Clinical PaperHow accurately can the aetiology of cardiac arrest be established in an out-of-hospital setting? Analysis by “Concordance in Diagnosis Crosscheck Tables”
Introduction
Many previous studies have sought to increase the number of patients with a good neurological outcome after successful resuscitation. These studies have concentrated on better basic life support (BLS) provided by lay persons,1, 2 telephone assisted cardio-pulmonary resuscitation (CPR),3, 4, 5, 6, 7 more effective chest compressions,8, 9, 10 optimizing the ventilation/compression ratio,11, 12 cooling after CPR13, 14, 15 and other possibilities.
Several previous studies have focused on establishing the cause of cardiac arrest (CA) during CPR that is carried out in an out-of-hospital setting.16, 17, 18, 19, 20, 21, 22, 23, 24 Some of these studies concluded that the most frequent cause of cardiac arrest is cardiac failure.25, 26 Other studies were aimed at identification of massive pulmonary embolism as the cause of cardiac arrest.27, 28, 29 The TROICA study (Thrombolysis during Resuscitation for Out-of-Hospital Cardiac Arrest) aimed to improve the outcome of cardiac arrest patients with either cardiac aetiology or pulmonary embolism by early introduction of thrombolytic therapy. Unfortunately, the study was ended in 2006 without achieving its goal.30, 31
Since for example early application of thrombolytic therapy depends on recognition of the cause of cardiac arrest, the ability of physicians to recognize the cause of cardiac arrest is important. This study examined the accuracy of the assumed diagnoses made by physicians at the time of CPR in an out-of-hospital setting.
Section snippets
Objectives
- 1.
Assessing the ability of professionals giving advanced life support (ALS) to establish the correct aetiology of cardiac arrest in an out-of-hospital setting.
- 2.
Testing utility of the “Concordance in Diagnosis Crosscheck Tables” in assessing diagnostic ability of the EMS personnel including testing their ability to identify patients with cardiac arrest caused by AMI and PE.
Study design
This is a retrospective cohort study analysing 211 cases with out-of-hospital cardiac arrest.
Methods
The patients were resuscitated in an out-of-hospital setting by personnel of the EMS (Emergency Medical Service) serving an area of 496 km2 with 1.2 million inhabitants, responding to approximately 240 cases classified as “emergencies” per day. The EMS consisted of seven bases with physicians and 23 bases of teams with paramedics. Only one EMS base with physicians (base with a good cooperation with surrounding hospitals) participated in the study. The rescue team worked in a “two-tiered
Results
Table 1 contains overall information about the patients, including their outcomes.
Fig. 2 assigns diagnoses to five basic diagnostic groups, which are contained in the Utstein style template.33, 34 An overall concordance/discordance between diagnoses made by rescue team physicians at the scene and the final diagnoses are presented for these five basic groups. Concordant diagnoses were made in 157 (74.4%) cases from 211 (i.e., Cardiac 112; Respiratory 11; Other non-traumatic 24; Trauma 8;
Discussion
The ability to establish the precise aetiology of cardiac arrest during resuscitation could be generally beneficial for the patients. However, as demonstrated in this study, accurate diagnosis during resuscitation in an out-of-hospital setting is not always possible. The present study is consistent with previous studies in that it identified cardiac aetiology as the most frequent cause of a sudden cardiac arrest (Fig. 2).25, 26 This is the first study that compares diagnoses given by
Conclusions
The ability to establish a precise aetiology of the cause of cardiac arrest during resuscitation could be beneficial. However, as demonstrated in this study, accurate diagnosis during resuscitation at the scene is not always possible. The present study demonstrates the importance of comparison of an out-of-hospital diagnosis regarding the aetiology of the cardiac arrest with the final hospital diagnosis. Such comparisons should be made for each individual patient rather than collectively for
Conflict of interests
The authors declare no conflict of interests.
Acknowledgments
The work was supported by the grants IGA NR/7970-3 provided by the Ministry of Health of the Czech Republic and MSM 0021620806. We would like to thank Petra Sukupová for her help in collecting data from the hospitals and all cooperative physicians of Prague's hospitals and departments of pathology.
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