Elsevier

Resuscitation

Volume 83, Issue 7, July 2012, Pages 819-822
Resuscitation

Clinical paper
Does appropriate treatment of the primary underlying cause of PEA during resuscitation improve patients’ survival?

https://doi.org/10.1016/j.resuscitation.2011.12.018Get rights and content

Abstract

Aim of the study

We aimed to document how often patients received appropriate treatment of the primary cause underlying pulseless electrical activity (PEA) during cardiopulmonary resuscitation (CPR) and how it affected their outcome.

Methods

Data were collected between 2003 and 2010 in Finland and Sweden. All adult patients who underwent in-hospital cardiac arrest (IHCA) with PEA as the initial rhythm were included, if CPR was attempted. Patients were divided into two groups: those who received appropriate treatment of the primary cause during CPR (treatment of the primary cause group) and those who received conventional CPR (non-specific treatment group). Survival between groups was compared and a multivariable logistic regression analysis was performed to exclude the effect of possible confounders.

Results

Of 104 study patients, 19 (18%) received treatment of the primary cause and 85 (82%) received non-specific treatment. 30-Days survival of patients in treatment of primary cause group was superior compared to patients in the non-specific treatment group: 6 (32%) vs. 9 (11%) were alive 30 days after IHCA, p = 0.03. Multivariable analysis suggested that treatment of the primary cause improves the odds of survival 2.5-fold, but this was not statistically significant. Age was the only significant independent prognostic factor for 30-days survival.

Conclusion

During CPR, only a fifth of patients received appropriate treatment of the primary cause underlying PEA. Those patients were more likely to be alive 30 days after IHCA, but age turned out to be the only significant individual factor for better 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.

Cited by (26)

  • Pulseless electrical activity is associated with improved survival in out-of-hospital cardiac arrest with initial non-shockable rhythm

    2018, Resuscitation
    Citation 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.

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