Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan.
Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan.
J Cardiol. 2019 Mar;73(3):240-246. doi: 10.1016/j.jjcc.2018.12.002. Epub 2018 Dec 20.
Guidelines for cardiopulmonary resuscitation (CPR) recommend using the universal termination-of-resuscitation (TOR) rule to identify out-of-hospital cardiac arrest (OHCA) patients eligible for field termination of resuscitation, thus avoiding medically futile transportation to the hospital. However, in Japan, emergency medical services (EMS) personnel are forbidden from terminating CPR in the field and transport almost all patients with OHCA to hospitals. We aimed to develop and validate a novel TOR rule to identify patients eligible for field termination of CPR.
We analyzed 540,478 patients with OHCA from 2011 to 2015 using a Japanese registry. Main outcome measures were specificity and positive predictive value (PPV) of the newly developed TOR rule in predicting 1-month mortality after OHCA.
Recursive partitioning analysis in the development group (n=434,208) showed that EMS personnel could consider TOR if patients with OHCA met all of the following five criteria: (1) initial asystole, (2) arrest unwitnessed by a bystander, (3) age ≥81 years, (4) no bystander-administered CPR or automated external defibrillator use before EMS arrival, and (5) no return of spontaneous circulation after EMS-initiated CPR for 14min. For patients meeting these criteria, specificity and PPV for predicting 1-month mortality were 99.2% [95% confidence interval (CI), 99.0-99.3%] and 99.7% (95% CI, 99.6-99.7%), respectively, for the development group and were 99.5% (95% CI, 99.3-99.7%) and 99.8% (95% CI, 99.7-99.9%), respectively, for the validation group. Implementation of this novel rule would reduce patient transports to hospitals by 10.6% in the development group and 10.4% in the validation group.
Having both high specificity and PPV of >99% for predicting 1-month mortality, our developed TOR rule may be applied in the field for Japanese patients with OHCA who meet all five criteria. Prospective validation studies and establishment of prehospital EMS protocol are required before implementing this rule.
心肺复苏（CPR）指南建议使用通用终止复苏（TOR）规则来识别适合现场终止复苏的院外心脏骤停（OHCA）患者，从而避免对无意义的医疗救治进行无效的转运至医院。然而，在日本，急救医疗服务（EMS）人员被禁止在现场终止 CPR，并几乎将所有 OHCA 患者转运至医院。我们旨在开发和验证一种新的 TOR 规则，以识别适合现场终止 CPR 的患者。
我们使用日本登记处分析了 2011 年至 2015 年期间的 540478 名 OHCA 患者。主要结局指标是新开发的 TOR 规则在预测 OHCA 后 1 个月死亡率方面的特异性和阳性预测值（PPV）。
在开发组（n=434208）中进行递归分区分析显示，如果满足以下五个标准的 OHCA 患者，EMS 人员可以考虑 TOR：（1）初始为心搏停止，（2）无旁观者见证的骤停，（3）年龄≥81 岁，（4）在 EMS 到达之前无旁观者实施的 CPR 或自动体外除颤器使用，以及（5）EMS 开始 CPR 14 分钟后无自主循环恢复。对于符合这些标准的患者，开发组的特异性和 PPV 分别为 99.2%（95%CI，99.0-99.3%）和 99.7%（95%CI，99.6-99.7%），验证组分别为 99.5%（95%CI，99.3-99.7%）和 99.8%（95%CI，99.7-99.9%）。在开发组和验证组中，该新规则的实施将分别减少 10.6%和 10.4%的患者转运至医院。
对于符合所有五个标准的日本 OHCA 患者，我们开发的 TOR 规则具有>99%的高特异性和 PPV 预测 1 个月死亡率，可在现场应用。在实施该规则之前，需要进行前瞻性验证研究和建立院前 EMS 协议。
