Department of Emergency Medicine, University of California at San Francisco, San Francisco, CaliforniaUSA.
Prehosp Disaster Med. 2020 Jun;35(3):285-292. doi: 10.1017/S1049023X20000473.
Out-of-hospital cardiac arrest (OHCA) is a leading cause of death in the United States, and efforts have been made to develop termination of resuscitation protocols utilizing clinical criteria predictive of successful resuscitation and survival to discharge. A termination of resuscitation protocol utilizing longer resuscitation time and end-tidal carbon dioxide (EtCO2) monitoring criteria for termination was implemented for Emergency Medical Service (EMS) providers in an urban prehospital system in 2017. This study examines the effect the modified termination of resuscitation protocol had on rates of patient transport to a hospital, return of spontaneous circulation (ROSC), and survival to discharge.
A retrospective analysis was performed utilizing data from the Cardiac Arrest Registry to Enhance Survival (CARES) database. A total of 1,005 prehospital cardiac arrest patients 18 years and older from 2016 through 2017 were included in the analysis. Patients with traumatic cardiac arrest or had valid do-not-resuscitate orders were excluded. Unadjusted analysis using chi-square statistics was performed, including an analysis stratified by Utstein style reporting. Adjusted analysis was also performed using logistic regression with multiple imputation for missing values.
Unadjusted analysis showed a significant decrease in ROSC on emergency department (ED) arrival (30% versus 13%; P <.001) following the change in protocol. There was no significant difference in patient transport rate (62%) and a statistically non-significant decrease in overall survival (15% versus 11%). When stratified by Utstein style analysis, statistically significant decreases in ED arrival with ROSC were seen for unwitnessed asystolic, as well as bystander witnessed asystolic, pulseless electrical activity (PEA), and shockable OHCA. Adjusted analysis showed a decreased likelihood of ROSC with the protocol change (0.337; 95% CI, 0.235-0.482).
The modification of termination of resuscitation protocol was not associated with a statistically significant change in transport rate or survival. A significant decrease in rate of arrivals to the ED with ROSC was seen, particularly for bystander witnessed OHCA.
院外心脏骤停（OHCA）是美国的主要死亡原因，人们已经努力制定复苏终止协议，利用预测成功复苏和出院存活的临床标准。2017 年，在城市院前系统中，为急诊医疗服务（EMS）提供者实施了一项利用较长复苏时间和呼气末二氧化碳（EtCO2）监测标准来终止复苏的复苏终止协议。本研究探讨了修改后的复苏终止协议对患者转运至医院、自主循环恢复（ROSC）和出院存活率的影响。
利用心脏骤停登记以提高存活率（CARES）数据库中的数据进行回顾性分析。纳入了 2016 年至 2017 年期间的 1005 例年龄在 18 岁及以上的院前心脏骤停患者。排除创伤性心脏骤停或有有效的不复苏医嘱的患者。使用卡方检验进行未调整分析，包括按 Utstein 报告模式进行的分层分析。使用逻辑回归进行调整分析，并对缺失值进行多重插补。
未调整分析显示，协议改变后，急诊科（ED）到达时 ROSC 显著下降（30%对 13%；P<0.001）。转运率无显著差异（62%），总体存活率略有下降（15%对 11%）。按 Utstein 分析模式分层，未目击的心脏停搏、旁观者目击的心脏停搏、无脉性电活动（PEA）和可电击性 OHCA 的 ED 到达时 ROSC 显著下降。调整分析显示，随着协议的改变，ROSC 的可能性降低（0.337；95%置信区间，0.235-0.482）。
复苏终止协议的修改与转运率或存活率无统计学显著变化相关。ED 到达时 ROSC 的比例显著下降，尤其是旁观者目击的 OHCA。
