Blogger: Lekshmi Santhosh
About the blogger: Lekshmi Santhosh is currently a second-year Pulmonary & Critical Care Medicine fellow at UCSF. She completed her M.D. from Harvard Medical School and moved to UCSF for her internship and residency, after which she completed an inpatient chief resident year at UCSF. She is interested in graduate medical education with a particular focus in critical care.
Link: http://annals.org/article.aspx?articleid=2552075
Citation: Jabre P, Bougouin W, Dumas F, Carli P, Antoine C, Jacob L, et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. [Epub ahead of print 13 September 2016] doi:10.7326/M16-0402
Why this Paper: This paper was a retrospective study focusing on out-of-hospital cardiac arrest data from registries in France and the US.
Retrospective analysis focused on the following 3 objective criteria:
a. Out-of-hospital cardiac arrest unwitnessed by EMS
b. Nonshockable initial cardiac rhythm
c. No ROSC before 3rd epinephrine dose
They found that in the 772 patients who met these 3 criteria, survival rate was 0% with a specificity of 100% and positive predictive value of 100%.
The authors purported that knowing these poor prognostic signs earlier could help aid decision-making about out-of-hospital arrest, medical futility, ceasing resuscitation efforts earlier, and focusing more on organ donation after cardiac death.
As clinicians, we often identify poor prognostic factors clinically during prolonged resuscitation efforts. This quick and easy-to-remember 3-part-criteria can serve as an objective tool that refocuses the prognosis. Of course, this is a complex and somewhat ethically fraught decision that is hard to check-list-ify, but this study can help point us in the right direction.
When debriefing with trainees after prolonged resuscitations, it may be more helpful to go through these criteria rather than statements like 'the patient had poor substrate' that may ring hollow. In addition to emotionally and ethically debriefing the code, it may be helpful for some learners to point out specific poor prognostic signs that the patient had. As an educator, I'll try to remember these 3 criteria the next time I debrief with a trainee about a prolonged out-of-hospital cardiac arrest.
