Early head‐to‐pelvis computed tomography in out‐of‐hospital circulatory arrest without obvious etiology

Abstract

Objectives Patients resuscitated from an out‐of‐hospital circulatory arrest (OHCA) commonly present without an obvious etiology. We assessed the diagnostic capability and safety of early head‐to‐pelvis computed tomography (CT) imaging in such patients. Methods From November 2015 to February 2018, we enrolled 104 patients resuscitated from OHCA without obvious cause (idiopathic OHCA) to an early sudden‐death CT (SDCT) scan protocol within 6 h of hospital arrival. The SDCT protocol included a noncontrast CT head, an electrocardiogram‐gated cardiac and thoracic CT angiogram, and a nongated venous‐phase abdominopelvic CT angiogram. Patients needing urgent cardiac catheterization or hemodynamically unable to tolerate SDCT were excluded. Cardiac CT analyses were blinded, but other SDCT findings were clinically available. Primary endpoints were the number of OHCA causes identified by SDCT compared to the adjudicated cause and critical diagnoses identified by SDCT, including resuscitation complications. Safety endpoints were acute kidney injury (AKI) and inappropriate treatments based on SDCT findings. Acute coronary syndrome was the presumed etiology if any major coronary artery had a >50% stenosis without another OHCA cause. Results SDCT scans occurred within 1.9 ± 1.0 h of hospital arrival and identified 39% (41/104) of all OHCA causes and 95% (39/41) of causes potentially identifiable by SDCT. Critical findings were identified by SDCT in 98% (43/44) of patients that included potentially life‐threatening resuscitation complications of liver or spleen laceration (n = 6); pneumothorax or thoracic organ laceration (n = 8); and mediastinal, pericardial, or vascular hemorrhage (n = 3). SDCT exclusively identified 13 (13%) OHCA causes that would otherwise not be identified without SDCT imaging. No inappropriate treatments resulted from SDCT findings. AKI was common (28%) but only one (1%) patient required new dialysis. Conclusions This observational cohort study suggests that early SDCT scanning is safe, can expedite the diagnosis of potential causes, and can meaningfully change clinical management after idiopathic OHCA.

Prevalence and Patterns of Resuscitation‐Associated Injury Detected by Head‐to‐Pelvis Computed Tomography After Successful Out‐of‐Hospital Cardiac Arrest Resuscitation

“…The full methods of the study have been previously described (National Clinical Trial number 03111043). 4 , 5 Briefly, CT‐FIRST (CT Feasibility In Resuscitated Patients for Sudden Death Triage) was a prospective, observational study of patients resuscitated after an OHCA event but without obvious cause for the OHCA event (termed idiopathic OHCA ). The study was designed to evaluate the incremental diagnostic capability and safety of early (<6 hours from hospital arrival) head‐to‐pelvis SDCT in addition to standard care.…”

“…As previously described, all SDCT data, except for coronary imaging data, were read by an attending radiologist and were released to treating providers in real time. 4 , 5 These data included resuscitation injuries. For the purpose of this research analysis, the SDCT studies were independently reviewed by 2 board‐certified radiologists (M.L.G.…”

“…to assess the likelihood the findings were potentially associated to resuscitation (rather than preceding or unrelated to resuscitative efforts) and graded to “time‐critical” if the findings warranted urgent evaluation by specialty services, urgent additional imaging, or urgent treatments. 4 All discrepancies were resolved by consensus. Clinical outcomes studied were death from CPR injury detected by SDCT and survival to hospital discharge.…”

“…We have previously reported the findings of a prospective observational study examining the utility of early head‐to‐pelvis sudden‐death computed tomography (SDCT) in patients resuscitated after OHCA to identify the cause of circulatory arrest. 4 SDCT can also evaluate for resuscitation injuries, such as organ laceration, rib fracture, and vascular disruption. Rapid detection of such injuries may allow for early targeted intervention and improvement in outcomes.…”

Out of hospital cardiac arrest: Past, present, and future

“…115 For example, whole-body CT imaging may identify etiology including acute coronary occlusion that may support catheterization among resuscitated patients without acute ST segment elevation myocardial infarction. 116 In addition, trials are ongoing to address the optimal degree and duration of targeted temperature management, and multidisciplinary approaches to assess neurological prognosis. 117 Advances in risk stratification may also impact the use of implantable defibrillator use and other medical treatments to improve secondary prevention.…”