Neurological outcomes in patients transported to hospital without a prehospital return of spontaneous circulation after cardiac arrest

Abstract

IntroductionAs emergency medical services (EMS) personnel in Japan are not allowed to perform termination of resuscitation in the field, most patients experiencing an out-of-hospital cardiac arrest (OHCA) are transported to hospitals without a prehospital return of spontaneous circulation (ROSC). As the crucial prehospital factors for outcomes are not clear in patients who had an OHCA without a prehospital ROSC, we aimed to determine the prehospital factors associated with 1-month favorable neurological outcomes (Cerebral Performance Category scale 1 or 2 (CPC 1–2)).MethodsWe analyzed the data of 398,121 adult OHCA patients without a prehospital ROSC from a prospectively recorded nationwide Utstein-style Japanese database from 2007 to 2010. The primary endpoint was 1-month CPC 1–2.ResultsThe rate of 1-month CPC 1–2 was 0.49%. Multivariate logistic regression analysis indicated that the independent variables associated with CPC 1–2 were the following nine prehospital factors: (1) initial non-asystole rhythm (ventricular fibrillation (VF): adjusted odds ratio (aOR), 9.37; 95% confidence interval (CI), 7.71 to 11.4; pulseless ventricular tachycardia (VT): aOR, 8.50; 95% CI, 5.36 to 12.9; pulseless electrical activity (PEA): aOR, 2.75; 95% CI, 2.40 to 3.15), (2) age <65 years (aOR, 3.90; 95% CI, 3.28 to 4.67), (3) arrest witnessed by EMS personnel (aOR, 2.82; 95% CI, 2.48 to 3.19), (4) call-to-hospital arrival time <24 minutes (aOR, 2.58; 95% CI, 2.22 to 3.01), (5) arrest witnessed by any layperson, (6) physician-staffed ambulance, (7) call-to-response time <5 minutes, (8) prehospital shock delivery, and (9) presumed cardiac cause. When four crucial key factors (with an aOR >2.0 in the regression model: initial non-asystole rhythm, age <65 years, EMS-witnessed arrest, and call-to-hospital arrival time <24 minutes) were present, the rates of 1-month CPC 1–2 and 1-month survival were 16.1% and 23.2% in initial VF, 8.3% and 16.7% in pulseless VT, and 3.8% and 9.4% in PEA, respectively.ConclusionsIn OHCA patients transported to hospitals without a prehospital ROSC, nine prehospital factors were significantly associated with 1-month CPC 1–2. Of those, four are crucial key factors: initial non-asystole rhythm, age <65 years, EMS-witnessed arrest, and call-to-hospital arrival time <24 minutes.

Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest

“…[24][25][26][27] However, it has become evident that the Utstein core elements incompletely explain the variability in OHCA survival across populations, [25][26][27] even allowing for the declining incidence of ventricular fibrillation in OHCA. 28,29 Since the last iteration of the Utstein style, 11 there has been increased recognition of the importance of additional factors associated with the likelihood of survival after OHCA, such as public access defibrillation, 24,30 dispatcher-assisted CPR, 31 the quality of CPR, 32,33 postresuscitation care, 34-36 variability in "not for resuscitation" order policies and procedures, 37 and accurate prognostication. 38 In addition there have been changing trends in organ recovery and transplantation.…”

Relationship Between the Duration of Cardiopulmonary Resuscitation and Favorable Neurological Outcomes After Out‐of‐Hospital Cardiac Arrest: A Prospective, Nationwide, Population‐Based Cohort Study

“…During the study period, all EMS providers performed CPR according to the 2010 Japanese CPR guidelines . Emergency lifesaving technicians, who are EMS providers, are allowed to use several resuscitation methods, including automated external defibrillators, insertion of an airway adjunct, insertion of a peripheral intravenous line, and administration of Ringer's Lactate solution . However, only specially trained emergency lifesaving technicians receiving online physician instruction are permitted to insert a tracheal tube and administer intravenous epinephrine in the field .…”

“…However, the 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care and the 2015 AHA Guidelines Update for CPR and Emergency Cardiovascular Care did not specify the appropriate duration of CPR to be conducted before out‐of‐hospital resuscitation efforts could cease . Moreover, initial shockable rhythm has been shown to be a crucial prehospital variable for predicting favorable neurological outcomes after OHCA . Therefore, we hypothesized that the appropriate duration of CPR before terminating resuscitation efforts is ≈30 minutes.…”

Overall survival and brain death frequency following out-of-hospital cardiac arrest

“…Additionally, the improved outcomes with shockable compared to nonshockable rhythms has been noted for many years. 13 Three of the 4 patients who had evidence of ST elevation or left bundle branch block were taken for emergent catheterization. Patients with evidence of ischemia were more likely to go for catheterization despite studies suggesting that postresuscitation electrocardiograms may not be reliable in determining myocardial ischemia.…”