a field termination-of-resuscitation rule for refractory out-of-hospital cardiac arrests in Japan

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
Y Goto ◽  
A Funada ◽  
T Maeda ◽  
F Okada ◽  
Y Goto
Keyword(s):  
Medical Service ◽  
Basic Life Support ◽  
Life Support ◽  
High Specificity ◽  
Spontaneous Circulation ◽  
Return Of Spontaneous Circulation ◽  
Primary Endpoints ◽  
Using Data ◽  
Utstein Style ◽  
Hospital Cardiac Arrest

Abstract Background A universal basic life support termination-of-resuscitation (BLS-TOR) rule was developed to identify patients with out-of-hospital cardiac arrest (OHCA) eligible for field termination of cardiopulmonary resuscitation (CPR). In Japan, however, emergency medical service (EMS) providers are not allowed field termination of CPR and must transport all patients with OHCA to hospitals, regardless of return of spontaneous circulation (ROSC). Therefore, we previously developed a Japanese TOR (JP-TOR) rule in the field for refractory OHCAs using data from the All-Japan Utstein registry between 2011 and 2015, when CPR was performed according to the 2010 guidelines. The JP-TOR rule recommends CPR termination when patients meet all the following criteria: initial asystole, unwitnessed arrest, age ≥81 years, no bystander interventions before EMS arrival, and no ROSC after EMS-initiated CPR for 14 min. Purpose To validate the JP-TOR rule using more recent data where CPR was performed according to the 2015 guidelines, comparing the relevance of JP-TOR rule with the BLS-TOR rule, which consists of the following criteria: no prehospital ROSC after 6-min EMS-initiated CPR, arrest unwitnessed by EMS providers, and no shock received. Methods We analysed the records of 242,184 patients (age ≥18 years) who experienced OHCA treated by EMS providers. Data were obtained from a prospectively recorded Japanese nationwide Utstein-style database from 2016 to 2017. The primary endpoints were specificity and positive predictive value (PPV) for predicting the 1-month mortality after OHCA with the JP-TOR and BLS-TOR rules. Results The overall 1-month survival rate was 5.3% (12,847/242,184). The proportions of patients with OHCA fulfilled the JP-TOR and BLS-TOR criteria were 10.4% and 89.3%, respectively. The specificity and PPV of the JP-TOR and BLS-TOR rules for predicting 1-month mortality were 99.5% (95% confidence interval [CI], 99.4%–99.5%) and 99.8% (95% CI, 99.7%–99.8%) and 44.7% (95% CI, 43.8%–45.5%) and 96.7% (95% CI, 96.6%–96.8%), respectively. Conclusions The JP-TOR rule for EMS providers treating patients with OHCA in the field was successfully validated using more recent data from a Japanese registry where CPR was performed according to the 2015 guidelines. The JP-TOR rule was superior to the BLS-TOR rule in Japanese EMS systems, having both high specificity and PPV of >99% for predicting 1-month mortality. The JP-TOR rule may help EMS providers decide whether to terminate resuscitation efforts for unresuscitable patients with OHCA in the field. Prospective validation studies and establishment of prehospital EMS protocol are required before implementing this rule in Japan.

Abstract 125: "Load & Go" Criteria in Out-of-Hospital Cardiac Arrest Patients for the Use of Emergency-Extracorporal Life Support at the Emergency Department

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Michael Poppe ◽  
Andreas Schober ◽  
Christoph Weiser ◽  
Patrick Sulzgruber ◽  
Philip Datler ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Basic Life Support ◽  
Life Support ◽  
Final Analysis ◽  
Spontaneous Circulation ◽  
Emergency Physicians ◽  
Return Of Spontaneous Circulation ◽  
Utstein Style ◽  
Hospital Cardiac Arrest ◽  
Over Time

Background: The outcome of patients after OHCA has been poor. The probability of return of spontaneous circulation decreases over time. New therapeutic attempts like E-ECLS at the ED are tried to improve outcome of selected cases. The "Vienna Cardiac Arrest Registry" (VICAR) was introduced August 1, 2013 to collect Utstein-style data. Our aim was to identify those patients which might fulfill ‘load&go’ criteria for E-ECLS at the ED after OHCA. Methods: Therefore VICAR was retrospectively analysed for following criteria: age<75a;witnessed OHCA; basic life support (BLS); ventricular fibrillation/ventricular tachycardia (VF/VT); no return of spontaneous circulation (ROSC) within 15min CPR by EMS. Patients had to fulfill all these criteria. Results: Overall 701 patients were registered from August 1, 2013 to April 30, 2014. Excluded were because of poor documentation 26(4%) patients, because of missing criteria data 49(7%) and because they were younger than 18 years 7 (1%). The final analysis included 619(88%) patients; of those 68(11%) were transported under ongoing CPR to the ED. Moreover E-ECLS was applied in 15 patients at the ED. Conclusion: We found 30 (5%) patients to fulfill ’load & go’ criteria. Of 68 patients, who were transported with ongoing CPR to the ED only 8 (8%) met the criteria. Further promotion of these criteria within the ambulance crews is needed. Maybe these criteria could then serve as a decision support for emergency physicians/paramedics, which patients to transport under ongoing CPR to the ED for E-ECLS.

Pupillary Light Reflex Is Not Abolished by Epinephrine and Atropine Given During Advanced Cardiac Life Support in Patients Who Achieve Return of Spontaneous Circulation

2020 ◽  
pp. 088506662090680
Author(s):  
Natalie Achamallah ◽  
Jeffrey Fried ◽  
Rebecca Love ◽  
Yuri Matusov ◽  
Rohit Sharma
Keyword(s):  
Cardiac Arrest ◽  
Life Support ◽  
Advanced Cardiac Life Support ◽  
Spontaneous Circulation ◽  
Pupillary Light Reflex ◽  
Return Of Spontaneous Circulation ◽  
Neurologic Recovery ◽  
Light Reflex ◽  
Pupillary Light ◽  
Hospital Cardiac Arrest

Introduction: Absence of pupillary light reflex (PLR) is a well-studied indicator of poor neurologic recovery after cardiac arrest. Interpretation of absent PLR is difficult in patients with hypothermia or hypotension, or who have electrolyte or acid-base disturbances. Additionally, many studies exclude patients who receive epinephrine or atropine from their analysis on the basis that these drugs are thought to abolish the PLR. This observational cohort study assessed for presence or absence of PLR in in-hospital cardiac arrest patients who received epinephrine with or without atropine during advanced cardiac life support and achieved return of spontaneous circulation (ROSC). Methods: Pupil size and reactivity were assessed in adult patients who had an in-hospital cardiac arrest, received epinephrine with or without atropine, and achieved ROSC. Measurements were taken using a NeurOptics NPi-200 infrared pupillometer. Results: Forty patients had pupillometry performed within 1 hour (median: 6 minutes) after ROSC. Of these only 1 (2.5%) patient had nonreactive pupils at first measurement after ROSC. The remaining 39 (97.5%) had reactive pupils. Of the 19 patients who had pupils checked within 3 minutes of ROSC, 100% had reactive pupils. Degree of pupil responsiveness was not correlated with cumulative dose of epinephrine. Ten patients received atropine in addition to epinephrine, including the sole patient with nonreactive pupils. The remaining 9 (90%) had reactive pupils. Conclusion: Epinephrine and atropine do not abolish the PLR in patients who achieve ROSC after in-hospital cardiac arrest. Lack of pupillary response in the post-arrest patient should not be attributed to these drugs.

Improving Survival After In-Hospital Cardiac Arrest: The Australian Experience

2007 ◽  
Vol 16 (3) ◽  
pp. 240-247 ◽  
Author(s):  
Robyn Peters ◽  
Mary Boyde
Keyword(s):  
Cardiac Arrest ◽  
Life Support ◽  
Survival Rates ◽  
Spontaneous Circulation ◽  
High Rate ◽  
Hospital Data ◽  
Return Of Spontaneous Circulation ◽  
Shockable Rhythm ◽  
Resuscitation Training ◽  
Hospital Cardiac Arrest

Background Survival rates after in-hospital cardiac arrest have not improved markedly despite improvements in technology and resuscitation training. Objectives To investigate clinical variables that influence return of spontaneous circulation and survival to discharge after in-hospital cardiac arrest. Methods An Utstein-style resuscitation template was implemented in a 750-bed hospital. Data on 158 events were collected from January 2004 through November 2004. Significant variables were analyzed by using a multiple logistic regression model. Results Of the 158 events, 128 were confirmed cardiac arrests. Return of spontaneous circulation occurred in 69 cases (54%), and the patient survived to discharge in 41 (32%). An initial shockable rhythm was present in 42 cases (33%), with a return of spontaneous circulation in 32 (76%) and survival to discharge in 24 (57%). An initial nonshockable rhythm was present in the remaining 86 cases (67%), with a return of spontaneous circulation in 37 (43%) and survival to discharge in 17 (20%). Witnessed or monitored arrests (P=.006), time to arrival of the cardiac arrest team (P=.002), afternoon shift (P=.02), and initial shockable rhythm (P=.005) were independently associated with return of spontaneous circulation. Location of patient in a critical care area (P=.002), initial shockable rhythm (P&lt;.001), and length of resuscitation (P=.02) were independently associated with survival to hospital discharge. Conclusions The high rate of survival to discharge after cardiac arrest is attributed to extensive education and the incorporation of semiautomatic external defibrillators into basic life support management.

Out-of-hospital cardiac arrest

2021 ◽  
pp. 76-87
Author(s):  
Jerry P Nolan ◽  
Christian Hassager
Keyword(s):  
Cardiac Arrest ◽  
Basic Life Support ◽  
Life Support ◽  
Spontaneous Circulation ◽  
Neurological Injury ◽  
Shockable Rhythm ◽  
Initial Rhythm ◽  
Medical Emergencies ◽  
Hospital Cardiac Arrest

Cardiac arrest is the most extreme of medical emergencies. If the victim is to have any chance of high-quality neurological recovery, cardiac arrest must be diagnosed quickly, followed by summoning for help as basic life support (chest compressions and ventilations) is started. In most cases, the initial rhythm will be shockable, but this will have often deteriorated to a non-shockable rhythm by the time a monitor and/or defibrillator is applied. While basic life support will sustain some oxygen delivery to the heart and brain and will help to slow the rate of deterioration in these vital organs, it is important to achieve restoration of a spontaneous circulation as soon as possible (by defibrillation if the rhythm is shockable). Once return of spontaneous circulation is achieved, the quality of post-cardiac arrest management will influence the patient's final neurological and cardiological outcome. These interventions aim to restore myocardial function and minimize neurological injury.

Abstract 132: Neurological Favorable Outcome Associated With Number of Prehospital Defibrillation Attempts in Out-of-Hospital Cardiac Arrest Without Return of Spontaneous Circulation on Scene

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Seulki Choi ◽  
Tae Han Kim ◽  
Ki Jeong Hong ◽  
Sung Wook Song ◽  
Joo Jeong ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Neurological Outcome ◽  
Life Support ◽  
Discharge Rate ◽  
Spontaneous Circulation ◽  
Successful Resuscitation ◽  
Return Of Spontaneous Circulation ◽  
Hospital Transport ◽  
Favorable Neurological Outcome ◽  
Hospital Cardiac Arrest

Background: The early and timely defibrillation in shockable rhythm of out-of-hospital cardiac arrest (OHCA) by prehospital EMS providers is crucial for successful resuscitation. In emergency medical service (EMS) system, where advanced cardiac life support could not be fully provided before hospital transport, optimal range of prehospital defibrillation attempts is debatable. We evaluated association between number of prehospital defibrillation attempts and survival outcomes in OHCA patients who were unresponsive to field resuscitation and defibrillations. Methods: This is a retrospective observational study using nationwide OHCA registry of Korea from 2013 to 2016. Adult EMS treated OHCA with presumed cardiac origin with shockable initial ECG rhythm were enrolled. Final analysis was performed in patients who did not achieve return of spontaneous circulation (ROSC) on scene before hospital transport. We categorized number of prehospital defibrillation attempt into 3 groups: ≤3 attempts, 4-5 attempts and ≥6 attempts. Primary outcome was favorable neurological outcome at hospital discharge. Multivariable logistic regression modeling was used to evaluate association between neurological outcome and defibrillation attempts. Result: Total 6,679 patients were enrolled for final analyzed. Among total ≤3 defibrillations were attempted in 5015 patients (75.1%), 1050 patients (15.7%) for 4-5 attempts, 614 patient. (9.2%) for ≥6 attempts. Although survival to discharge rate was highest in group with ≤3 defibrillation attempts (8.1% vs. 7.0% vs. 2.9%, p<0.01), survival rate with favorable neurological outcome was highest in group with 4-5 defibrillation attempts (3.0% vs. 4.5% vs. 2.1%, p=0.02). As 4-5 attempts group reference, adjusted odds ratio for favorable neurological outcome of ≤3 attempts was 0.66 (95% CI 0.46 - 0.94) and of ≥6 attempts was 0.47 (95% CI 0.25 - 0.89). Conclusion: For patients with shockable initial cardiac rhythm who were unresponsive to filed defibrillation and resuscitation, moderate amount of defibrillation attempt was associated with favorable neurological outcome compared to fewer defibrillation attempts and prolonged number of defibrillation attempts on scene.

scholarly journals Initial capnography values and resuscitation outcomes of patients assisted by basic life support units in first instance; descriptive prospective study

2021 ◽  
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Work Experience ◽  
Basic Life Support ◽  
Life Support ◽  
Survival Rates ◽  
Spontaneous Circulation ◽  
Patient Treatment ◽  
Mean Values ◽  
Hospital Cardiac Arrest

Introduction: Understanding the key factors which affect out hospital cardiac arrest (OHCA) outcomes is essential in order to promote patient treatment. The main objective of this research was to describe the correlations between the capnographic values obtained during the first minute of monitoring on cardiopulmonary resuscitation, assisted by basic life-support units, with the results as return of spontaneous circulation (ROSC) and alive hospital admission. The secondary objectives were to describe the sociodemographic characteristics of the patients assisted, and to analyze any correlations between receiving basic life-support units and/or defibrillation prior to the arrival of basic life-support units, and the results of the cardiopulmonary resuscitation maneuvers. Methods: A prospective, descriptive, observational study of adult non-traumatic out hospital cardiac arrest patients was conducted. The patients were initially assisted by basic life-support units on the island of Mallorca, with one minute of initial capnography monitoring. Results: From July 2018 to March 2020, fifty-nine patients meeting the inclusion criteria were assisted, 76% were men and their mean age was 64.45 (±15.07) years old. The number of emergency lifesaving technicians who participated in the study was 58, they had a mean work experience of 14.05 (±6.7) years. Thirty-seven (63.7%) patients underwent basic life-support by bystanders and in 91.5% of cases the semi-automatic external defibrillator was used. Capnometry values during the first minute were obtained in 34 (58.6%) patients, their mean values were 22 (±19.07) mmHg, 35.5% of patients had values <10 mmHg. In 25.4% of the patients, spontaneous circulation returned during cardiopulmonary resuscitation, and 18.6% were admitted to hospital alive. Conclusion: No correlations were found between initial capnography values scoring above or below 10 mmHg and survival, however, basic life-support maneuvers, and defibrillation by bystanders and first responders, did correlate with survival rates. The average patient assisted in out of hospital cardiac arrest by the basic life-support units sampled was an adult male aged over 65 years.

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