Romolo Gaspari1, Anthony Weekes2, Srikar Adhikari3, Vicki Noble4, Jason T Nomura5, Daniel Theodoro6, Michael Woo7, Paul Atkinson8, David Blehar9, Samuel Brown10, Terrell Caffery11, Emily Douglass4, Jacqueline Fraser12, Christine Haines13, Samuel Lam14, Michael Lanspa10, Margaret Lewis2, Otto Liebmann15, Alexander Limkakeng16, Fernando Lopez16, Elke Platz17, Michelle Mendoza9, Hal Minnigan18, Christopher Moore19, Joseph Novik20, Louise Rang21, Will Scruggs22, Christopher Raio13. 1. University of Massachusetts Medical School, Worcester, MA, United States. Electronic address: Romolo.Gaspari@umassmemorial.org. 2. Carolinas Medical Center, Charlotte, NC, United States. 3. University of Arizona, Tucson, AZ, United States. 4. Massachusetts General Hospital, Boston, MA, United States. 5. Christiana Care Health Systems, Newark, DE, United States. 6. Washington University School of Medicine, St Louis, MO, United States. 7. University of Ottawa, Ottawa, ON, Canada. 8. Dalhousie University, Saint John, NB, Canada. 9. University of Massachusetts Medical School, Worcester, MA, United States. 10. University of Utah, Salt Lake City, UT, United States. 11. LSU Health Sciences Center, Baton Rouge, LA, United States. 12. Saint John Regional Hospital, Saint John, NB, Canada. 13. North Shore University Hospital, Manhasset, NY, United States. 14. Advocate Christ Medical Center, Chicago, IL, United States. 15. Brown University, Providence, RI, United States. 16. Duke University School of Medicine, Durham, NC, United States. 17. Brigham and Women's Hospital, Boston, MA, United States. 18. Indiana University, Tiptin, IN, United States. 19. Yale University School of Medicine, New Haven, CT, United States. 20. NYU Bellevue Hospital, New York, NY, United States. 21. Kingston General Hospital, Kingston, ON, Canada. 22. Castle Hospital, Kailua, HI, United States.
Abstract
OBJECTIVE: Our objective was to determine whether organized or disorganized cardiac activity is associated with increased survival in patients who present in pulseless electrical activity (PEA) treated with either 1) standard advanced cardiac life support (ACLS) medications or 2) other interventions. METHODS: This was a secondary analysis of a prospective, multi-center observational study utilizing ultrasound in out-of-hospital or inemergency department PEA arrest. Bedside ultrasound was performed as ACLS protocol started and during pulse checks. Only cases with visible cardiac activity on ultrasound were included in the present analysis. Cardiac activity was categorized as disorganized (agonal twitching) or organized (contractions with changes in ventricular dimensions). Patients were categorized as receiving either standard bolus ACLS medications or alternative medications during the resuscitation (continuous adrenergic agents, thrombolytics, others). The primary outcome was survival to hospital admission. The secondary outcome was return of spontaneous circulation (ROSC). Multivariate modeling was performed to assess association between survival to hospital admission in patients with intravenous adrenergic agents and cardiac activity. RESULTS: In our cohort of 225 patients in PEA cardiac arrest with cardiac activity on ultrasound, the overall survival rate was higher in patients with organized cardiac activity than with disorganized cardiac activity. PEA cardiac arrest patients with organized cardiac activity treated with standard ACLS interventions demonstrated improved survival to hospital admission compared to those with disorganized activity (37.7% (95%CI 24.8-50.2%) versus 17.9% (95%CI 10.9-28%). PEA cardiac arrest patients with organized cardiac activity who received continuous adrenergic agents during the resuscitation and prior to ROSC demonstrated higher survival to hospital admission 45.5% (95%CI 26.9-65.4%) and ROSC 90.9% (95%CI 71.0-98.7%) compared to those with disorganized cardiac activity who received continuous adrenergic agents during the resuscitation 0% (95%CI 0-23.0%) and 47.1% (95%CI 26-69%). Regression analysis demonstrates an association between increased survival in patients receiving intravenous adrenergic agents and organized cardiac activity. CONCLUSION: Survival in patients following PEA arrest is higher in patients with organized cardiac activity. The initiation of continuous adrenergic agents during PEA was associated with improved survival to hospital admission in patients with organized cardiac activity on bedside ultrasound, but this improvement was not seen in patients in PEA with disorganized cardiac activity. Bedside ultrasound may identify a subset of patients that respond differently to ACLS interventions.
OBJECTIVE: Our objective was to determine whether organized or disorganized cardiac activity is associated with increased survival in patients who present in pulseless electrical activity (PEA) treated with either 1) standard advanced cardiac life support (ACLS) medications or 2) other interventions. METHODS: This was a secondary analysis of a prospective, multi-center observational study utilizing ultrasound in out-of-hospital or inemergency department PEA arrest. Bedside ultrasound was performed as ACLS protocol started and during pulse checks. Only cases with visible cardiac activity on ultrasound were included in the present analysis. Cardiac activity was categorized as disorganized (agonal twitching) or organized (contractions with changes in ventricular dimensions). Patients were categorized as receiving either standard bolus ACLS medications or alternative medications during the resuscitation (continuous adrenergic agents, thrombolytics, others). The primary outcome was survival to hospital admission. The secondary outcome was return of spontaneous circulation (ROSC). Multivariate modeling was performed to assess association between survival to hospital admission in patients with intravenous adrenergic agents and cardiac activity. RESULTS: In our cohort of 225 patients in PEA cardiac arrest with cardiac activity on ultrasound, the overall survival rate was higher in patients with organized cardiac activity than with disorganized cardiac activity. PEA cardiac arrestpatients with organized cardiac activity treated with standard ACLS interventions demonstrated improved survival to hospital admission compared to those with disorganized activity (37.7% (95%CI 24.8-50.2%) versus 17.9% (95%CI 10.9-28%). PEA cardiac arrestpatients with organized cardiac activity who received continuous adrenergic agents during the resuscitation and prior to ROSC demonstrated higher survival to hospital admission 45.5% (95%CI 26.9-65.4%) and ROSC 90.9% (95%CI 71.0-98.7%) compared to those with disorganized cardiac activity who received continuous adrenergic agents during the resuscitation 0% (95%CI 0-23.0%) and 47.1% (95%CI 26-69%). Regression analysis demonstrates an association between increased survival in patients receiving intravenous adrenergic agents and organized cardiac activity. CONCLUSION: Survival in patients following PEA arrest is higher in patients with organized cardiac activity. The initiation of continuous adrenergic agents during PEA was associated with improved survival to hospital admission in patients with organized cardiac activity on bedside ultrasound, but this improvement was not seen in patients in PEA with disorganized cardiac activity. Bedside ultrasound may identify a subset of patients that respond differently to ACLS interventions.
Authors: Mustapha Amin; Danesh Kella; Ammar M Killu; Deepak Padmanabhan; David O Hodge; Michael A Golafshar; Alanna M Chamberlain; Justin Z Lee; Win-Kuang Shen; Paul A Friedman; Samuel J Asirvatham; Véronique L Roger; Bernard J Gersh; Siva K Mulpuru Journal: J Cardiovasc Electrophysiol Date: 2019-10-17
Authors: Romolo Gaspari; Justin Harvey; Christopher DiCroce; Ari Nalbandian; Michael Hill; Robert Lindsay; Alexandra Nordberg; Powell Graham; Andrew Kamilaris; Timothy Gleeson Journal: Resusc Plus Date: 2021-03-06
Authors: Felipe Teran; Claire Centeno; Alexander L Lindqwister; William J Hunckler; William P Landis; Karen L Moodie; Frances S Shofer; Benjamin S Abella; Norman A Paradis Journal: Resusc Plus Date: 2021-04-02