Elsevier

Resuscitation

Volume 47, Issue 2, October 2000, Pages 155-161
Resuscitation

Successful out-of-hospital cardiopulmonary resuscitation: what is the optimal in-hospital treatment strategy?

https://doi.org/10.1016/S0300-9572(00)00217-3Get rights and content

Abstract

The aim of the study was to evaluate prognostic factors in patients after successful out-of-hospital resuscitation (sOHR) within 30 min after admission. A prognostic scoring scale in patients surviving OHR was analysed. We also studied the effect of these predictive factors and the in-hospital treatment (percutaneous transluminal coronary angioplasty (PTCA) vs. thrombolysis) on mortality. We performed a retrospective analysis of the emergency medical system forms and medical files of 72 consecutive patients aged ≥18 years with sOHR. Of these 72 patients 37 (51%) met the electrocardiographic and enzymatic criteria for acute myocardial infarction (AMI). Ten of the 37 AMI patients (27%) underwent acute PTCA as primary treatment and seven patients (19%) received thrombolytic therapy for AMI despite prolonged (mean 24±13 min) cardiopulmonary resuscitation (CPR). The remaining 20 patients had no specific infarct treatment. Despite successful PTCA, in eight out of ten patients, their mortality in hospital was 60% (6/10). Mortality in the thrombolysis group was 57% (4/7). For the remaining 20 MI-patients the mortality was 65% (13/20). Univariate and multivariate analyses were performed to design a weighted prognostic scoring system. The Glasgow coma scale (GCS) was the strongest independent predictor (r=0.76, P≤0.001) for in-hospital death. Conclusions: in-hospital mortality after successful OHR seems to largely depend on neurological status at admission and much less on the specific treatment of myocardial infarction. The prognostic scoring system accurately predicted the in-hospital mortality and can be used for early treatment stratification; however, it should be proven in a prospective study.

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)

  • Edgren E, Hedstrand U, Kelsey S, Sutton-Tyrell K, Safar P, BRCT I Study Group. Assessment of neurological prognosis in...
  • B.D. Snyder et al.

    Neurologic prognosis after cardiopulmonary arrest: IV. Brainstem reflexes

    Neurology

    (1981)
  • R. Chen et al.

    Prediction of outcome in patients with anoxic coma: a clinical and electrophysiologic study

    Crit. Care Med.

    (1996)
  • Cited by (0)

    View full text