Survival and neurological outcome after out-of-hospital cardiac arrest treated with and without mechanical circulatory support
Sivagowry Rasalingam MørkMorten Thingemann BøtkerSteffen ChristensenMariann TangChristian Juhl Terkelsen
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The aim of this study was to describe the survival and neurological outcome in patients with OHCA treated with and without mechanical circulatory support (MCS). This was a retrospective observational cohort study on patients with OHCA admitted to Aarhus University Hospital, Denmark, between January 2015 and December 2019. Kaplan-Meier estimates were used to evaluate 30-day and 30–180-day survival. Cox regression analysis was used to assess the association between covariates and one-year mortality. Among 1,015 patients admitted, 698 achieved return of spontaneous circulation (ROSC) before admission, 101 patients with refractory OHCA received mechanical circulatory support (MCS) and the remaining 216 patients with refractory OHCA did not receive MCS treatment. Survival to hospital discharge was 47% (478/1015). Good neurological outcome defined as Cerebral Performance Categories 1–2 were seen among 92% (438/478) of the patients discharged from hospital. Median low-flow was 15 [8–22] minutes in the ROSC group and 105 [94–123] minutes in the MCS group. Mortality rates were high within the first 30 days, however; 30–180-day survival in patients discharged remained constant over time in both patients with ROSC on admission and patients admitted with MCS. Advanced age > 70 years (hazard ratio (HR) 1.98, 95% confidence interval (CI) 1.11–3.49), pulseless electrical activity (HR 2.39, 95% CI 1.25–4.60) and asystole HR 2.70, 95% CI 1.25–5.95) as initial rhythms were associated with one-year mortality in patients with ROSC. Short-term survival rates were high among patients with ROSC and patients receiving MCS. Among patients who survived to day 30, landmark analyses showed comparable 180-day survival in the two groups despite long low-flow times in the MCS group. Advanced age and initial non-shockable rhythms were independent predictors of one-year mortality in patients with ROSC on admission.Keywords:
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Abstract Background Out-of-hospital cardiac arrest (OHCA) is a common reason for calls for intervention by emergency medical teams (EMTs) in Poland. Regardless of the mechanism, OHCA is a state in which the chance of survival is dependent on rapid action from bystanders and responding health professionals in emergency medical services (EMS). We aimed to identify factors associated with return of spontaneous circulation (ROSC). Methods The medical records of 2137 EMS responses to OHCA in the city of Wroclaw, Poland between July 2017 and June 2018 were analyzed. Results The OHCA incidence rate for the year studied was 102 cases per 100,000 inhabitants. EMS were called to 2317 OHCA events of which 1167 (50.4%) did not have resuscitation attempted on EMS arrival. The difference between the number of successful and failed cardiopulmonary resuscitations (CPRs) was statistically significant ( p < 0.001). Of 1150 patients in whom resuscitation was attempted, ROSC was achieved in 250 (27.8%). Rate of ROSC was significantly higher when CPR was initiated by bystanders ( p < 0.001). Patients presenting with asystole or pulseless electrical activity (PEA) had a higher risk of CPR failure (86%) than those with ventricular fibrillation/ventricular tachycardia (VF/VT). Patients with VF/VT had a higher chance of ROSC (OR 2.68, 1.86–3.85) than those with asystole ( p < 0.001). The chance of ROSC was 1.78 times higher when the event occurred in a public place ( p < 0.001). Conclusions The factors associated with ROSC were occurrence in a public place, CPR initiation by witnesses, and presence of a shockable rhythm. Gender, age, and the type of EMT did not influence ROSC. Low bystander CPR rates reinforce the need for further efforts to train the public in CPR.
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Background: Early achievement of Return Of Spontaneous Circulation (ROSC) after cardiac arrest is critical to neurologically intact survival, but few data are available comparing this factor in various cardiac arrest rhythms. Methods: From the All-Japan Utstein Registry between 2005 and 2010, 12,566 adult viticums who had bystander-witnessed out-of-hospital cardiac arrest due to cardiac etiology, whose arrest rhythm was confirmed by emergency medical service responders on arrival at the scene and whose ROSC was identified on arrival at the hospital were included; 7,282 (58%) had ROSC from shockable arrest, 3,140 (25%) from pulseless electrical activity (PEA) and 2,134 (17%) from asystole. The study endpoint was favorable neurological outcome 30 days after cardiac arrest. Results: Among the three arrest groups, significant differences were seen in the collapse-to-ROSC interval (median; 16 minutes in the shockable arrest group, 20 minutes in the PEA group, 26 minutes in the asystole group, p<0.001) and in frequency of 30-day favorable neurological outcome (52.8% in the shockable arrest group, 13.3% in the PEA group, 4.1% in the asystole group, p<0.001). Likelihood of favorable neurological outcome decreased in each group for every 1 minute increment in the collapse-to-ROSC interval (adjusted OR; 0.93 in the shockable arrest group and PEA group, and 0.91 in the asystole group). For every minute that passes between collapse and ROSC, frequency of favorable neurological outcome decreased from 90% to 0% over a 60 minute period in the shockable arrest group, from 50% to 0% over a 50 minute period in the PEA group, and from 40% to 0% over a 40 minute period in the asystole group. Conclusion: Collapse-to-ROSC interval for the attainment of neurologically intact survival differed among cardiac arrest rhythms. The marginal collapse-to-ROSC interval was 60 minutes in shockable arrest, 50 minutes in PEA and 40 minutes in asystole.
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Background: Early achievement of return of spontaneous circulation (ROSC) after cardiac arrest is critical to neurologically intact survival, but few data are available concerning this interval comparing pulseless electrical activity (PEA) and asystole. Methods: From the All-Japan Utstein Registry, a prospective, nationwide, population-based registry of out-of-hospital cardiac arrest (OHCA) between 2005 and 2011, we included adult patients who received resuscitation care after witnessed OHCA due to non-shockable arrest and whose ROSC was achieved before hospital arrival. We divided study patients into two groups according to the initial cardiac arrest rhythm and evaluated the relationship between the collapse-to-ROSC interval and favorable neurological outcome 30 days after cardiac arrest. Results: Of the 31,845 patients who achieved ROSC after witnessed OHCA, 12,905 (40.8%) achieved ROSC after PEA and 7,259 (22.8%) after asystole. The PEA group had a significantly shorter collapse-to-ROSC interval compared with the asystole group (18.9±11.6 vs. 25.3±12.6 minutes, p<0.0001) and a significantly higher frequency of 30-day favorable neurological outcome (15.5% vs. 7.1%, p<0.0001). After adjustment for resuscitation, the likelihood of favorable neurological outcome decreased for every 1 minute increment in the collapse-to-ROSC interval in the PEA group (adjusted OR; 0.94, 95% CI, 0.93 to 0.95) and in the asystole group (adjusted OR; 0.93, 95% CI, 0.91 to 0.94). Non-linear regression analysis showed that frequency of favorable neurological outcome decreased from 33.6% to 0% for every minute that passed between collapse and ROSC in the PEA group and from 29.2% to 0% in the asystole group. For favorable neurological outcome, a collapse-to-ROSC interval of 56.5 minutes had a sensitivity of 100% with a negative predictive value of 99.6% in the PEA group, and that of 56.5 minutes had a sensitivity of 100% with a negative predictive value of 99.1% in the asystole group. Conclusion: In patients achieving ROSC after witnessed OHCA, PEA patients had a significantly higher favorable neurological outcome than asystole patients. However, the interval in which resuscitation efforts must be sustained is similar for both arrest rhythms.
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Background: Although cardiopulmonary resuscitation (CPR) is a very effective therapy in cardiac arrest, it is hard to prove the true effectiveness of CPR. Several studies about out-of-hospital and emergency department CPR exist, but only a few reports about in-hospital CPR are available. This study was designed to investigate in-hospital cardiac arrest, to analyze the result of CPR, and to evaluate the problems associated with in-hospital CPR. Methods: A clinical analysis of 71 cases of in-hospital CPR announcement from January 2000 to August 2000 was performed. The initial rhythm on cardiac arrest, return of spontaneous circulation (ROSC), and the survivals were analyzed in the case of the 46 true cardiac arrest patients. Results: During 8 months, there were 71 cases of in-hospital CPR announcement. Among them, there were 46 cases of true cardiac arrest and 25 cases of non-cardiac arrest. Of the 46 true cardiac-arrest cases, 27(58.7%) experienced ROSC, 15(32.6) survived for over 24 hours, and 7(15.2%) survived to be discharged. The initial rhythms on cardiac arrest were 30 cases (65.2%) of asystole, 14(30.4%) of PEA (pulseless electrical activity), and 2(4.3%) of ventricular fibrillation, with ROSC being 17 cases (56.7%), 9(64.3%) and 1(50.0%) cases and discharged survivors being 4 cases (13.3%), 3(21.4%) and 0(0.0%) cases, respectively. Conclusion: Extraordinarily high proportions of asystole and PEA were seen in the initial rhythm of cardiac arrest, and those were associated with high survival rates. Although further study is needed to evaluate the course leading to this high proportion of asystole and PEA, this result suggests that if the EMS system in the hospital is activated promptly and systematically, a better outcome will be achieved in case of cardiac arrest with asystole and PEA.
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Objective: This aim examined the outcomes of resuscitation and the clinical characteristics of patients with pre-hospital traumatic cardiac arrests (TCA).
Methods: The charts of patients with pre-hospital TCA who visited the various emergency department (ED) in Gangwondo from January 2013 to December 2017 were reviewed retrospectively.
Results: TCA patients comprised 0.3% of patients transferred by 119. A total of 367 patients were enrolled in the study. Traffic accidents were the leading cause of the arrest. The initial field and ED rhythm were mostly asystole (field, 79.6%; ED, 82.3%). It took 11.24±9.95 minutes from the call to the field. From the field to ED, it took 22.87±15.37 minutes. The total CPR time before ED arrival was 21.62±15.29 minutes. The causes of TCA were brain injury (35.7%), hypovolemic shock (29.2%), and severe lung injury (16.3%). Seventy TCA patients experienced at least one return of spontaneous circulation (ROSC). Twenty-six patients (7.14%) were admitted to the ward, and their average injury severity score was 38.96. Eight patients expired before 12 hours after transient ROSC. Four more patients expired before 24 hours. Four patients were discharged alive among patients who lived for more than 24 hours.
Conclusion: In this study, 1.5% of patients were discharged alive. The possibility of ROSC was higher as the time to ED, and the cardiopulmonary resuscitation time of 119 was shorter. Pulseless electrical activity rather than asystole tends to promote ROSC. The survival rate increased when ROSC occurred before arriving at the ED.
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Several studies recommend not initiating advanced life support in traumatic cardiac arrest (TCA), mainly owing to the poor prognosis in several series that have been published. This study aimed to analyze the survival of the TCA in our series and to determine which factors are more frequently associated with recovery of spontaneous circulation (ROSC) and complete neurologic recovery (CNR).This is a cohort study (2006-2009) of treatment benefits.A total of 167 TCAs were analyzed. ROSC was obtained in 49.1%, and 6.6% achieved a CNR. Survival rate by age groups was 23.1% in children, 5.7% in adults, and 3.7% in the elderly (p < 0.05). There was no significant difference in ROSC according to which type of ambulance arrived first, but if the advanced ambulance first, 9.41% achieved a CNR, whereas only 3.7% if the basic ambulance first. We found significant differences between the response time and survival with a CNR (response time was 6.9 minutes for those who achieved a CNR and 9.2 minutes for those who died). Of the patients, 67.5% were in asystole, 25.9% in pulseless electrical activity (PEA), and 6.6% in VF. ROSC was achieved in 90.9% of VFs, 60.5% of PEAs, and 40.2% of those in asystole (p < 0.05), and CNR was achieved in 36.4% of VFs, 7% of PEAs, and 2.7% of those in asystole (p < 0.05). The mean (SD) quantity of fluid replacement was greater in ROSC (1,188.8 [786.7] mL of crystalloids and 487.7 [688.9] mL of colloids) than in those without ROSC (890.4 [622.4] mL of crystalloids and 184.2 [359.3] mL of colloids) (p < 0.05).In our series, 6.6% of the patients survived with a CNR. Our data allow us to state beyond any doubt that advanced life support should be initiated in TCA patients regardless of the initial rhythm, especially in children and those with VF or PEA as the initial rhythm and that a rapid response time and aggressive fluid replacement are the keys to the survival of these patients.Therapeutic study, level IV; epidemiologic study, level III.
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