320 Post Cardiac Arrest Care: Does Usual Care Comply With Guidelines and Impact Outcomes?

Abstract

Guideline-based post-arrest care includes efforts to determine and treat the cause of arrest while minimizing cardiac dysfunction and brain injury resulting from lack of perfusion. Diagnostic testing such as early head imaging, electrocardiogram and other imaging studies may help determine the etiology of arrest. Mitigating injury to brain and heart involves maintaining adequate blood pressure, targeted temperature management (TTM) and early diagnosis and treatment of seizures with electroencephalogram (EEG). Our institution created a set of evidence-based guidelines for the management of post-arrest patients which, in addition to the above, also recommends early consultation with the neurocritical care service and an early echocardiogram. We aim to examine compliance with the guidelines in a cohort of survivors of out-of-hospital cardiac arrest (OHCA) and related outcomes. Retrospective cohort study of patients with OHCA at two urban emergency departments (ED) within a health system between 7/2016 and 7/2018. Exclusion criteria included age < 18 years old and if CPR was terminated upon arrival. Data were extracted from an internal institutional quality improvement database maintained of all resuscitative measures. We abstracted demographic data, Utstein criteria (rhythm, bystander CPR) and time of arrest (day vs night). Quality measures included NCC consultation, cEEG, and computed tomography (CT) of the brain within 6 hours of admission. Descriptive statistics are provided as indicated. Chi-squared and two-sided t tests were used to determine differences in univariate analysis. An alpha < 0.05 was used for statistical significance. 124 patients presented with OHCA, of which 41 (33.0%) were comatose and survived to admission. Nearly 83% (34 /41patients) of these patients received guideline-recommended TTM:, 15 were targeted to low temperature (34 C) and 19 targeted to higher temperature (35 C). Seventeen patients of 41 (41.4%) received an early head CT in the ED, 17/41 (41.4%) patients were placed on cEEG and 23/41 (56.1%) patients received a NCC consult. Five of these comatose 43 patients (11.6 %) survived to discharge. The presence of a shockable rhythm was associated with a higher likelihood of receiving TTM (p= 0.005), and also higher rates of survival to discharge (p= 0.025). No significant differences were seen in the initiation of TTM when comparing demographics and Utstein criteria, and variation in temperature goal did not affect survival to discharge. Seventeen patients received an early head CT, 17 patients were placed on cEEG and 23 patients received a NCC consult. 5 patients (12 %) survived to discharge. Of these quality processes, only initiation of TTM was associated with survival to hospital discharge. No significant differences were seen in the initiation of TTM when comparing demographics and Utstein criteria, and variation in temperature goal did not affect survival to discharge. While four out of five survivors of OHCA received TTM, compliance with the other recommendations for the post arrest algorithm was variable. Presence of a shockable rhythm was most associated with TTM compliance and was the strongest predictor of survival to hospital discharge. Further studies are needed to investigate whether better outcomes will result from improving usual care to include compliance with the guidelines.