Unsuccessful Emergency Medical Resuscitation — Are Continued Efforts in the Emergency Department Justified?

Gray, William A.; Capone, Robert J.; Most, Albert S.

doi:10.1056/nejm199111143252001

Cited by 251 publications

(86 citation statements)

References 30 publications

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“…The need for protracted high-intensity care of neurologically devastated survivors presents an immense burden to healthcare systems, patients' families, and society in general. 251,252 To limit this burden, clinical factors and diagnostic tests are used to prognosticate functional outcome. With the limitation of care or withdrawal of life-sustaining therapies as a likely outcome of prognostication, studies have focused on poor long-term prognosis (vegetative state or death) based on clinical or test findings that indicate irreversible brain injury.…”

Section: Post-cardiac Arrest Prognosticationmentioning

confidence: 99%

Post–Cardiac Arrest Syndrome

Neumar¹,

Nolan²,

Adrie³

et al. 2008

Circulation

1,249

398

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Section: Post-cardiac Arrest Prognosticationmentioning

confidence: 99%

Post–Cardiac Arrest Syndrome

Neumar¹,

Nolan²,

Adrie³

et al. 2008

Circulation

1,249

398

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“…Protracted hospitalization for post‐OHCA patients, the majority of whom will not survive with meaningful neurologic recovery, carries considerable ethical and economic implications 16, 17. Multiple models have previously been developed with the goal of earlier outcome stratification,18, 19, 20, 21 yet all are significantly limited by invalidity in TTM populations and/or weighting toward historically unreliable arrest timing variables (eg, time to return of spontaneous circulation [ROSC]) 22.…”

Section: Introductionmentioning

confidence: 99%

C‐GRApH : A Validated Scoring System for Early Stratification of Neurologic Outcome After Out‐of‐Hospital Cardiac Arrest Treated With Targeted Temperature Management

Kiehl

Parker

Matar

et al. 2017

JAHA

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BackgroundOut‐of‐hospital cardiac arrest (OHCA) results in significant morbidity and mortality, primarily from neurologic injury. Predicting neurologic outcome early post‐OHCA remains difficult in patients receiving targeted temperature management.Methods and ResultsRetrospective analysis was performed on consecutive OHCA patients receiving targeted temperature management (32–34°C) for 24 hours at a tertiary‐care center from 2008 to 2012 (development cohort, n=122). The primary outcome was favorable neurologic outcome at hospital discharge, defined as cerebral performance category 1 to 2 (poor 3–5). Patient demographics, pre‐OHCA diagnoses, and initial laboratory studies post‐resuscitation were compared between favorable and poor neurologic outcomes with multivariable logistic regression used to develop a simple scoring system (C‐GRApH). The C‐GRApH score ranges 0 to 5 using equally weighted variables: (C): coronary artery disease, known pre‐OHCA; (G): glucose ≥200 mg/dL; (R): rhythm of arrest not ventricular tachycardia/fibrillation; (A): age >45; (pH): arterial pH ≤7.0. A validation cohort (n=344) included subsequent patients from the initial site (n=72) and an external quaternary‐care health system (n=272) from 2012 to 2014. The c‐statistic for predicting neurologic outcome was 0.82 (0.74–0.90, P<0.001) in the development cohort and 0.81 (0.76–0.87, P<0.001) in the validation cohort. When subdivided by C‐GRApH score, similar rates of favorable neurologic outcome were seen in both cohorts, 70% each for low (0–1, n=60), 22% versus 19% for medium (2–3, n=307), and 0% versus 2% for high (4–5, n=99) C‐GRApH scores in the development and validation cohorts, respectively.Conclusions C‐GRApH stratifies neurologic outcomes following OHCA in patients receiving targeted temperature management (32–34°C) using objective data available at hospital presentation, identifying patient subsets with disproportionally favorable (C‐GRApH ≤1) and poor (C‐GRApH ≥4) prognoses.

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“…Studies have shown that except in extremely rare situations, resuscitation in these patients is futile. 10,11 In the age group over 70 years, only one of our patients survived out of 23 cardiac arrests and he was discharged to his local hospital in a persistent vegetative state. None survived to discharge in 77 elderly hospital patients reviewed by Taffet 12 in 1988.…”

Section: Discussionmentioning

confidence: 88%

“…At the same time, it is becoming clear that a blanket policy for the provision of CPR for all patients may not be appropriate and that a more flexible approach may be justified. It is becoming clear that certain groups of patients should not be resuscitated, such as those patients brought into the Emergency Department after failed resuscitation in the community, 11 or those with metastatic cancer. 17 It may be reasonable for some groups of patients to be subjected to modified resuscitation, e.g., defibrillation, only in the case of a witnessed cardiac arrest in a hospitalized, debilitated, elderly patient.…”

Section: Discussionmentioning

confidence: 99%