Successful out-of-hospital cardiopulmonary resuscitation: what is the optimal in-hospital treatment strategy?
Introduction
In-hospital management of patients surviving out-of-hospital resuscitation (OHR) is complicated by uncertainty about prognosis. Also, the markers for adverse outcome still need to be identified. Most predictors for prognosis (such as the Glasgow coma score (GCS)) can not be relied on for at least 72 h after successful OHR [1], [2], [3], [4], [5], [6], [7], [8].
Early and accurate assessment of prognosis after survival of initial OHR is needed to plan for different treatment strategies for acute myocardial infarction (AMI) in cardiac arrest.
The role and effectiveness of reperfusion therapies in patients surviving OHR secondary to AMI is still being discussed. Prolonged cardiopulmonary resuscitation (CPR) is considered to be a contraindication for the use of thrombolytic agents in the treatment of AMI. Mechanical recanalisation of the obstructed artery via percutaneous transluminal coronary angioplasty (PTCA) is assumed to be a safer and more effective treatment in such patients. However, it is questionable to perform this procedure routinely in patients with a bad neurological prognosis.
Van Campen et al. [9] found that thrombolytic therapy for AMI, despite prolonged CPR, was safe and did not have a higher incidence of CPR-related bleeding complications than the PTCA treatment. These findings were also reported by Tenaglia [10] and Scholz [11].
The purpose of our study is to identify prognostic factors in OHR survivors and to test them in a prospective model.
Section snippets
Emergency medical system configuration
Nijmegen and the surrounding area consists of approximately 250 000 inhabitants. The city of Nijmegen has a community hospital and a University Hospital. Patients from Nijmegen and the surrounding area were sent to one of these hospitals. Ambulances were dispatched by one ambulance dispatch centre located in the city of Nijmegen. The ambulances are staffed by a driver with a paramedical background and a nurse who has the skills and permission to administer inotropic drugs and use a
Results
During the study period a total of 78 patients were admitted alive after OHR at the emergency department of the University Hospital Nijmegen. Six patients were excluded because of insufficient data. The mean age of the remaining 72 patients was 65 years and 65% (47/72) were male. Ventricular fibrillation (VF) was present in 60%. Other relevant data are listed in Table 1.
Discussion
Reperfusion therapy for acute myocardial infarction using either primary angioplasty or thrombolytic agents has become standard treatment and results in reduced morbidity and mortality.
In patients with out of hospital cardiac arrest the prevalence of acute coronary occlusion varies from 50 to 100%. Lo and co-workers [12] studied the angiographic coronary morphology in 49 survivors of cardiac arrest. All patients had 50% stenotic of one coronary artery. Spaulding et al. [13] found that 48% of
Conclusions
In-hospital mortality after successful out-of-hospital CPR largely depends on the neurological status at admission and much less on the specific treatment of myocardial infarction. If the prognostic scoring system has been proven successful in a prospective study, it may be used for planning early treatment.
References (27)
- et al.
Safety and efficacy of thrombolysis for acute myocardial infarction in patients with prolonged out-of-hospital cardiopulmonary resuscitation
Am. J. Cardiol.
(1994) - et al.
Thrombolytic therapy in patients requiring cardiopulmonary resuscitation
Am. J. Cardiol.
(1991) - et al.
Frequency of complications of cardiopulmonary resuscitation after thrombolysis during acute myocardial infarction
Am. J. Cardiol.
(1992) - et al.
Primary coronary angioplasty for acute myocardial infarction complicated by out-of-hospital cardiac arrest
Am. J. Cardiol.
(1995) - et al.
Early prediction of individual outcome after cardiopulmonary resuscitation
Lancet
(1993) - et al.
Predictions of survival after out-of-hospital cardiac arrest: results of a community-based study in Vienna
Resuscitation
(1996) - et al.
Predictors of early and late survival after out-of-hospital cardiac arrest in which asystole was the first recorded arrhythmia on scene
Resuscitation
(1994) - et al.
Survival after cardiac arrest outside hospital over a 12-year period in Gothenburg
Resuscitation
(1994) - et al.
In hospital mortality after out-of-hospital cardiac arrest
Lancet
(1995) - et al.
Predictive value of Glasgow Coma Score for awakening after out-of-hospital-cardiac arrest
Lancet
(1988)