Objectives To characterize the prevalence of withdrawal of life-sustaining treatment, as well as the time to awakening, short-term neurologic outcomes, and cause of death in comatose survivors of out-of-hospital resuscitated cardiopulmonary arrests treated with therapeutic hypothermia. Design Single center, prospective observational cohort study of consecutive patients with out-of-hospital cardiopulmonary arrests. Setting Academic tertiary care hospital and level one trauma center in Minneapolis, MN. Patients Adults with witnessed, nontraumatic, out-of-hospital cardiopulmonary arrests regardless of initial electrocardiographic rhythm with return of spontaneous circulation who were admitted to an ICU. Interventions None. Measurements and Main Results The study cohort included 154 comatose survivors of witnessed out-of-hospital cardiopulmonary arrests who were admitted to an ICU during the 54-month study period. One hundred eighteen patients (77%) were treated with therapeutic hypothermia. The mean age was 59 years, 104 (68%) were men, and 83 (54%) had an initial rhythm of ventricular tachycardia or fibrillation. Only eight of all 78 patients (10%) who died qualified as brain dead; and 81% of all patients (63 of 78) who died did so after withdrawal of life-sustaining treatment. Twenty of 56 comatose survivors (32%) treated with hypothermia who awoke (as defined by Glasgow Motor Score of 6) and had good neurologic outcomes (defined as Cerebral Performance Category 1–2) did so after 72 hours. Conclusions Our study supports delaying prognostication and withdrawal of life-sustaining treatment to beyond 72 hours in cases treated with therapeutic hypothermia. Larger multicenter prospective studies are needed to better define the most appropriate time frame for prognostication in comatose cardiac arrest survivors treated with therapeutic hypothermia. These data are also consistent with the notion that a majority of out-of-hospital cardiopulmonary arrest survivors die after a decision to withdrawal of life-sustaining treatment and that very few of these survivors progress to brain death.

Objectives-To characterize the prevalence of withdrawal of life-sustaining treatment, as well as the time to awakening, short-term neurologic outcomes, and cause of death in comatose survivors of out-of-hospital resuscitated cardiopulmonary arrests treated with therapeutic hypothermia.Design-Single center, prospective observational cohort study of consecutive patients with outof-hospital cardiopulmonary arrests. Setting-Academic HHS Public Access Author Manuscript Author ManuscriptAuthor Manuscript Author ManuscriptPatients-Adults with witnessed, nontraumatic, out-of-hospital cardiopulmonary arrests regardless of initial electrocardiographic rhythm with return of spontaneous circulation who were admitted to an ICU. Interventions-None.Measurements and Main Results-The study cohort included 154 comatose survivors of witnessed out-of-hospital cardiopulmonary arrests who were admitted to an ICU during the 54-month study period. One hundred eighteen patients (77%) were treated with therapeutic hypothermia. The mean age was 59 years, 104 (68%) were men, and 83 (54%) had an initial rhythm of ventricular tachycardia or fibrillation. Only eight of all 78 patients (10%) who died qualified as brain dead; and 81% of all patients (63 of 78) who died did so after withdrawal of lifesustaining treatment. Twenty of 56 comatose survivors (32%) treated with hypothermia who awoke (as defined by Glasgow Motor Score of 6) and had good neurologic outcomes (defined as Cerebral Performance Category 1-2) did so after 72 hours.Conclusions-Our study supports delaying prognostication and withdrawal of life-sustaining treatment to beyond 72 hours in cases treated with therapeutic hypothermia. Larger multicenter prospective studies are needed to better define the most appropriate time frame for prognostication in comatose cardiac arrest survivors treated with therapeutic hypothermia. These data are also consistent with the notion that a majority of out-of-hospital cardiopulmonary arrest survivors die after a decision to withdrawal of life-sustaining treatment and that very few of these survivors progress to brain death. Keywordsbrain death; cardiac arrest; outcome; prognostication; therapeutic hypothermia; withdrawal of lifesustaining treatmentOut-of-hospital cardiopulmonary arrests (OHCA) pose a significant public health burden, with an estimated annual prevalence of over 380,000 arrests evaluated by emergency medical services in the United States alone (1-4). In the decade following the 2002 landmark trials of therapeutic hypothermia (TH) to improve outcomes in comatose cardiac arrest survivors, little additional progress has been made in finding and implementing successful new neuroprotective interventions (5, 6). Therefore, TH remains the only proven neuroprotective strategy available and the focus of the resuscitation community. A number of factors explain this lack of progress: a lack of understanding of the mechanisms and circumstances leading to poor outcomes, lead time and selection biases, as well as funding and ethical co...