Early Prediction of Quality Survival After Cardiac Arrest with Return of Spontaneous Circulation
Administration and Operational Issues, Cardinal Presentations / Presenting Problems, Cardiovascular, Critical Care / Resuscitation, Neurological
First 5 Minutes
- All patients should be aggressively treated to reverse the cause, stabilize hemodynamics and ventilation, and prevent hyperthermia.
- Do not try to predict futility of resuscitative efforts in the Emergency Department (ED).
- When we receive a patient in the ED who has suffered cardiac arrest and remains comatose we would like to be able to predict whether that patient has a chance of good neurologic outcome or no chance.
- However, the circumstances of the arrest (witnessed, duration, bystander CPR, initial rhythm, age, etc.) have never been shown to predict outcomes.
- It is important in the initial stages that we provide optimum critical support to all of these patients until the course is better defined.
- Appropriate ventilation and oxygenation.
- Hemodynamic support if necessary.
- Temperature management to prevent hyperthermia.
- Search for and correction of all potential causes and cardiac catheterization if there is evidence of acute ischemia.
- The exception to this approach is for patients who have clear advanced directives defining the patient’s choice that they would not want aggressive resuscitation.
- Many clinicians use their own experiences to predict the likelihood of survival even with full critical care.
- However, a recent comprehensive review from 2023 concluded that we need to let several days pass and use multiple predictors to ensure we are not contributing to a self-fulfilling prophecy.
- Literature was reviewed regarding initial arrest circumstances, focused neurologic exam, myoclonus and seizures, serum biomarkers, neuroimaging, neurophysiologic testing and multimodal prognostication.
- From the emergency perspective and early decision-making, over 3000 papers were systematically reviewed. They were of low to moderate quality most often due to lack of clear withdrawal guidelines or small sample size.
- No early clinical score, attributes of the early neurologic examination or early lab tests were accurate enough to predict poor outcome without risking harming potential survivors.
- The study team concluded that care during the first 48 hours should focus on stabilization and neuroprotection.
This point of care summary focuses on early decisions to withdraw life support. Proactive critical care for these patients is beyond the scope of this paper.
Criteria For Hospital Admission
All patients who have had hemodynamics stabilized or require invasive investigations or advanced treatments to stabilize should be admitted to hospital. If the patient continues to re-arrest or is in profound shock, all attempts to stabilize the patient should be provided in the ED.
Criteria For Transfer To Another Facility
If ICU support is not available in your facility, patients should be transported to a hospital with high level ICU care and cardiac intervention capability.
Criteria For Close Observation And/or Consult
All patients who suffered cardiac arrest will require close, monitored observation in conjunction with ICU and other appropriate consultation. The above guidance refers to patients who remain comatose. Those who have responded quickly and wake up will require investigations to determine the cause and reverse it or provide other therapies (e.g., ICD placement) to prevent recurrence.
Criteria For Safe Discharge Home
No patient who suffered true cardiac arrest should be discharged from the ED. On occasion a patient with respiratory arrest who were unresponsive and not breathing are believed to be in cardiac arrest at the scene. If reversal with naloxone or ventilatory support was all that was required to stabilize the patient and they are awake and neurologically normal, they were not truly in cardiac arrest. If investigations rule out other non-overdose causes then discharge with appropriate support to prevent further overdose can be considered.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
It is hard to define the quality of evidence when there are no quality positive results. We reviewed over 3000 papers related to early prognostication and none provided high level evidence that any clinical or early lab predictors would allow us to confidently withdraw maximum care without risking losing potential survivors.
Christopher B. Fordyce, MD, MHS, MSc, Andreas H. Kramer, MD, MSc, Craig Ainsworth, MD, Jim Christenson, MD, Gary Hunter, MD, Julie Kromm, MD, Carmen Lopez Soto, MD, MSc, Damon C. Scales, MD, PhD, Mypinder Sekhon, MD, PhD, Sean van Diepen, MD, MSc, Laura Dragoi, MD, MSc, Colin Josephson, MD, Jim Kutsogiannis, MD, PhD, Michel R. Le May, MD, Christopher B. Overgaard, MD, Martin Savard, MD, Gregory Schnell, MD, Graham C. Wong, MD, MPH, Emilie Belley-Côte, MD, PhD. Neuroprognostication in the Post Cardiac Arrest Patient: A Canadian Cardiovascular Society Position Statement.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Apr 24, 2023
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