Utility of prehospital electrocardiogram characteristics as prognostic markers in out-of-hospital pulseless electrical activity arrests

Ho, Michael L.; Gatien, Mathieu; Vaillancourt, Christian; Whitham, Veronica; Stiell, Ian G.

doi:10.1136/emermed-2017-206878

Cited by 10 publications

(4 citation statements)

References 26 publications

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“…In three OHCA studies examining PEA characteristics, of which one was published more than 25 years ago and two more recently, similar initial heart rates but narrower initial QRS widths were found when compared to the results in our study [10][11][12][13]. None of these studies have examined the dynamics of the ECG-characteristics during ongoing ALS.…”

Section: Discussionsupporting

confidence: 81%

“…Previous studies on out of hospital cardiac arrest (OHCA) have reported conflicting results regarding the association between initial heart rate and QRS width and subsequent survival. While some studies report increased survival with higher heart rates and narrower QRS complexes, others report no such association [10][11][12][13]. An animal study on post-defibrillation PEA demonstrated increased likelihood of return of spontaneous circulation (ROSC) with higher initial heart rates and narrower QRS complexes [14].…”

Section: Introductionmentioning

confidence: 99%

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ECG changes during resuscitation of patients with initial pulseless electrical activity are associated with return of spontaneous circulation

et al. 2018

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Section: Discussionsupporting

confidence: 81%

Section: Introductionmentioning

confidence: 99%

ECG changes during resuscitation of patients with initial pulseless electrical activity are associated with return of spontaneous circulation

et al. 2018

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“…(25) In this study, 44% of patients progressed to a shockable rhythm and 16% achieved ROSC, albeit intermittent. Previous studies found progression to a shockable rhythm (26,27) and ROSC (6,7) increased the chance of survivability. This result suggests senior paramedics ceased resuscitation in patients with known factors which prognosticate survival.…”

Section: Paramedic Experiences Of Ceasing Resuscitationmentioning

confidence: 80%

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

Coppola¹,

Black²,

Endacott³

2020

Preprint

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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.

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“…Electrocardiogram (ECG) morphology was well considered with the majority of patients reporting a heart rate below 50 bpm (n = 46, 92%). A slow heart rate is widely accepted as a poor prognostic marker for survival [23], however, one study found morphology inaccurate to predict patient outcome [24]. A slow wide morphology indicates no cardiac movement, often categorised as a true PEA.…”

Section: Discussionmentioning

confidence: 99%

How senior paramedics decide to cease resuscitation in pulseless electrical activity out of hospital cardiac arrest: a mixed methods study

Coppola

Black

Endacott

2021

Scand J Trauma Resusc Emerg Med

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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.

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Utility of prehospital electrocardiogram characteristics as prognostic markers in out-of-hospital pulseless electrical activity arrests

Abstract: NCT00394706; post-results.

Cited by 10 publications

References 26 publications

ECG changes during resuscitation of patients with initial pulseless electrical activity are associated with return of spontaneous circulation

ECG changes during resuscitation of patients with initial pulseless electrical activity are associated with return of spontaneous circulation

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

How senior paramedics decide to cease resuscitation in pulseless electrical activity out of hospital cardiac arrest: a mixed methods study

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