Highlights
- •We compared PEA with Asystole in cases without bystander witness or bystander CPR.
- •Neurological outcome was more favorable in PEA than in Asystole.
- •Neurologically favorable survival rate was ≥1% in PEA even for patients aged ≥85 years.
- •Neurologically favorable survival rate was <1% in Asystole among all age groups.
- •PEA and Asystole should be distinguished from the perspective of medical futility.
Abstract
Background
Out-of-hospital cardiac arrest (OHCA) has a predominantly non-shockable rhythm. Non-shockable
rhythm, and the absence of a bystander witness or bystander cardiopulmonary resuscitation
(CPR) are associated with poor outcomes. However, the association between the type
of non-shockable rhythm and outcomes is not well known.
Objective
To examine the association between the initial rhythm and neurologically favorable
outcomes after non-shockable OHCA without a bystander witness or bystander CPR.
Methods
In a nationwide, population-based, cohort study, we analyzed 213,984 adult OHCA patients
with a non-shockable rhythm who had neither a bystander witness nor bystander CPR.
They were identified through the Japanese national OHCA registry data from January
1, 2005 to December 31, 2010. The primary outcome was neurologically favorable survival.
Results
Among 213,984 patients, the initial rhythm was Pulseless Electrical Activity (PEA)
in 31,179 patients (14.6%) and Asystole in 182,805 patients (85.4%). The neurological
outcome was more favorable in PEA than in Asystole (1.4% vs. 0.2%, p < 0.0001). After adjusting for age, sex, etiology of arrest, epinephrine administration,
advanced airway management, time from call to contact with patient, and calendar year,
PEA was associated with an increased neurologically favorable survival rate (odds
ratio 7.86; 95% confidence interval 6.81–9.07). In subgroup analysis stratified by
age group (18–64, 65–84, or ≥85 years), the neurologically favorable survival rate was ≥1% in PEA, even for patients aged ≥85 years, but <1% in Asystole among all age groups.
Conclusion
PEA and Asystole should not be considered to be identical to non-shockable rhythm,
but rather should be clearly distinguished from each other from the perspective of
quantitative medical futility.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to European Journal of Internal MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Part 1: executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.Circulation. 2010; 122: S250-S275
- Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2010; 122: S729-S767
- European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support.Resuscitation. 2010; 81: 1305-1352
- Current practice in out-of-hospital cardiac arrest management: a European heart rhythm association EP network survey.Europace. 2012; 14: 1195-1198
- Impact of intensified postresuscitation treatment on outcome of comatose survivors of out-of-hospital cardiac arrest according to initial rhythm.Resuscitation. 2014; 85: 1364-1369
- Recent trends in survival from out-of-hospital cardiac arrest in the United States.Circulation. 2014; 130: 1876-1882
- Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective.Circulation. 2003; 107: 2780-2785
- Factors associated with survival to hospital discharge among patients hospitalised alive after out of hospital cardiac arrest: change in outcome over 20 years in the community of Göteborg, Sweden.Heart. 2003; 89: 25-30
- Predictors of favorable and poor prognosis in unwitnessed out-of-hospital cardiac arrest with a non-shockable initial rhythm.Int J Cardiol. 2014; 176: 910-915
- Out-of-hospital cardiac arrest surveillance — Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010.MMWR Surveill Summ. 2011; 60: 1-19
- Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis.Circ Cardiovasc Qual Outcomes. 2010; 3: 63-81
- Derivation and evaluation of a termination of resuscitation clinical prediction rule for advanced life support providers.Resuscitation. 2007; 74: 266-275
- Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest.N Engl J Med. 2015; 372: 2307-2315
- Association of bystander interventions with neurologically intact survival among patients with bystander-witnessed out-of-hospital cardiac arrest in Japan.JAMA. 2015; 314: 247-254
- Association of bystander and first-responder intervention with survival after out-of-hospital cardiac arrest in North Carolina, 2010–2013.JAMA. 2015; 314: 255-264
- Part 3: ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.Circulation. 2010; 122: S665-S675
- Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest.N Engl J Med. 2006; 355: 478-487
- Prehospital termination of resuscitation in cases of refractory out-of-hospital cardiac arrest.JAMA. 2008; 300: 1432-1438
- Validation of a universal prehospital termination of resuscitation clinical prediction rule for advanced and basic life support providers.Resuscitation. 2009; 80: 324-328
- Comparison of termination-of-resuscitation guidelines for basic life support: defibrillator providers in out-of-hospital cardiac arrest.Ann Emerg Med. 2006; 47: 337-343
- International Liaison Committee on Resuscitation; American Heart Association; European Resuscitation Council; Australian Resuscitation Council; New Zealand Resuscitation Council; Heart and Stroke Foundation of Canada; InterAmerican Heart Foundation; Resuscitation Councils of Southern Africa; ILCOR Task Force on Cardiac Arrest and Cardiopulmonary Resuscitation Outcomes. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa).Circulation. 2004; 110: 3385-3397
- Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital ‘Utstein style’.Am Heart Assoc Circ. 1997; 95: 2213-2239
- Assessment of outcome after severe brain damage.Lancet. 1975; 1: 480-484
- Trends in outcomes for out-of-hospital cardiac arrest by age in Japan: an observational study.Medicine (Baltimore). 2015; 94e2049
- Outcomes following out-of-hospital cardiac arrest with an initial cardiac rhythm of asystole or pulseless electrical activity in Victoria, Australia.Resuscitation. 2014; 85: 1633-1639
- Progressing from initial non-shockable rhythms to a shockable rhythm is associated with improved outcome after out-of-hospital cardiac arrest.Resuscitation. 2009; 80: 24-29
- Subsequent ventricular fibrillation and survival in out-of-hospital cardiac arrests presenting with PEA or asystole.Resuscitation. 2008; 79: 34-40
- The relationship between shocks and survival in out-of-hospital cardiac arrest patients initially found in PEA or asystole.Resuscitation. 2007; 74: 418-426
- Dynamic effects of adrenaline (epinephrine) in out-of-hospital cardiac arrest with initial pulseless electrical activity (PEA).Resuscitation. 2012; 83: 946-952
- Neurologic outcome in comatose patients resuscitated from out-of-hospital cardiac arrest with prolonged downtime and treated with therapeutic hypothermia.Resuscitation. 2014; 85: 1042-1046
- A practical approach to the aetiology of pulseless electrical activity. A simple 10-step training mnemonic.Resuscitation. 1995; 30: 157-159
- Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest.JAMA. 2012; 307: 1161-1168
- Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest.JAMA. 2013; 309: 257-266
- Medical futility: its meaning and ethical implications.Ann Intern Med. 1990; 112: 949-954
- The rise and fall of the futility movement.N Engl J Med. 2000; 343: 293-296
- Do-not-resuscitate orders and medical futility.Arch Intern Med. 2003; 163: 2689-2694
Article info
Publication history
Published online: March 01, 2016
Accepted:
January 25,
2016
Received in revised form:
January 7,
2016
Received:
October 10,
2015
Footnotes
☆Contributors: T. Fukuda, the principal investigator, participated in the study con- ception, design and completion, the data collection, management, and analysis, the interpretation of results and the revision of the manuscript and contributed to the final report. N. Ohashi-Fukuda, T. Matsubara, K. Doi, Y. Kitsuta, S. Nakajima, and N. Yahagi participated in the study con- ception, the data collection and management, and the interpretation of results. T. Fukuda performed the statistical analysis. All of the authors approved the final version. T. Fukuda takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
☆☆Role of the funding source: We received no funding for this study. There were no sponsors who played a role in the data analysis, the data interpretation, or the compo- sition of the report. The FDMA collected and managed the data, but played no role in the design or performance of the study. The corre- sponding author had full access to all of the data in the study and had final responsibility for the decision to submit the manuscript for publication.
Identification
Copyright
© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
