Clinical paperDoes appropriate treatment of the primary underlying cause of PEA during resuscitation improve patients’ survival?☆
Introduction
The most common initial rhythm in in-hospital cardiac arrest (IHCA) is pulseless electrical activity (PEA), accounting for 30–37% of IHCA.1, 2, 3 Survival from IHCA has remained almost the same for nearly 40 years, with those surviving to hospital discharge numbering only 2–10%.1, 4 Because PEA has a poor prognosis, current interest focuses on identifying patients at high risk for IHCA and finding and treating potentially reversible causes of PEA.
Recently published European Resuscitation Council (ERC) Guidelines for Resuscitation 2010 lists reversible causes of PEA (Table 1).5 The most common reversible aetiologies on general wards seem to be myocardial ischaemia (44%) and hypoxia (20%), but prevalence of other reversible conditions is not well known.4 It also remains unknown how often physicians try to treat the primary cause underlying PEA and if the treatment improve patients’ survival.
The aims of this study were to report how often PEA patients received appropriate treatment of the primary cause during CPR and how this treatment affected their outcome. In addition, the frequency of measuring vital signs within 24 h preceding IHCA and the prevalence of disturbances were reported. We also estimated whether reversible causes of PEA were potentially present or absent in each patient.
Section snippets
Methods
The study was retrospective. The Institutional Review Boards of Helsinki and Oulu University Hospitals and Ethics Committee of Stockholm approved this study. All adult (>18 years) IHCA patients with attempted CPR were included if PEA was their initial rhythm. CPR was attempted unless a patient had a do not attempt resuscitation (DNAR)-order. Hospital medical records, including nurses’ notes, and autopsy reports provided the data.
The data collection form was piloted in Sahlgrenska University
Study population
During the study period the incidences of IHCA were 359 (1.3 per 1000 admissions), 180 (2.1 per 1000 admissions) and 90 (1.0 per 1000 admissions) in Södersjukhuset, Oulu University Hospital and Hyvinkää Hospital, respectively. The study population consisted of 105 patients, but one was excluded because of incomplete survival data. The 104 patients were 34 from Hyvinkää Hospital, 32 from Södersjukhuset, and 38 from Oulu University Hospital. Appropriate treatment of the primary cause of PEA was
Discussion
Young patients, patients receiving treatment of the primary cause during CPR and patients treated elsewhere than on general wards had favourable 30-days outcome. However, age turned out to be the only statistically significant individual prognostic factor. In addition, a notable deficiency appeared in registering vital functions and over half of patients had documented disturbances in vital signs during preceding 24 h before IHCA.
The majority of previous IHCA studies have shown that age is
Limitations of the study
This study is limited by its retrospective nature and relatively small sample size. It relays on medical record markings, which may lack some essential information and lead physicians to false conclusions. Some reversible causes of PEA, hypoxia for example, do not have specific treatment that differs from conventional CPR and these patients were in this study included in non-specific treatment group. The estimate whether given treatment was appropriate or not was based on medical record and
Conclusions
The most common potentially reversible causes of PEA are hypoxia, myocardial infarction and pulmonary embolism. Only a fifth of PEA patients receive appropriate treatment of the primary cause. Patients receiving appropriate treatment of the primary cause were more likely to be alive 30 days after IHCA, although given treatment was not an independent predictor for outcome.
Conflict of interest statement
None.
Acknowledgements
We want to acknowledge M.B. Sofia Eldh and Professor Johan Herlitz, who did the pilot study in Sahlgrenska University Hospital, in Göteborg, Sweden. We would also like to thank Professor Mårten Rosenqvist from Karolinska Institutet and the Section of Cardiology at Södersjukhuset for valuable help with the data from Sweden. Special thanks also for Janne Pitkäniemi for important statistical advises.
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Cited by (26)
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2018, ResuscitationCitation Excerpt :It could also in part explain our finding of increased survival rates in the later study period, as patients with PEA and a beating heart but without palpable pulses have been shown to have survival rates approaching those of patients with a shockable initial rhythm [24–26]. For these patients, reversibility might be largely dependent on specific care to counter the shock state rather than chest compressions alone [18,19,27]. Diagnostic tools, such as point of care ultrasound, have proved to aid in the identification of PEA-patients with a beating heart and might thus add valuable prognostic information [25,26].
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.12.018.