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

Abstract

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

Diagnostic performance of the basic and advanced life support termination of resuscitation rules: A systematic review and diagnostic meta-analysis

“…3). 11,17,18,33,36,37,39,40 The pooled specificity and sensitivity for all studies were 0.98 (0.96À0.99) and 0.27 (0.23À0.30), respectively. The pooled PPV and NPV were 1.00 (0.99À1.00) and 0.05 (0.03À0.08), respectively.…”

“…Nine studies reported on 173.224 patients. 11,12,17,19,33,36,37,39,40 Test characteristics and forest plots are shown in Fig. 3.…”

Clinical Investigations External Validation of Multimodal Termination of Resuscitation Rules for Out-of-hospital Cardiac Arrest Patients in the Covid-19 Era

“…Fortunately, recent cardiopulmonary resuscitation (CPR) guidelineswere changed, recommendingthat all healthcare providers assess the safety of the scene and wear higher levels of PPE for protection against infectious airborne dropletsand detailing the criteria for the basic life support termination of resuscitation (BLS-TOR) rule. These guidelines stated that before terminating resuscitative efforts, the healthcare workers must check that 1) the arrest was not witnessed byemergency medical service (EMS) personnel or a rst responder,2)ROSC was not observed prior to the patient being transported to the emergency medical centre (EMC), and 3) no electrical shocks were delivered [7][8][9][10][11][12][13][14].…”

“…We applied the rules that were typically selected depending on the country or region where the derivation and validation phaseswere conducted.These included the(1) International BLS and advanced life support (ALS) rules derived and validated in the United States and Europe [8], (2) Goto and KANTO-SOS rules developed in Japan and Asian countries [13,14], and (3) Korean OHCA registry-based TOR models,Korean Cardiac Arrest Research Consortium (KoCARC) TOR rules, and two new TOR models, whichwere used in our previous studies [7,11].…”

“…In Daegu metropolitan city, the number of patients with COVID-19 increased rapidlyat the community level fromFebruary 18, 2020, in response to the pandemic outbreak in South Korea.During its 7-week peak, we resuscitated 184 OHCA patients at six EMCs. This was the rst study to determine the e cacy of these TOR guidelinesfor an emerging infectious disease [7,11,12].…”