A comparison of the universal TOR Guideline to the absence of prehospital ROSC and duration of resuscitation in predicting futility from out-of-hospital cardiac arrest

Abstract

Introduction: The Universal Termination of Resuscitation (TOR) Guideline accurately identifies potential out-of-hospital cardiac arrest (OHCA) survivors. However, implementation is inconsistent with some Emergency Medical Service (EMS) agencies using absence of return of spontaneous circulation (ROSC) as sole criterion for termination.

Objective: To compare the performance of the Universal TOR Guideline with the single criterion of no prehospital ROSC. Second, to determine factors associated with survival for patients transported without a ROSC. Lastly, to compare the impact of time to ROSC as a marker of futility to the Universal TOR Guideline.

Design: Retrospective, observational cohort study.

Participants: Non-traumatic, adult (≥18 years) OHCA patients of presumed cardiac etiology treated by EMS providers.

Setting: ROC-PRIMED and ROC-Epistry post ROC-PRIMED databases between 2007 and 2011.

Outcomes: Primary outcome was survival to hospital discharge and the secondary outcome was functional survival. We used multivariable regression to evaluate factors associated with survival in patients transported without a ROSC.

Results: 36,543 treated OHCAs occurred of which 9467 (26%) were transported to hospital without a ROSC. Patients transported without a ROSC who met the Universal TOR Guideline for transport had a survival of 3.0% (95% CI 2.5-3.4%) compared to 0.7% (95% CI 0.4-0.9%) in patients who met the Universal TOR Guideline for termination. The Universal TOR Guideline identified 99% of survivors requiring continued resuscitation and transportation to hospital including early identification of survivors who sustained a ROSC after extended durations of CPR.

Conclusion: Using absence of ROSC as a sole predictor of futility misses potential survivors. The Universal TOR Guideline remains a strong predictor of survival.

Keywords: Cardiopulmonary resuscitation; Emergency Medical Services; Heart arrest.

Conflict of interest statement

The authors report no conflicts of interest. The authors alone are responsible for the writing and content of the paper.

Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Figures

Figure 1

Consort Diagram for Study Population

Figure 2

Comparison of the time of return of spontaneous circulation and patient outcome at hospital discharge mRS= Modified Rankin Scale; CPR= Cardiopulmonary Resuscitation; ROSC= Return of Spontaneous Circulation