Applying the termination of resuscitation rules to out-of-hospital cardiac arrests of both cardiac and non-cardiac etiologies: a prospective cohort study

Abstract

BackgroundThe 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation recommend Basic Life Support (BLS) and Advanced Life Support (ALS) rules for termination of resuscitation (TOR). However, it is unclear whether the TOR rules are valid for out-of-hospital cardiac arrests (OHCAs) of both cardiac and non-cardiac etiologies. In this study, we validated the TOR rules for OHCA resulting from both etiologies.MethodsThis was a prospective multicenter observational study of OHCA patients transported to 67 emergency hospitals between January 2012 and March 2013 in the Kanto region of Japan. We calculated the specificity and positive predictive value (PPV) for neurologically unfavorable outcomes at one month in patients with OHCA of cardiac and non-cardiac etiologies.ResultsOf 11,505 eligible cases, 6,138 and 5,367 cases were of cardiac and non-cardiac etiology, respectively. BLS was performed on 2,818 and 2,606 patients with OHCA of cardiac and non-cardiac etiology, respectively. ALS was performed on 3,320 and 2,761 patients with OHCA of cardiac and non-cardiac etiology, respectively. The diagnostic accuracy of the TOR rules for predicting unfavorable outcomes in patients with OHCA of cardiac etiology who received BLS included a specificity of 0.985 (95 % confidence interval [CI]: 0.956–0.997) and a PPV of 0.999 (95 % CI: 0.996–1.000). In patients with OHCA from cardiac etiologies who received ALS, the TOR rules had a specificity of 0.963 (95 % CI: 0.896–0.992) and a PPV of 0.997 (95 % CI: 0.991–0.999). In patients with OHCA from non-cardiac etiologies who received BLS, the specificity was 0.915 (95 % CI: 0.796–0.976) and PPV was 0.998 (95 % CI: 0.995–0.999). For patients with OHCA from non-cardiac etiologies who received ALS, the specificity was 0.833 (95 % CI: 0.586–0.964) and PPV was 0.996 (95 % CI: 0.988–0.999).ConclusionsBoth TOR rules have high specificity and PPV in patients with OHCA from cardiac etiologies. For patients with OHCA from non-cardiac etiologies, the rules had a high PPV, but relatively low specificity. Therefore, TOR rules are useful in patients with OHCA from cardiac etiologies, but should be applied with caution to patients with OHCA from non-cardiac etiologies.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1226-4) contains supplementary material, which is available to authorized users.

Should we resuscitate or not—that is the question!

“…This may be particularly important for patients transported to a hospital with prolonged and ongoing CPR during transport (17). No such data are reported in the study by Kashiura et al (13).…”

“…In a prospective multi-center observational study (SOS Kanto 2012) of OHCA patients transported to 67 emergency hospitals between January 2012 and March 2013 in the Kanto region of Japan, the BLS and ALS TOR rules for OHCA resulting from both cardiac and non-cardiac etiologies were again validated (13). Ambulance crews included three EMS providers, with at least one emergency lifesaving technician (ELST) as the highest qualification capable of performing standard ALS interventions.…”

“…For example, concerns about airway management in Japanese EMS exist (14), and outcome associated with out-ofhospital OHCA resuscitation by non-physicians appears to be inferior to physician-directed CPR (15). It is also important to note that Kashiura et al (13) did not assess the use of the BLS TOR as "universal" TOR rule in patients who received ALS measures. It is thus impossible to draw conclusions on the validity of this universal TOR rule based on this study.…”

Mechanical Cardiopulmonary Resuscitation and Hospital Survival Among Adult Patients With Nontraumatic Out‐of‐Hospital Cardiac Arrest Attending the Emergency Department: A Prospective, Multicenter, Observational Study in Japan (SOS‐KANTO [Survey of Survivors after Out‐of‐Hospital Cardiac Arrest in Kanto Area] 2012 Study)

“…A total of 16 452 patients with OHCA who were transported to 67 emergency hospitals by EMS personnel were included in this prospective, multicenter, observational study 11, 12, 13, 14, 15, 16. In this study, patients treated with mCPR devices during advanced cardiovascular life support in the ED were compared with patients who received manual CPR alone.…”

“…The data collection of this study has been reported previously 11, 12, 13, 14, 15, 16. The prehospital information was collected by EMS providers.…”