Ian R Drennan1, Erin Case2, P Richard Verbeek3, Joshua C Reynolds4, Zachary D Goldberger5, Jamie Jasti6, Mark Charleston7, Heather Herren8, Ahamed H Idris9, Paul R Leslie10, Michael A Austin11, Yan Xiong12, Robert H Schmicker13, Laurie J Morrison14. 1. Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, 30 Bond St. Toronto, Ontario M5B 1W8, Canada. Electronic address: DrennanI@smh.ca. 2. Clinical Trial Center, University of Washington Department of Biostatistics, Seattle, WA 98103, United States. Electronic address: ecase@uw.edu. 3. Sunnybrook Centre for Prehospital Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. Electronic address: richard.verbeek@sunnybrook.ca. 4. Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, United States. Electronic address: Reyno406@msu.edu. 5. University of Washington School of Medicine, Department of Internal Medicine, Division of Cardiology, Harborview Medical Center, Seattle, WA, United States. Electronic address: zgoldber@uw.edu. 6. Resuscitation Research Centre, Department of Emergency Medicine, Medical College of Wisconsin, WI, United States. Electronic address: jjasti@mcw.edu. 7. Tualatin Valley Fire and Rescue, OR, United States. Electronic address: Mark.Charleston@tvfr.com. 8. ROC Clinical Trial Center, University of Washington, Seattle, WA, United States. Electronic address: hherren@uw.edu. 9. Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, United States. Electronic address: aidris@sbcglobal.net. 10. British Columbia Emergency Health Services, British Columbia, Canada. Electronic address: Paul.Leslie@bcehs.ca. 11. The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada. Electronic address: Maustin@toh.on.ca. 12. Departments of Emergency Medicine and Internal Medicine, University of Texas Southwestern Medical Center, United States. Electronic address: Way1111@126.com. 13. Clinical Trial Center, University of Washington Department of Biostatistics, Seattle, WA 98103, United States. Electronic address: rschmick@uw.edu. 14. Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Division of Emergency Medicine, Department of Medicine, University of Toronto, Ontario, Canada. Electronic address: morrisonl@smh.ca.
Abstract
INTRODUCTION: The Universal Termination of Resuscitation (TOR) Guideline accurately identifies potential out-of-hospital cardiac arrest (OHCA) survivors. However, implementation is inconsistent with some Emergency Medical Service (EMS) agencies using absence of return of spontaneous circulation (ROSC) as sole criterion for termination. OBJECTIVE: To compare the performance of the Universal TOR Guideline with the single criterion of no prehospital ROSC. Second, to determine factors associated with survival for patients transported without a ROSC. Lastly, to compare the impact of time to ROSC as a marker of futility to the Universal TOR Guideline. DESIGN: Retrospective, observational cohort study. PARTICIPANTS: Non-traumatic, adult (≥18 years) OHCA patients of presumed cardiac etiology treated by EMS providers. SETTING: ROC-PRIMED and ROC-Epistry post ROC-PRIMED databases between 2007 and 2011. OUTCOMES: Primary outcome was survival to hospital discharge and the secondary outcome was functional survival. We used multivariable regression to evaluate factors associated with survival in patients transported without a ROSC. RESULTS: 36,543 treated OHCAs occurred of which 9467 (26%) were transported to hospital without a ROSC. Patients transported without a ROSC who met the Universal TOR Guideline for transport had a survival of 3.0% (95% CI 2.5-3.4%) compared to 0.7% (95% CI 0.4-0.9%) in patients who met the Universal TOR Guideline for termination. The Universal TOR Guideline identified 99% of survivors requiring continued resuscitation and transportation to hospital including early identification of survivors who sustained a ROSC after extended durations of CPR. CONCLUSION: Using absence of ROSC as a sole predictor of futility misses potential survivors. The Universal TOR Guideline remains a strong predictor of survival.
INTRODUCTION: The Universal Termination of Resuscitation (TOR) Guideline accurately identifies potential out-of-hospital cardiac arrest (OHCA) survivors. However, implementation is inconsistent with some Emergency Medical Service (EMS) agencies using absence of return of spontaneous circulation (ROSC) as sole criterion for termination. OBJECTIVE: To compare the performance of the Universal TOR Guideline with the single criterion of no prehospital ROSC. Second, to determine factors associated with survival for patients transported without a ROSC. Lastly, to compare the impact of time to ROSC as a marker of futility to the Universal TOR Guideline. DESIGN: Retrospective, observational cohort study. PARTICIPANTS: Non-traumatic, adult (≥18 years) OHCA patients of presumed cardiac etiology treated by EMS providers. SETTING: ROC-PRIMED and ROC-Epistry post ROC-PRIMED databases between 2007 and 2011. OUTCOMES: Primary outcome was survival to hospital discharge and the secondary outcome was functional survival. We used multivariable regression to evaluate factors associated with survival in patients transported without a ROSC. RESULTS: 36,543 treated OHCAs occurred of which 9467 (26%) were transported to hospital without a ROSC. Patients transported without a ROSC who met the Universal TOR Guideline for transport had a survival of 3.0% (95% CI 2.5-3.4%) compared to 0.7% (95% CI 0.4-0.9%) in patients who met the Universal TOR Guideline for termination. The Universal TOR Guideline identified 99% of survivors requiring continued resuscitation and transportation to hospital including early identification of survivors who sustained a ROSC after extended durations of CPR. CONCLUSION: Using absence of ROSC as a sole predictor of futility misses potential survivors. The Universal TOR Guideline remains a strong predictor of survival.
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