Impact of Transitory ROSC Events on Neurological Outcome in Patients with Out-of-Hospital Cardiac Arrest

Dynamic Course of Clinical State Transitions in Patients Undergoing Advanced Life Support after Out-of-Hospital Cardiac Arrest

OBJECTIVES

Studies of out-of-hospital cardiac arrest generally document the presenting (pulseless electrical activity [PEA], ventricular fibrillation/tachycardia (VF/VT), asystole), and the final states (resuming stable spontaneous circulation [s-ROSC], being declared dead). Only a few studies described the transitions between clinical states during advanced life support (ALS). The aim of this study was to describe and analyze the dynamics of state transitions during ALS.

METHODS

A retrospective analysis of 464 OHCA events was conducted. Any observed state and its corresponding changing time were documented through continuous electrocardiographic and trans-thoracic impedance recording.

RESULTS

When achieved, most s-ROSCs were obtained by 30 min, regardless of the presenting state. After this time point, the persistence of any transient state was associated with a great probability of being declared dead. The most probable change for VF/VT or PEA at any time was the transition to asystole (36.4% and 34.4%, respectively); patients in asystole at any time had a 70% probability of death. Patients achieving s-ROSC mostly came from a VF/VT state.In most cases, the presenting rhythm tended to persist over time during ALS. Asystole was the most stable state; a higher degree of instability was observed when the presenting rhythms were VF/VT or PEA. Transient ROSC episodes occurred mainly as the first transition after the presenting state, especially for initial PEA.

CONCLUSIONS

An understanding of the dynamic course of clinical state transitions during ALS may allow treatment strategies to be tailored in patients affected by OHCA.

Successful Coil Embolization Using Percutaneous Cardiopulmonary Support in a Patient with Refractory Out-of-hospital Cardiac Arrest Caused by Aneurysmal Subarachnoid Hemorrhage

In recent years, extracorporeal cardiopulmonary resuscitation (ECPR) has been reported to be an effective alternative to conventional CPR for treating patients with reversible causes of cardiac arrest. Nevertheless, the definite indication for ECPR and also surgical interventions during ECPR treatment have not been established, especially in patients with out-of-hospital cardiac arrest (OHCA) caused by subarachnoid hemorrhage (SAH). We treated a comatose 50-year-old woman with refractory cardiac arrest due to aneurysmal SAH-induced takotsubo cardiomyopathy (TCM). The initial cardiac rhythm was ventricular fibrillation. This is the first case report on coil embolization being successfully performed on a patient undergoing ECPR and therapeutic hypothermia (TH) while the patient was still in cardiac arrest, which resulted in complete social rehabilitation. Moreover, the success of this treatment suggests that ECPR and endovascular therapy should be considered for highly selected patients when cardiopulmonary and neurological functions are potentially reversible even in the setting of SAH.

Factors associated with prolonged cardiopulmonary resuscitation attempts in out-of-hospital cardiac arrest patients presenting to the emergency department

BACKGROUND

There is high variability among clinicians' decision of appropriate cardiopulmonary resuscitation (CPR) duration before deciding for termination of resuscitation. This study attempted to investigate factors associated with the decision to prolong resuscitation attempts in cardiac arrest patients treated in an emergencydepartment (ED).

METHODS

A retrospective study that evaluated two years of mortality registry starting in 2015 was conducted in the ED of University Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia. Adult out-hospital cardiac arrest (OHCA) patients treated in the ED were included. Multivariate logistic regression analysis was utilized for the exploration of factors associated with prolonged CPR attempts (> 30min).

RESULTS

The median CPR duration was 24min (range 2-68min). Four variables were independently associated with prolonged CPR attempts: younger age (OR, 0.97; 95% CI, 0.95-0.99; p<0.001), pre-existing heart disease (OR, 1.97; 95% CI, 1.07-3.65; p=0.031), occurrence of transient return of spontaneous circulation (ROSC) (OR, 2.38; 95% CI, 1.05-5.36; p=0.037), and access to the ED by nonemergency medical services (EMS) transport (OR, 1.92; 95% CI, 1.09-3.37; p=0.024).

CONCLUSION

Patient-related and access-related factors were associated with prolonged CPR attempts among OHCA patients resuscitated in the ED.