Elsevier

Resuscitation

Volume 85, Issue 11, November 2014, Pages 1488-1493
Resuscitation

Clinical Paper
Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: An observational cohort study

https://doi.org/10.1016/j.resuscitation.2014.07.011Get rights and content

Abstract

Background

Some Emergency Medical Services currently use just one component of the Universal Termination of Resuscitation (TOR) Guideline, the absence of prehospital return of spontaneous circulation (ROSC), as the single criteria to terminate resuscitation, which may deny transport to potential survivors.

Objective

This study aimed to report the survival to hospital discharge rate in non-traumatic, adult out-of-hospital cardiac arrest (OHCA) patients transported to hospital without a prehospital ROSC.

Methods

An observational study of OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport to hospital with ongoing resuscitation. Multivariable logistic regression was used to determine the association of each variable with survival to hospital discharge.

Results

Of 20,207 OHCA treated by EMS, 3374 (16.4%) did not have a prehospital ROSC but met the Universal TOR guideline for transport to hospital with ongoing resuscitation. Of these patients, 122 (3.6%) survived to hospital discharge. Survival to discharge was associated with initial shockable VF/VT rhythms (OR 5.07; 95% CI 2.77–9.30), EMS-witnessed arrests (OR 3.51; 95% CI 1.73–7.15), bystander-witnessed arrests (OR 2.11; 95% CI 1.18–3.77), and public locations (OR 1.57; 95% CI 1.02–2.40).

Conclusion

In OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport with ongoing resuscitation survival rates were above the 1% futility rate. Employing only the lack of ROSC as criteria for termination of resuscitation may miss survivors after OHCA.

Section snippets

Background

With over 400,000 occurrences every year, out-of-hospital cardiac arrests (OHCA) represent a significant public health burden across North America.1, 2 Survival from OHCA varies, with most regions reporting rates of survival to hospital discharge of less than 10%.1, 2

Historically, following full resuscitative effort by emergency medical services (EMS), OHCA patients were transported to hospital for continued resuscitation efforts in the emergency department. Most of these patients, however, did

Study design and setting

This study was a retrospective analysis of the Toronto site of the Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac Arrest database.24 This database is a population-based registry of consecutive EMS attended OHCA from 7 municipalities in southern Ontario (Toronto, Peel, York, Halton, Durham, Muskoka, and Simcoe), a population of 6.6 million people. Data collected for each OHCA patient included details regarding the 911 call, pick-up location, bystander CPR, EMS response and treatment,

Results

During the study period, there were a total of 20,207 adult OHCA of presumed cardiac etiology treated by EMS; 10,704 (52.9%) were transported to the hospital and 9152 (45.3%) had resuscitation discontinued on scene due to presumed futility after conversation with medical physician oversight. Of the transported patients, 5871 (54.8%) did not have a prehospital ROSC and met the inclusion criteria of our study (Fig. 2). Patient characteristics are listed in Table 1. Of these eligible patients,

Discussion

The results of our study indicate that using the absence of a prehospital ROSC as the sole criterion to terminate resuscitation in the field misses an unacceptably high number of potential survivors from OHCA, above the 1% defined as the threshold for medical futility.3, 4 Due to the increased rate of survival, it is important to consider the other contributory predictors of survival in the published Universal TOR Guideline. Sudden cardiac arrest is complex and dynamic process and it is

Limitations

Although the data presented was derived from a large population-based registry, there were several limitations in our study. First, like other observational studies, there was a risk of measurement bias in data collection. However, this risk was minimized with the use of trained data guardians, computerized error checks, and random re-abstraction. Second, confounding by indication may have resulted in certain patients who may have not been transported to the hospital. Confounding by indication

Conclusion

Employing the lack of prehospital ROSC as the sole criterion to terminate resuscitation in the prehospital setting is not recommended as this may lead to the termination of resuscitation in patients who may potentially survive. The validated Universal TOR Guideline, which is based on three criteria (shock delivered, EMS witnessed arrest and ROSC), misses <1% of patients who survive and it remains the best available tool to predict OHCA survival in the prehospital setting.

Conflict of interest statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.07.011.

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