Assessment of futility in out-of-hospital cardiac arrest (original) (raw)
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Please cite this article in press as: Rajagopal S, et al. Characteristics of patients who are not resuscitated in out of hospital cardiac arrests and opportunities to improve community response to cardiac arrest. Resuscitation (2016), a b s t r a c t Aim: This study explores why resuscitation is withheld when emergency medical staff arrive at the scene of a cardiac arrest and identifies modifiable factors associated with this decision. Methods: This is a secondary analysis of unselected patients who sustained an out of hospital cardiac arrest attended by ambulance vehicles participating in a randomized controlled trial of a mechanical chest compression device (PARAMEDIC trial). Patients were categorized as 'non-resuscitation' patients if there was a do-not-attempt-cardiopulmonary-resuscitation (DNACPR) order, signs unequivocally associated with death or resuscitation was deemed futile (15 min had elapsed since collapse with no bystander-CPR and asystole recorded on EMS arrival). Results: Emergency Medical Services attended 11,451 cardiac arrests. Resuscitation was attempted or continued by Emergency Medical Service staff in 4805 (42%) of cases. Resuscitation was withheld in 6646 cases (58%). 711 (6.2%) had a do not attempt resuscitation decision, 4439 (38.8%) had signs unequivocally associated with death and in 1496 cases (13.1%) CPR was considered futile. Those where resuscitation was withheld due to futility were characterised by low bystander CPR rates (7.2%) and by being female. Conclusions: Resuscitation was withheld by ambulance staff in over one in ten (13.1%) victims of out of hospital cardiac arrest on the basis of futility. These cases were associated with a very low rate of bystander CPR. Future studies should explore strengthening the 'Chain of Survival' to increase the community bystander CPR response and evaluate the effect on the numbers of survivors from out of hospital cardiac arrest.
Successful resuscitation of out of hospital cardiac arrest patients in the emergency department
Signa Vitae - A Journal In Intensive Care And Emergency Medicine, 2011
Background. We examined factors associated with the successful resuscitation, in the emergency department (ED), of adult, out-of-hospital cardiac arrest (OHCA) patients. Methods. The study cohort consisted of adult patients (over 18 years of age) who presented to the ED in 2009 with a diagnosis of cardiac arrest. Data were retrieved from the institutional database. Results. A total of 122 adult, non-traumatic, OHCA patients were enrolled in the study. There were no significant differences between the sustained return of spontaneous circulation (ROSC) and non-sustained ROSC groups in initial body temperature (P = 0.420), time to successful intubation (P = 0.524), time to first intravenous epinephrine injection (P = 0.108), blood sugar levels (P = 0.122), hematocrit (P = 0.977), cardiac enzymes (P = 0.116) and serum sodium level (P = 0.429). Leukocytosis (P = 0.047) and cardiac rhythm of pulseless ventricular tachycardia/ ventricular fibrillation and pulseless electrical activity (P = 0.022), were significantly associated with sustained ROSC. In contrast, patients with more severe acidosis (P = 0.003) and hyperkalemia (P < 0.001) had a reduced likelihood of achieving sustained ROSC. After multiple variable logistic regression analysis adjusting for variables, the correlation between sustained ROSC and leukocytosis and hyperkalemia remained high (leukocytosis,
Resuscitation
Background: Since development of the Utstein style recommendations for the uniform reporting of cardiac arrest, increasing numbers of national and regional out-of-hospital cardiac arrest (OHCA) registries have been established worldwide. The International Liaison Committee on Resuscitation (ILCOR) created the Research and Registries Working Group and aimed to systematically report data collected from these registries. Methods: We conducted two surveys of voluntarily participating national and regional registries. The first survey aimed to identify which core elements of the current Utstein style for OHCA were collected by each registry. The second survey collected descriptive summary data from each registry. We chose the data collected for the second survey based on the availability of core elements identified by the first survey. Results: Seven national and four regional registries were included in the first survey and nine national and seven regional registries in the second survey. The estimated annual incidence of emergency medical services (EMS)-treated OHCA was 30.0À97.1 individuals per 100,000 population. The combined data showed the median age varied from 64 to 79 years and more than half were male in all 16 registries. The provision of bystander cardiopulmonary resuscitation (CPR) and bystander automated external defibrillator (AED) use was 19.1À79.0% in all registries and 2.0À37.4% among 11 registries, respectively. Survival to hospital discharge or 30-day survival after EMS-treated OHCA was 3.1À20.4% across all registries. Favorable neurological outcome at hospital discharge or 30 days after EMS-treated OHCA was 2.8À18.2%. Survival to hospital discharge or 30-day survival after bystander-witnessed shockable OHCA ranged from 11.7% to 47.4% and favorable neurological outcome from 9.9% to 33.3%. Conclusion: This report from ILCOR describes data on systems of care and outcomes following OHCA from nine national and seven regional registries across the world. We found variation in reported survival outcomes and other core elements of the current Utstein style recommendations for OHCA across nations and regions.
Journal of Palliative Medicine, 2010
Objective: To describe the postresuscitative hospital course of emergency department patients who initially survive nontraumatic out-of-hospital cardiac arrests (OOHCA) but die in the hospital. Methods: A 12-month case series of all nontraumatic OOHCA patients at two large urban Midwestern teaching hospitals who survived to hospital admission but died before discharge. Medical records from identified patients were reviewed for demographics, resuscitation sequelae, do-not-attempt-resuscitation (DNAR) code status, pain declarations, and withdrawal of life support. Descriptive statistics are reported. Results: Between August 31, 2005 and July 31, 2006, there were 468 nontraumatic OOHCA patients treated at the study hospitals. Forty-one (8.8%) patients initially survived and were admitted to the hospital, of whom 32 (78.0%) expired before hospital discharge. Pain declarations were noted in 8 (25.0%) patients, of whom 4 had more than one assessment. Median postresuscitation survival time was 1.5 days (range, 9.3 hours to 18.6 days). Overall, 19 (59.4%) patients died after withdrawal of life support, 8 (25.0%) while actively on life support, and 5 (15.6%) died with subsequent cardiopulmonary resuscitation (CPR). Possible complications of CPR included pneumothorax in 2 (6.3%) and intracranial hemorrhage in 1 (3.1%). Conclusions: In this urban setting, approximately three of four OOHCA patients who are initially resuscitated do not survive to hospital discharge. This short in-hospital course post-CPR is often marked by pain and ends with the withdrawal of life support. This information may be an important component of advance planning discussions and may assist patients as they weigh the pros and cons associated with resuscitation preferences.
Utstein-style guidelines contribute to improved public health internationally by providing a structured framework with which to compare emergency medical services systems. Advances in resuscitation science , new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessons learned from methodological research prompted this review and update of the 2004 Utstein guidelines. Representatives of the International Liaison Committee on Resuscitation developed an updated Utstein reporting framework iteratively by meeting face to face, by teleconference, and by Web survey during 2012 through 2014. Herein are recommendations for reporting out-of-hospital cardiac arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resus-citation/postresuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process primarily based on respondents' assessment of the evidence-based importance of capturing those elements, tempered by the challenges to collect them. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, postresuscitation care, prognostication tools, and trends in organ recovery. A standard reporting A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx. et al. / Resuscitation 96 (2015) 328-340 329 template is recommended to promote standardized reporting. This template facilitates reporting of the bystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacy and all emergency medical services system-treated arrests as a measure of system effectiveness. Several additional important subgroups are identified that enable an estimate of the specific contribution of rhythm and bystander actions that are key determinants of outcome.
Termination of Resuscitative Efforts for Out-of-hospital Cardiac Arrests
Academic Emergency Medicine, 2005
Objective: To determine the rate of termination of resuscitative efforts for out-of-hospital cardiac arrest patients and whether variability exists among different base hospitals providing online medical control (OLMC). Methods: This was an observational one-year study that included all adult patients in the city of Los Angeles with nontraumatic, out-ofhospital cardiac arrests with attempted resuscitative efforts by paramedics. OLMC was provided by 13 base hospitals. The main outcome measure was the incidence of termination of resuscitative efforts on scene as directed by OLMC. Results: Of 1,700 patients, 151 (9%) had resuscitative efforts terminated on scene via direction by OLMC. Patients pronounced on scene were statistically more likely to be older, be found in an extended care facility, have an unwitnessed arrest, and present in asystole. Two base hospitals were more likely to terminate resuscitative efforts via OLMC than all others. Incidence at base hospital A was 37% (odds ratio, 18.6; 95% confidence interval = 11.7 to 30.0; p , 0.0001); incidence
Unsuccessful resuscitation after cardiac arrest in the intensive care unit: single center analysis 1
complains out of the hospital, so we can assume that the cardiac arrest event they suffered was the result of an acute issue, and not of a prolonged suffering. Nevertheless, facts considered potential factors for a poor outcome in OHCA, such as early recognition of the medical emergency, bystander CPR, early advanced life support, are not an issue for patients admitted in the ICU. The ICU represents a special medical facility with medical personnel of high expertise, nursing care and complex life sustaining medical equipment. The patients admitted in the ICU are in severe condition; therefore it is not unexpected for cardiac arrest to occur. In the Intensive Care Unit (ICU) the patients are permanently monitored, and this fact lowers the possibility for an un-witnessed or unmonitored cardiac arrest to occur (Myrianthefs et al 2003). Nevertheless, the patients admitted in the ICU are already in poor condition, often with hemodynamic and/or respiratory impairment and the characteristi...