Prediction of Death and Neurologic Outcome in the Emergency Department in Out - of - Hospital Cardiac Arrest Survivors

doi:10.1016/S0002-9149(97)00798-4

The American Journal of Cardiology

Volume 81, Issue 1, 1 January 1998, Pages 17-21

https://doi.org/10.1016/S0002-9149(97)00798-4 Get rights and content

Abstract

We reviewed the hospital records of 127 consecutive patients who were resuscitated from cardiac arrest in a retrospective cohort analysis. A cardiac arrest score utilizing time to return of spontaneous circulation, systolic blood pressure at the time of presentation, and initial neurologic exam were calculated. This score was analyzed with 39 other clinical variables for significance with regard to mortality or neurologic survival using multivariate analysis. Combining these variables into a cardiac arrest score (levels 0, 1, 2, 3, from least to most favorable) allowed prediction of neurologic outcomes and mortality from a single variable in an independent fashion (p <0.0001). Logistic regression models found scores of 0, 1, 2, and 3 predicted in-hospital mortality rates of 90%, 71%, 42%, 18%, and neurologic recovery in 3%, 17%, 57%, and 89%, respectively. The cardiac arrest score was able to predict in-hospital mortality and neurologic outcomes in those who survived to emergency department arrival. This scoring scheme may aide in selection of patients for early aggressive measures, including triage coronary angiography and angio-plasty.

Section snippets

Methods

A retrospective cohort of 127 cardiac arrest survivors who were successfully resuscitated and admitted to William Beaumont Hospital between January 1989 and January 1996 was identified from a prospective database of all emergency room admissions. Complete medical records were available and reviewed in all patients. All arrests were witnessed and had the event attributed to primary cardiac etiology. Cardiopulmonary arrests due to factors other than primary cardiac etiology (i.e., respiratory

Baseline Characteristics:

Mean age was 69 ± 12 years (range of 38 to 93). Eighty-four patients (66%) were men and 43 (34%) were women. Both male and female median ages were 69. Tobacco abuse was recorded in 40 patients (32%), systemic hypertension in 64 (50%), diabetes mellitus in 27 patients (21%), and dyslipidemia in 23 (18%). Prior evidence of myocardial infarction (as determined by the presence of Q waves on electrocardiography or by echocardiographic features) was found in 50 patients (39%). A history of congestive

Discussion

Coronary artery disease has a predominant role in cardiac arrest,16, 17, 18, 19, 20, 21, 22, 23 and primary angioplasty has become a proven mode of therapy for acute myocardial infarction.[24] Recently, immediate coronary intervention has been shown to be a potential option in those with cardiac arrest due to acute myocardial infarction.[7] To date, no study has demonstrated a survival benefit of early intervention in cardiac arrest survivors. A survival advantage attributable to immediate

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Cited by (31)

COVID-19 lockdown and bystander cardiopulmonary resuscitation: All associations are local
2023, Resuscitation
Out-of-hospital cardiac arrest: A systematic review of current risk scores to predict survival
2021, American Heart Journal
Citation Excerpt :
We were unable to identify any subsequent validation. This score was derived from 127 patients with witnessed OHCA secondary to a cardiac cause.13 This score uses a combination of arrest characteristics with initial blood pressure and neurological status.
The arrest and the post-arrest period are an incredibly emotionally traumatic time for family and friends of the affected individual. There is a need to assess prognosis early in the patient pathway to offer objective, realistic and non-emotive information to the next-of-kin regarding the likelihood of survival.
To present a systematic review of the clinical risk scores available to assess patients on admission following out-of-hospital cardiac arrest (OHCA) which can predict in-hospital mortality.
A systematic search of online databases Embase, MEDLINE and Cochrane Central Register of Controlled Trials was conducted up until 20th November 2020.
Out of 1,817 initial articles, we identified a total of 28 scoring systems, with 11 of the scores predicting mortality following OHCA included in this review. The majority of the scores included arrest characteristics (initial rhythm and time to return of spontaneous circulation) as prognostic indicators. Out of these, the 3 most clinically-useful scores, namely those which are easy-to-use, comprise of commonly available parameters and measurements, and which have high predictive value are the OHCA, NULL-PLEASE, and rCAST scores, which appear to perform similarly. Of these, the NULL-PLEASE score is the easiest to calculate and has also been externally validated.
Clinicians should be aware of these risk scores, which can be used to provide objective, nonemotive and reproducible information to the next-of-kin on the likely prognosis following OHCA. However, in isolation, these scores should not form the basis for clinical decision-making.
Usefulness of the NULL-PLEASE Score to Predict Survival in Out-of-Hospital Cardiac Arrest
2020, American Journal of Medicine
Citation Excerpt :
The Prediction Tool is also complex and cumbersome to calculate, and not externally validated.9 Some scores have been evaluated only in small cohorts,6,10 some not prospectively assessed,7,8,10 some not externally or prospectively validated,8-12 and some only predict survival to 1 month, but not in the hospital setting.6,9-11 There is, therefore, an urgent, unmet need for a simple, easy-to-use clinical scoring system to predict survival to hospital discharge, with high sensitivity and specificity.
Out-of-hospital cardiac arrest (OHCA) carries a very high mortality rate even after successful cardiopulmonary resuscitation. Currently, information given to relatives about prognosis following resuscitation is often emotive and subjective, and varies with clinician experience. We aimed to validate the NULL-PLEASE score to predict survival following OHCA.
A multicenter cohort study was conducted, with retrospective and prospective validation in consecutive unselected patients presenting with OHCA. The NULL-PLEASE score was calculated by attributing points to the following variables: Nonshockable initial rhythm, Unwitnessed arrest, Long low-flow period, Long no-flow period, pH <7.2, Lactate >7.0 mmol/L, End-stage renal failure, Age ≥85 years, Still resuscitation, and Extracardiac cause. The primary outcome was in-hospital death.
We assessed 700 patients admitted with OHCA, of whom 47% survived to discharge. In 300 patients we performed a retrospective validation, followed by prospective validation in 400 patients. The NULL-PLEASE score was lower in patients who survived compared with those who died (0 [interquartile range 0-1] vs 4 [interquartile range 2-4], P < .0005) and strongly predictive of in-hospital death (C-statistic 0.874; 95% confidence interval, 0.848-0.899). Patients with a score ≥3 had a 24-fold increased risk of death (odds ratio 23.6; 95% confidence interval, 14.840-37.5; P < .0005) compared with those with lower scores. A score ≥3 has a 91% positive predictive value for in-hospital death, while a score <3 predicts a 71% chance of survival.
The easy-to-use NULL-PLEASE score predicts in-hospital mortality with high specificity and can help clinicians explain the prognosis to relatives in an easy-to-understand, objective fashion, to realistically prepare them for the future.
Prognosis of patients admitted in a coronary care unit after resucitating from out-of-hospital sudden cardiac death
2006, Medicina Clinica
Los objetivos del presente estudio han sido analizar el pronóstico en pacientes recuperados de una muerte súbita cardíaca extrahospitalaria que ingresaron en la unidad de cuidados intensivos coronarios, así como identificar los factores asociados a la morbimortalidad.
Analizamos a 63 pacientes consecutivos (47 varones), con una edad media (desviación estándar) de 61 (12) años, que ingresaron entre noviembre de 1999 y enero de 2004 recuperados de una muerte súbita cardíaca y permanecieron en la unidad de cuidados intensivos coronarios. Se examinó la relación de las características clínicas y lectrocardiográficas con la mortalidad y las secuelas neurólogicas.
Sobrevivieron 35 pacientes (55,5%), mientras que 28 (44,5%) fallecieron transcurridos una media de 28 (4) días desde el ingreso, la mayoría en el hospital. El sustrato anatómico principal fue la cardiopatía isquémica (80,9%). En los pacientes que fallecieron, comparados con los que sobrevivieron, las variables que se asociaron a un peor pronóstico fueron la diabetes mellitus (un 68,4 frente al 17,1%; p < 0,02), la presencia de cardiopatía valvular (el 28,6 frente al 0%; p < 0,003), la fibrilación auricular crónica (un 42,9 frente al 14,3%; p < 0,02) y la asistolia como primer ritmo observado (el 42,9 frente al 11,4%; p < 0,01). El análisis multivariable identificó la asistolia como factor independiente de mal pronóstico (p < 0,02). En 23 de los 28 pacientes que fallecieron la muerte fue secundaria a secuelas cerebrales postanóxicas graves (82,1%), mientras que los 5 pacientes restantes fallecieron a consecuencia de su cardiopatía subyacente (p < 0,01). Las variables que se asociaron a daño neurológico fueron la reanimación realizada extrahospitalariamente, el hecho de que el paciente ingresara inconsciente, el tiempo de llegada superior a 5 min y el tiempo de retraso en el inicio de la resucitación cardiopulmonar.
La supervivencia en pacientes recuperados de una muerte súbita cardíaca extrahospitalaria es alta, aunque la mortalidad todavía sigue siendo elevada. Las complicaciones neurológicas son la principal causa de mortalidad. El pronóstico viene determinado por la presencia de factores relacionados con la enfermedad subyacente, el tiempo en iniciar las maniobras de recuperación y la lesión cerebral postanóxica.
The aims of the present study were to analyze the prognosis after resuscitation from out-of-hospital sudden cardiac death in patients admitted to the coronary care unit, and to identify the predictor variables of morbi-mortality.
From November 1999 to January 2004 we analyzed 63 patients (47 males) aged 61±12 years who were admitted to the coronary care unit following successful resuscitation from sudden cardiac death. The clinical and electrocardiographic characteristics were correlated with the mortality and neurological impairment.
Thirty-five patients (55.5%) were discharged, while twenty-eight patients (45.5%) died 28±4 days after admission, most of them during hospitalization. The main underlying disorder was coronary artery disease (80.9%). When survivors and non-survivors were compared, the variables associated with a worse prognosis were diabetes mellitus (68.4% vs 17.1%, P<.02), the presence of valvular heart disease (28.6% vs 0%, p<0.003), chronic atrial fibrillation (42.9% vs 14.3%, P<.02) and asystole as the initial rhythm observed (42.9% vs 11.4%, P<.01). Multivariate analysis identified asystole as an independent factor of poor prognosis(P<.02). Death was due to severe postanoxic neurological damage in 23 of 28 deaths (82.1%). The remaining 5 patients died due to their underlying cardiac disease (P<.01). The variables associated with neurological damage were out-of hospital resuscitation, delay in beginning resuscitation maneuvers, arrival time >5 minutes and unconsciousness on admission.
Although many patients survive following resuscitation from out-of-hospital udden cardiac death, mortality remains high. Neurological impairment is the main cause of mortality. Prognosis is determined by the variables related to the underlying disease, the delay in onset of resuscitation maneuvers and postanoxia cerebral damage.
Recommended guidelines for reviewing, reporting, and conducting research on post-resuscitation care: The Utstein style
2005, Resuscitation
The aim of this report is to establish recommendations for reviewing, reporting, and conducting research during the post-resuscitation period in hospital. It defines data that are needed for research and more specialised registries and therefore supplements the recently updated Utstein template for resuscitation registries. The updated Utstein template and the out-of-hospital “Chain of Survival” describe factors of importance for successful resuscitation up until return of spontaneous circulation (ROSC). Several factors in the in-hospital phase after ROSC are also likely to affect the ultimate outcome of the patient. Large differences in survival to hospital discharge for patients admitted alive are reported between hospitals. Therapeutic hypothermia has been demonstrated to improve the outcome, and other factors such as blood glucose, haemodynamics, ventilatory support, etc., might also influence the result. No generally accepted, scientifically based protocol exists for the post-resuscitation period in hospital, other than general brain-oriented intensive care. There is little published information on this in-hospital phase. This statement is the result of a scientific consensus development process started as a symposium by a task force at the Utstein Abbey, Norway, in September 2003. Suggested data are defined as core and supplementary and include the following categories: pre-arrest co-morbidity and functional status, cause of death, patients’ quality of life, in-hospital system factors, investigations and treatment, and physiological data at various time points during the first three days after admission. It is hoped that the publication of these recommendations will encourage research into the in-hospital post-resuscitation phase, which we propose should be included in the chain-of-survival as a fifth ring. Following these recommendations should enable better understanding of the impact of different in-hospital treatment strategies on outcome.
El objetivo de este reporte es establecer recomendaciones para revisar, reportar y dirigir investigación durante el periodo de post resucitación en el hospital. Define los datos que son necesarios para investigación y registros más especializados, y por lo tanto suplementa el templado de Utstein para registro de resucitación, recientemente puesto al día. El templado actualizado y la cadena de sobrevida extrahospitalaria describen los factores de importancia para la resucitación exitosa hasta el retorno a circulación espontánea (ROSC). Varios factores en la fase intrahospitalaria después del ROSC pueden afectar el resultado final del paciente. Se han reportado grandes diferencias, en sobrevida al alta de pacientes admitidos vivos, entre distintos hospitales. Se ha demostrado que la hipotermia terapéutica mejora el resultado, y se piensa que otros factores tales como la glicemia en sangre, hemodinamia, apoyo ventilatorio, etc., podrían también influenciar el resultado. No existe, aparte de cuidados intensivos generales orientados a cuidados cerebrales, un protocolo de base científica aceptado en forma general para el período post resucitación en el hospital. Existe muy poca información publicada acerca de esta fase intrahospitalaria. Este documento es el resultado de un proceso de desarrollo de consenso científico iniciado como un simposio por un equipo de trabajo en la abadía de Utstein, Noruega, en Septiembre de 2003. Los datos sugeridos son definidos como fundamentales o suplementarios e incluyen las siguientes categorías: estado funcional y comorbilidad pre paro, causa de muerte, calidad de vida del paciente, factores sistémicos intrahospitalarios, exámenes y tratamientos, y los datos fisiológicos en varios puntos de tiempo durante los primeros tres días después de la admisión. Se espera que la publicación de estas recomendaciones estimularán la investigación hacia la fase intrahospitalaria post resucitación, la que proponemos que debería ser incluida como quinto anillo de la cadena de sobrevida. El seguir estas recomendaciones debería permitir mejor comprensión del impacto de las diferentes estrategias de tratamiento sobre el resultado.
Brain arrest neurological outcome scale (BrANOS): Predicting mortality and severe disability following cardiac arrest
2004, Resuscitation
Background: To create a predictive scale of neurological outcome following cardiac arrest (CA) that incorporates radiological and clinical markers of brain injury. Methods and results: Brain arrest neurologic outcome scale (BrANOS) is a prospective 16-point scale. It consisted of three variables: (1) duration of arrest (DAR), (2) reversed Glasgow coma scale (GCS), and (3) Hounsfield unit (HU) ratio on non-contrast CT scan of the head. Reversed GCS score was defined as 15-GCS (best GCS in the first 24 h). HU ratio was defined as the density ratio of the caudate nucleus over the posterior limb of the internal capsule measured on unenhanced CT scan of the brain. We identified 32 comatose patients who had: (1) CT scan performed within 48 h of event; (2) no previous history of either coma, severe head trauma, cardiac arrest or stroke. Primary outcome was defined as alive or dead. Secondary outcome was the Glasgow outcome score recorded on discharge. Patient demographics were collated from retrospective chart review. Patients’ mean age was 63±3 years (mean±S.E.M.); 44% were females. Mortality rate was 81%. Mean DAR was 21±2 min. Survivors had a significantly lower BrANOS score (8±2 points) compared to non-survivors (13±1) (P=0.006). BrANOS was a strong predictor of mortality alone (ROC=0.86) and mortality with severe disability combined (ROC=0.9). The scale had a 100% specificity and positive predictive value. Conclusions: BrANOS is a reliable predictor of neurological outcome following CA. It is the first scale to incorporate clinical and radiological markers of brain injury.
Contexto: Criar uma escala capaz de predizer o prognóstico neurológico associada a paragem cardı́aca (PC), incorporando marcadores clı́nicos e radiológicos de lesão cerebral. Métodos e resultados: A escala de prognóstico neurológico associada a paragem (BrANOS) tem carácter prospectivo e recorre a 16 parâmetros. Tem 3 grandes variáveis: (1) Duração da paragem (DAR), (2) Escala de coma de Glasgow (GCS) e (3) ratio de Hounsfield (HU) no TAC cerebral sem contraste. A escala de Coma de Glasgow deve entrar com a melhor pontuação nas primeiras 24 horas. O ratio HU foi definido como a razão da densidade do núcleo caudado sobre o ramo posterior da cápsula interna medido na TAC não amplificada. Identificaram-se 32 doentes comatosos com as seguintes caracterı́sticas. (1) TAC efectuado nas primeiras 48 horas pós paragem; (2) Ausência de história prévia de coma, TCE grave, paragem cardı́aca ou AVC. O prognóstico primário foi definido como morte ou sobrevivência. O prognóstico secundário foi definido como a GCS registada à saı́da. Foram registados os dados demográficos a partir da revisão dos processos clı́nicos. A idade média foi de 63 ± 3 anos (média ± S.E.M.); 44% foram mulheres. A taxa de mortalidade foi de 81%. A DAR média foi de 31 ± 2 min. Os sobreviventes apresentaram um BrANOS significativamente mais baixo (8 ± 2 pontos) comparativamente aos não sobreviventes (13 ± 1) (P = 0.006). A escala de BrANOS revelou-se como sendo um forte preditor de mortalidade, isolada (ROC = 0.86) ou associada a sequelas neurológicas severas (ROC = 0.9) A escala mostrou 100% de especificidade e capacidade preditiva positiva. Conclusão: A escala de BrANOS é fiável na antecipação do prognóstico neurológico após PC. É a primeira escala a incorporar variáveis clı́nica se radiológicas de lesão cerebral.
Antecedentes: Crear una escala predictiva de resultado neurológico después de un paro cardı́aco (CA) que incorpore marcadores clı́nicos y radiológico de daño cerebral. Métodos y resultados: La escala de resultado neurológico después de paro cerebral (BrANOS) es una escala prospectiva de 16 puntos. Ella consiste de tres variables (1) duración del paro (DAR), (2) escala de coma de Glasgow revertida (GCS), y (3) relación de unidad Hounsfield (HU) en la tomografı́a CF sin contraste de la cabeza. El GCS revertido se definió como 15 GCS (el mejor GCS en las primeras 24 horas). La relación HU fue definida como la relación de densidad del núcleo caudado encima de la extremidad posterior de la cápsula interna medida en una tomografı́a cerebral CT no aumentada. Identificamos 32 pacientes comatosos que tenı́an: (1) Tomografı́a CT realizada dentro de las 48 horas del evento; (2) sin historia previa de coma, trauma craneano severo, paro cardı́aco o accidente vascular. El resultado primario fue definido como vivo o muerto. El resultado secundario fue el registro de la escala de Glasgow al momento del alta. Los datos demográficos de los pacientes fueron obtenidos de revisión retrospectiva de fichas. La mediana de edad de los pacientes fue 63 ± 3 años (promedio ± S.E.M.); 44% fueron mujeres. La tasa de mortalidad fue 81%. El DAR promedio fue 21 ± 2 min. Los sobrevivientes tuvieron un puntaje de BrANOS significativamente menor (8 ± 2 puntos) comparado con los no sobrevivientes (13 ± 1) (P = 0.006). BrANOS predijo fuertemente la mortalidad sola (ROC = 0.86) y mortalidad combinada con discapacidad severa (ROC = 0.9). La escala tuvo un 100% de especificidad y valor de predicción positivo. Conclusiones: BrANOS es un predictor confiable del resultado neurológico después de un CA. Es la primera escala que incorpora marcadores clı́nicos y radiológicos de daño cerebral.

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Coronary Artery DiseasePrediction of Death and Neurologic Outcome in the Emergency Department in Out - of - Hospital Cardiac Arrest Survivors

Abstract

Section snippets

Methods

Baseline Characteristics:

Discussion

Am J Cardiol

Am J Med

Resuscitation

Am J Med

J Am Coll Cardiol

Prog Cardiovasc Dis

J Am Coll Cardiol

J Am Coll Cardiol

Ann Thoracic Surg

Cardiac Arrest and sudden cardiac death

Sudden cardiac deathepidemiology, transient risk, and interventional assessment

Ann Intern Med

Sudden cardiac in patients with chronic coronary heart disease

Circulation

Survivors of sudden cardiac deatha rational approach to evaluation and therapy of patients surviving ventricular fibrillation

Clev Clin J Med

Survival after resuscitation from out of hospital ventricular fibrillation

Circulation

Unsuccessful emergency medical resuscitation—are continued efforts in the emergency room justified?

N Engl J Med

Coronary Artery Disease
Prediction of Death and Neurologic Outcome in the Emergency Department in Out - of - Hospital Cardiac Arrest Survivors