Criteria for out-of-hospital cardiac arrest may assist in organ donation decision-making

1. Patients with out-of-hospital cardiac arrest (OHCA) who met the following three objective criteria were found to have a 0% survival rate: OHCA unwitnessed by EMS personnel or medical team members, non-shockable initial cardiac rhythm, and no return of spontaneous circulation.

2. Using these criteria could assist in making decisions about uncontrolled donation after cardiac death (UDCD).

Evidence Rating Level: 2 (Good)

Study Rundown: There is an enormous shortage of organs for transplantation. As a result, some transplantation programs have started using organs from UDCD. In patients with OHCA, termination-of-resuscitation rules help to determine when further resuscitation is futile. However, delays in recognizing this futility may result in missed chances to redirect efforts toward maintaining organs that may be viable for donation and that could help save other lives. This study found that patients with OHCA who met the following three objective criteria were found to have a 0% survival rate: OHCA unwitnessed by EMS personnel or medical team members, non-shockable initial cardiac rhythm, and no return of spontaneous circulation before a third 1 mg dose of epinephrine was administered. Therefore, using these three criteria could assist in making decisions about UDCD.

One strength of the study is that clinical application of the data is heightened because all 3 cohorts of patients were managed in EMS systems. In addition, the data was very strong, with narrow CIs and 100% specificity that was confirmed with external validation. One of the limitations of the study is that the results may be too high. Some UDCD eligibility criteria, such as infection screens and applicable medical history, are difficult to confirm on site. In addition, ethical, legal, and other issues should be considered before including these criteria in UDCD protocols. Patient survival must be the priority before any UDCD concerns. Thirdly, some patients had outcomes that were unknown.

Click to read the study, published today in Annals of Internal Medicine

Relevant Reading: Breakthrough in cardiac arrest: reports from the 4th Paris International Conference

In-Depth [retrospective cohort]: This study evaluated 1771 patients from the Paris Sudden Death Expertise Center (SDEC) and a combined 5192 from the PRESENCE multicenter cluster randomized trial and the King County EMS in Washington. The three criteria to identify OHCA patients with no chance of survival were chosen because they were reliable, objective, and simple to use. From the Paris SDEC, 772 patients with OHCA who met the criteria were found to have a 0% survival rate (95%CI 0.0% to 0.5%). The specificity was 100% (95%CI 97% to 100%). The likelihood of dying when meeting all three criteria was 100% (95%CI 99% to 100%). The data from the PRESENCE and King County cohorts confirmed these results.

Image: PD

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