Abstract 37: External Validation of Termination of Resuscitation Guidelines in the Setting of Intra-arrest Cold Saline, Mechanical CPR and Comprehensive Postresuscitation Care
Background: The development of Advanced Life Support (ALS) Termination of Resuscitation (TOR) guidelines for Out-of-Hospital Cardiac Arrest (OOH-CA) seeks to improve the efficiency of scarce pre-hospital resources. However, as pre-hospital treatment for OOH-CA evolves and survival improves, these TOR guidelines must be reevaluated in a contemporary context of EMS providing advanced resuscitation care.
Methods: Retrospective review of all adult (>18 years old), non-traumatic, OOH-CA patients (defined as patients with absence of pulse who received either CPR and/or defibrillation) treated by EMS in Richmond, Virginia, from January 1, 2009 to December 31, 2010. In addition to standard ALS, intra-arrest cold saline, mechanical CPR, and transportation to a comprehensive post-resuscitation center (CPRC) was provided. Survival at 30 days was presumed when death could not be verified from publically reportable sources.
Results: Of the 333 OOH-CA patients enrolled, the majority were male (59%), unwitnessed (52%), received no bystander CPR (67%), presented in a non-shockable initial rhythm (79%), with an average age of 62.5 years. Follow up data was obtained 324 (97.3%) of patients with overall survival of 19%, 15%, and 13% at 7, 14, and 30 days respectively. Of the 77 patients TOR guidelines recommended termination, none survived yielding both 100% specificity (95% CI 100- 92.8%) and positive predictive value (95% CI 100-94.1%). However, TOR guidelines recommended transport of 192 of the 269 patient who died, resulting in a sensitivity of 28.6% (95% CI 34.5-23.4%).
Conclusion: The TOR guidelines continue to have a reliable positive predictive value for death even in the setting of advanced EMS resuscitation methods and access to a CPRC. However, as the potential for survival from OOH-CA improves, the efficiency gained from their use is impacted greatly.
- © 2012 by American Heart Association, Inc.