Abstract 47: ECG Changes and Poor Outcomes for In-Hospital Cardiopulmonary Arrest in Patients with Multiple Organ Dysfunction

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Background: The likelihood of surviving to discharge after cardiac arrest (CA) is very low for patients with multi-organ dysfunction. However, at time of CA, many patients often undergo resuscitation attempts, which are either unsuccessful or lead to a prolonged, complicated and costly hospital course, ultimately ending in withdrawal of care. In this study, we evaluate the frequency ECG changes occurring prior to CA in patients with multi-organ failure and implications for “code status” discussions. Methods: We evaluated all “Code Blue” events at UCLA Medical Center, a 520 bed tertiary care hospital, from April 2010 to March 2012, and included all adult CA cases that had significant organ dysfunction in two or more systems with at least 3 hours of continuous telemetry data preceding CA available. We analyzed up to 24 hours of telemetry data prior to CA for any ECG changes from baseline including PR prolongation, QRS widening, ST segment changes, QT prolongation and new onset atrial fibrillation. Charts were reviewed for survival outcomes and code status at time of CA. All cases were adjudicated by a second observer. Results: There were 30 cases meeting inclusion criteria and included in this study. Of these 15 (50%) were classified as pulseless electrical activity (PEA) arrest, 11 (37%) were bradycardic arrests and 4 (13%) were ventricular tachycardia/ventricular fibrillation arrests. Amongst the PEA group, 13/15 (87%) had any ECG change up to 24 hours prior to CA with QRS widening in 10/15 (67%) and ST segment changes in 6/15 (40%). Amongst the bradycardic group, 8/11 (73%) had any ECG change up to 18.5 hours prior to CA, with QRS widening in 5/11 (45%) and ST segment changes in 4/11 (36%). Survival to discharge was 2/30 (7%) for all patients, with both survivors being discharged to hospice care. At the time of CA, 25/30 (83%) were full code status. Conclusions: In this limited case series, ECG changes within the 24 hours preceding CA were seen in 77% of patients with multiple organ dysfunction. Survival for this group after CA remains low, with a disproportionately high percentage of patients undergoing extreme life-saving measures despite poor prognosis. These findings may have important implications for discussions regarding the urgency of “code status” with such patients.