Lupton Joshua R, Jui Jonathan, Neth Matthew R, Sahni Ritu, Daya Mohamud R, Newgard Craig D
Department of Emergency Medicine, Oregon Health and Science University, United States.
Department of Emergency Medicine, Oregon Health and Science University, United States.
Resuscitation. 2022 Dec;181:60-67. doi: 10.1016/j.resuscitation.2022.10.010. Epub 2022 Oct 22.
Nearly half of ventricular fibrillation or ventricular tachycardia (VF/VT) out-of-hospital cardiac arrest (OHCA) patients receive three or more shocks, often referred to as refractory VF/VT. Our objective was to derive a clinical decision rule (CDR) for the early stratification of patients into risk categories for refractory VF/VT.
We included adults with non-traumatic OHCA in the Resuscitation Outcomes Consortium Epistry (2011-2015) with ≥ 1 EMS shock. We used Classification and Regression Tree analysis for CDR building using variables known at initial EMS rhythm analysis including age, sex, witness, location, bystander interventions, initial EMS rhythm, obvious non-cardiac etiology, and dispatch to arrival times. The outcome was refractory VF/VT (≥3 shocks). We calculated sensitivity, specificity, area under the receiver operating curve (AUROC), and odds ratios (OR). The rule was validated using the Portland Cardiac Arrest Epidemiologic Registry (2018-2020).
There were 17,140 eligible patients and 8,146 (47.5%) had refractory VF/VT. The optimal CDR (AUROC = 0.671) defined three groups: high-risk were any patients requiring an EMS shock after a bystander AED shock; moderate-risk were any non-EMS witnessed arrests with shockable initial EMS rhythms; and the remainder were low-risk. Refractory VF/VT increased across the low (30.7%), moderate (58.5%) and high-risk (84.8%) groups. Compared to low-risk, being moderate-risk or higher (OR [95% CI]:3.37 [3.16-3.59]; sensitivity 72.7%; specificity 55.9%) or high-risk (OR:12.63 [9.89-16.13]; sensitivity 5.4%; specificity 99.1%) had higher odds of refractory VF/VT. Results was similar in the validation cohort (n = 765, AUROC = 0.672).
Patients at higher risk for refractory VF/VT can be identified early in EMS care.
近一半的院外心脏骤停（OHCA）患者出现心室颤动或室性心动过速（VF/VT）时接受了三次或更多次电击，通常称为难治性VF/VT。我们的目标是得出一项临床决策规则（CDR），用于将患者早期分层为难治性VF/VT的风险类别。
我们纳入了复苏结果联盟Epistry（2011 - 2015年）中≥1次急救医疗服务（EMS）电击的非创伤性OHCA成年患者。我们使用分类与回归树分析构建CDR，使用初始EMS节律分析时已知的变量，包括年龄、性别、目击者、地点、旁观者干预措施、初始EMS节律、明显的非心脏病因以及调度到到达时间。结局为难治性VF/VT（≥3次电击）。我们计算了敏感性、特异性、受试者操作特征曲线下面积（AUROC）和比值比（OR）。该规则在波特兰心脏骤停流行病学登记处（2018 - 2020年）进行了验证。
有17140例符合条件的患者，8146例（47.5%）患有难治性VF/VT。最佳CDR（AUROC = 0.671）定义了三组：高风险组为在旁观者自动体外除颤器（AED）电击后需要EMS电击的任何患者；中风险组为任何非EMS目击的可电击初始EMS节律的心脏骤停患者；其余为低风险组。难治性VF/VT在低风险组（30.7%）、中风险组（58.5%）和高风险组（84.8%）中呈上升趋势。与低风险组相比，中风险或更高风险组（OR [95% CI]：3.37 [3.16 - 3.59]；敏感性72.7%；特异性55.9%）或高风险组（OR：12.63 [9.89 - 16.13]；敏感性5.4%；特异性99.1%）发生难治性VF/VT的几率更高。验证队列（n = 765，AUROC = 0.672）的结果相似。
在EMS救治早期即可识别出难治性VF/VT风险较高的患者。
