A New Rule for Terminating Resuscitation of Out-of-Hospital Cardiac Arrest Patients in Japan: A Prospective Study

Inokuchi, Sadaki; Masui, Yoshihiro; Miura, Keita; Tsutsumi, Haruhiko; Takuma, Kiyotsugu; Atsushi, Ishihara; Nakano, Minoru; Tanaka, Hiroshi; Ikegami, Keiichi; Arai, Takao; Yaguchi, Arino; Kitamura, Nobuya; Oda, Shinya; Kobayashi, Kenji; Suda, Takayuki; Ono, Katsushige; Morimura, Naoto; Furuya, Ryosuke; Koido, Yuichi; Iwase, Fumiaki; Nagao, Ken; Kanesaka, Shigeru; Okada, Yoshinori; Unemoto, Kyoko; Sadahiro, Tomohito; Iyanaga, Masayuki; Muraoka, Asaki; Hayashi, Mitsuhiro; Ishimatsu, Shinichi; Miyake, Yoshihiro; Yokokawa, Hideo; Koyama, Yoshinori; Tsuchiya, Asuka; Kashiyama, Tetsuya; Hayashi, Masanori; Oshima, Kiyohiro; Kiyota, Kazuya; Hamabe, Yuichi; Yokota, Hiroyuki; Hori, Shingo; Inaba, Susumu; Sakamoto, Tetsuya; Harada, Naoshige; Kimura, Akio; Kanai, Masayuki; Otomo, Yasuhiro; Sugita, Manabu; Kinoshita, Kosaku; Sakurai, Takatoshi; Kitano, Mitsuhide; Matsuda, Kiyoshi; Tanaka, Kotaro; Yoshihara, Kazuhiro; Yoh, Kikuo; Suzuki, Junichi; Toyoda, Hiroshi; Mashiko, Kunihiro; Shimizu, Naoki; Muguruma, Takashi; Shimada, Tadanaga; Kobe, Yoshiro; Shoko, Tomohisa; Nakanishi, Koji; Shiga, Takashi; Yamamoto, Takefumi; Sekine, Keitaro; Izuka, Shinichi

doi:10.1016/j.jemermed.2017.05.025

Cited by 18 publications

(8 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…4) SOS-KANTO's TOR rule: the combinations were unwitnessed by a bystander, asystole in the field and the hospital 13…”

Section: Methodsmentioning

confidence: 99%

“…Termination of resuscitation (TOR) guidelines also recommend to continue resuscitative efforts for patients with initial or subsequent shockable rhythm conversion 101112. However, results from the SOS-KANTO 2012 study suggest that the initial asystole rhythms documented in the field or emergency department (ED) affected TOR rules after OHCA 13…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

New Termination-of-Resuscitation Models and Prognostication in Out-of-Hospital Cardiac Arrest Using Electrocardiogram Rhythms Documented in the Field and the Emergency Department

Lee

Ahn

et al. 2019

J Korean Med Sci

View full text Add to dashboard Cite

Background Electrocardiogram (ECG) rhythms, particularly shockable rhythms, are crucial for planning cardiac arrest treatment. There are varying opinions regarding treatment guidelines depending on ECG rhythm types and documentation times within pre-hospital settings or after hospital arrivals. We aimed to determine survival and neurologic outcomes based on ECG rhythm types and documentation times. Methods This prospective observational study of 64 emergency medical centers was performed using non-traumatic out-of-hospital cardiac arrest registry data between October 2015 and June 2017. From among 4,608 adult participants, 4,219 patients with pre-hospital and hospital ECG rhythm data were enrolled. Patients were divided into 3 groups: those with initial-shockable, converted-shockable, and never-shockable rhythms. Patient characteristics and survival outcomes were compared between groups. Further, termination of resuscitation (TOR) validation was performed for 6 combinations of TOR criteria confirmed in previous studies, including 2 rules developed in the present study. Results Total survival to discharge after cardiac arrest was 11.7%, and discharge with good neurologic outcomes was 7.9%. Survival to discharge rates and favorable neurologic outcome rates for the initial-shockable group were the highest at 35.3% and 30.2%, respectively. There were no differences in survival to discharge rates and favorable neurologic outcome rates between the converted-shockable (4.2% and 2.0%, respectively) and never-shockable groups (5.7% and 1.9%, respectively). Irrespective of rhythm changes before and after hospital arrival, TOR criteria inclusive of unwitnessed events, no pre-hospital return of spontaneous circulation, and asystole in the emergency department best predicted poor neurologic outcomes (area under the receiver operating characteristic curve of 0.911) with no patients classified as Cerebral Performance Category 1 or 2 (specificity = 1.000). Conclusion Survival outcomes and TOR predictions varied depending on ECG rhythm types and documentation times within pre-hospital filed or emergency department and should, in the future, be considered in treatment algorithms and prognostications of patients with out-of-hospital cardiac arrest. Trial Registration ClinicalTrials.gov Identifier: NCT03222999

show abstract

“…4) SOS-KANTO's TOR rule: the combinations were unwitnessed by a bystander, asystole in the field and the hospital 13…”

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

New Termination-of-Resuscitation Models and Prognostication in Out-of-Hospital Cardiac Arrest Using Electrocardiogram Rhythms Documented in the Field and the Emergency Department

Lee

Ahn

et al. 2019

J Korean Med Sci

View full text Add to dashboard Cite

show abstract

“…Third, Marsden et al proposed a TOR rule with an exclusion criterion of hypothermia [ 38 ]. The SOS–KANTO 2012 Study Group found that all patients who met their TOR rule but had good neurological outcomes had severe hypothermia with body temperatures below 30 degrees Celsius [ 5 ]. However, this study did not perform relevant analysis since EMS protocols in Tainan did not include temperature measurements.…”

Section: Discussionmentioning

confidence: 99%

“…To decrease unnecessary consumption of medical resources and preserve energy for potential demand of emergent medical treatment in the ED, field termination was suggested as the best means to prevent needless transportation [ 4 ]. Many novel TOR rules have been developed in recent decades [ 5 – 7 ]. However, the basic life support (BLS) TOR rule and the advanced life support (ALS) TOR rule remain the mainstream rules [ 8 , 9 ].…”

Section: Introductionmentioning

confidence: 99%

Predictive performances of ALS and BLS termination of resuscitation rules in out-of-hospital cardiac arrest for different resuscitation protocols

et al. 2022

View full text Add to dashboard Cite

Background Resuscitation guidance has advanced; however, the predictive performance of the termination of resuscitation (TOR) rule has not been validated for different resuscitation protocols published by the American Heart Association (AHA). Methods A retrospective study validating the basic life support (BLS) and advanced life support (ALS) TOR rules was conducted using an Utstein-style database in Tainan city, Taiwan. Adult patients with nontraumatic out-of-hospital cardiac arrests from January 1, 2015, to December 31, 2015, (using the AHA 2010 resuscitation protocol) and from January 1, 2020, to December 31, 2020, (using the AHA 2015 resuscitation protocol) were included. The characteristics of rule performance were calculated, including sensitivity, specificity, positive predictive value (PPV) and negative predictive value. Results Among 1260 eligible OHCA patients in 2015, 757 met the BLS TOR rule and 124 met the ALS TOR rule. The specificity and PPV for predicting unfavorable neurological outcomes were 61.1% and 99.0%, respectively, for the BLS TOR rule and 93.8% and 99.2%, respectively, for the ALS TOR rule. A total of 970 OHCA patients were enrolled in 2020, of whom 438 met the BLS TOR rule and 104 met the ALS TOR rule. The specificity and PPV for predicting unfavorable neurological outcomes were 85.7% and 100%, respectively, for the BLS TOR rule and 99.5% and 100%, respectively, for the ALS TOR rule. Conclusions Both the BLS and ALS TOR rules performed better when using the 2015 AHA resuscitation protocols compared to the 2010 protocols, with increased PPVs and decreased false-positive rates in predicting survival to discharge and good neurological outcomes at discharge. The BLS and ALS TOR rules can perform differently while the resuscitation protocols are updated. As the concepts and practices of resuscitation progress, the BLS and ALS TOR rules should be evaluated and validated accordingly.

show abstract

“…(28,29,30) Previously only clinical features have been investigated to prognosticate the outcome of resuscitation. (4,13) This approach was not supported by the senior paramedics. The clinical features previously described were interpreted, however, they were balanced along with no ow time, advanced age, co-morbidities, duration of resuscitation and quality of life.…”

Section: Multifactorial Decision-makingmentioning

confidence: 99%

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

View full text Add to dashboard Cite

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.

show abstract

A New Rule for Terminating Resuscitation of Out-of-Hospital Cardiac Arrest Patients in Japan: A Prospective Study

Abstract: OHCA patients fulfilling the criteria unwitnessed by bystanders and asystole in the field and at hospital arrival had universally poor outcomes. Termination of resuscitation after hospital arrival for these patients may decrease unwarranted treatments.

Cited by 18 publications

References 26 publications

New Termination-of-Resuscitation Models and Prognostication in Out-of-Hospital Cardiac Arrest Using Electrocardiogram Rhythms Documented in the Field and the Emergency Department

New Termination-of-Resuscitation Models and Prognostication in Out-of-Hospital Cardiac Arrest Using Electrocardiogram Rhythms Documented in the Field and the Emergency Department

Predictive performances of ALS and BLS termination of resuscitation rules in out-of-hospital cardiac arrest for different resuscitation protocols

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

Contact Info

Product

Resources

About