Resuscitation 97 (2015) 9196

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Resuscitation
journal homepage:www.elsevier.com/locate/resuscitation

Clinical paper

Recognizing the causes of in-hospital cardiac arrest A survival benefit

a,b,d, a,c b,d a,c
Daniel Bergum , Bjrn Olav Haugen , Trond Nordseth , Ole Christian Mjlstad ,
a,b,d
Eirik Skogvoll

a b
Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway Department of Anaesthesia and
Intensive Care Medicine, St Olav University Hospital, Trondheim, Norway
c d
Department of Cardiology, St Olav University Hospital, Trondheim, Norway Norwegian Air Ambulance Foundation, Drbak, Norway
during the recognized was estimated after propensity score
provision of matching patients from these two groups.
cardiopulmon Results: Overall survival to hospital discharge
ary was 25%. After propensity score matching, the
article info resuscitation benefit of recognizing the cause regarding 1-hour
(CPR). In a survival of the episode was 29% (p < 0.01), and
Article history: previous 4.5- 19% regarding hospital discharge, respectively.
year Variables commonly known to affect the outcome
prospective after cardiac arrest were found to be balanced
Received 17 February 2015 study, this rate between the two groups. The largest difference
of recognition was found in patients with non-cardiac causes
was found to and non-shockable presenting rhythms. Patient
Received in revised form 21 August 2015 Accepted 26 September be 66%. The records and pre-arrest clinical symptoms were
2015
aim of this the information sources most frequently utilized
study was to by the ET to establish the causes of arrest.
Keywords: investigate
whether
survival Conclusions: Patients suffering an IHCA showed
In-hospital Cardiac arrest improved if the a substantial survival benefit if the causes of
Advanced life support Cardiopulmonary resuscitation Causes cause of arrest were recognized by the ET. Patient
Aetiology arrest was records and pre-arrest clinical symptoms were
recognized by the sources of information most frequently
the ET. utilized in these instances.
Methods: The 2015 The Authors. Published by Elsevier
difference in Ireland Ltd. This is an open access article under
abstract the CC BY-NC-ND license
survival if the
causes were (http://creativecommons.org/licenses/by-nc-
Background: The in-hospital emergency team (ET) may or may recognized nd/4.0/).
not recognize the causes of in-hospital cardiac arrest (IHCA) versus not
of this Intensive Care Medicine, St encouragement improved by
article Olav University Hospital, P.O. has been given to recognizing and
appear Box 3250, Sluppen, 7006
s as Trondheim, Norway. recognize & treat treat-ing the
Introduction Append and correct underlying cause,
ix in the reversible causes survival to hospital
final 811 discharge is likely
E-mail address: during CPR. In
In-hospital cardiac arrest (IHCA) is online
daniel.bergum@ntnu.no (D. to be less affected
the ultimate compli-cation to critical version a recent
depending on
illness among hospitalized patients. If at Bergum).X prospective and
additional factors
the triggering causes of arrest are http://d observational study
such as comor-
recognized by the in-hospital x.doi.or from our institution
bidity.
emergency team (ET), this may have g/10.10 we found the rate
16/j.res
crucial consequences for survival. and shockable cardiac of recognition of
uscitati
on.201 arrhythmias, and proper causes to be 198 The aim of this
5.09.39 care of imme-diate of 302 episodes study was to
Improvements of the cardiac arrest 12
(CA) chain-of-survival (COS) have 5. X survivors.
17
Further (66%). To what investigate whether
recognition of
contributed to increased survival in elements for extent the
causes during the
many regions: early recognition of improvement should be recognition of
cause of cardiac provision of ALS
CA, immediate and good quality sought.
Corres arrest influences led to improved
cardiopul-monary resuscitation
pondin
survival has not survival, and to
(CPR), early defibrillation in cases of g From the early days of been thoroughly describe the
pulseless author
at:
modern resuscitation to investigated. While sources of
Depart the current guidelines for return of information utilized
ment of advanced life support spontaneous by the ET to
Anaest (ALS) and in-hospital establish the
hesia circulation (ROSC)
resus-citation, ought to be causes.
and
A Spanish translated version of the summary
atio The Authors. open access
n.2 395 X Published by article under the license (
015 Elsevier Ireland CC BY-NC-ND http://creativecommons.org/licenses/
http://dx.doi.org/10.1016/j.resuscit
.09.
0300-9572/ 2015
Ltd. This is an
by-nc-nd/4.0/). X
92 D. Bergum et al. / Resuscitation 97 (2015) 9196

Table 1

Episode- and patient variables with/without recognized causes of arrest.

Episodes (n = 302)
Causes recognized by the ET (n = 198)
Causes not recognized by the ET (n = 104)

n
Percent
n
Percent

1-Hour survival
130
66%

34
33%

Age (mean, SD)

69y
12y
71y
12y

Male
128
69%

66
66%

Presenting rhythm

PEA
93
47%

51
49%

Asystole
38
19%
32
31%

VF/VT
63
32%

20
19%

Unknown
4
2%

1
1%

Witnessed
181
91%

76
73%

Monitored
128
65%

30
29%

Delay to CPR, 75th% percentile

1 min

1 min

Delay to defib., 75th% percentile

2 min

3 min

CPR end; median, IQR

17 min
730 min
17 min
1029 min

Epinephrine
124
63%

75
72%

Localization

Ward
80
40%

71
68%
Intermediate
73
37%

16
15%

Emergency dep.
15
8%

7
7%

Cardiac lab.
7
4%

Radiology dep.
6
3%

5
5%

ICU
4
2%

2
2%

Other dep.
13
7%

3
3%

Patients (n = 285)
Causes recognized by the ET (n = 185)
Causes not recognized by the ET (n = 100)

n
Percent
n
Percent

Survival to hospital discharge

61
33
10
10

ET: emergency team; PEA: pulseless electrical activity; VF/VT: ventricular fibrillation/ventricular tachycardia; CPR: cardiopulmonary resuscitation; defib.att.: defibrillator attached;
IQR: inter-quartile range; ICU: intensive care unit; dep.: department; lab.: laboratory.
N the ETs. The treatment effect
195
184
n0
Methods 65
63
n1
Material 130
121
From January 2009 to August 2013, we prospectively observed all IHCA
A coefficient (coef) of 0.285 means 28.5%
episodes at the St Olav University Hospital in Norway. The details
estimated increased survival if causes
concerning patients, inclusion strategy and the thor-ough investigation of were recognized by the emergency team
12,13 (ET). se: standard errors; p: p-values. N:
the IHCA causes, were described in recent papers. The ET consist
num-ber of cardiac arrest episodes (1-
of one resident anaesthesiologist, one resident cardiologist and one hour survival) and number of patients
nurse anaesthetist and responds to every location of the hospital, (hospital discharge) respectively; n0: the
including the emergency depart-ment. The ET are set up to provide group with unrecognized causes of arrest;
n1: the group with recognized causes of
respiratory and circulatory stabilizing measures at any time of the day.
arrest.
The ET may obtain fur-ther support from the intensive care physician or
interventional cardiologist, among others.
The study was registered at clinicaltrials.gov (NCT00920244). The Data analysis and statistical
regional committee for medical and health research ethics in central methods
Norway approved the study: REK 4.2008.2402, ref. no: 2009/1275.
To investigate the consequences
of recognizing the causes by the
ET and ROSC, we tabulated both
Table 2
the observed 1-hour survival and
the survival to hospital discharge,
Adjusted effect estimates if causes of arrest were recognized by the ET. against recognition of the under-
lying cause(s); yielding
unadjusted estimates of this
association. To further investigate
1-Hour survival
potential causality, we applied a
Hospital discharge
treat-ment effect estimator based
on propensity score matching
(teffects psmatch in STATA IC
13.1 for Windows, StataCorp LP,
Texas, USA). Propensity score
coef
matching reduces the bias due to
0.285
0.190 confounding variables in
se estimates of the effect of
0.103 treatment in observational data
0.086 sets. In this analysis we defined
p
0.006 treatment as the under-lying
0.026 cause of CA being recognized by
D. Bergum et al. / Resuscitation 97 (2015) 9196
93
was defined as the average
difference in survival between the
treated patients and propensity
score matched patients who did
not receive the treatment, i.e.
patients whose causes were not
recognized by the ET. The
propensity of a cardiac arrest
episode is the estimated
probability (between 0 and 1) that
the causes of arrest were
recognized by the attending ET,
conditional on the vari-ables
included. The following episode
variables were included in the
estimation of the propensity
scores: witnessed arrest, mon-
itored arrest, delay to CPR,
presenting cardiac rhythm, delay
to attachment of a defibrillator,
duration of CPR, whether or not
intra-venous epinephrine
(adrenaline) was administered,
and age. To closer identify
subgroups of patients where the
effect of recog-nition was most
pronounced, we stratified the
analysis according to cardiac/non-
cardiac causes and
shockable/non-shockable pre-
senting rhythms, and calculated
two-sided Fischers exact test
statistics.
An essential assumption
regarding treatment effect estima-
tion from observed data is the
overlap assumption. It states that
all individuals in the analysis must
have a positive and over-lapping
probability of being exposed to
the treatment in this case the
recognition of causes. We
constructed overlap plots

Table 3

Survival according to recognition of causes. Stratified according to cardiac aetiology and shockable arrhythmia.

Table 3. Survival according to recognion of causes. Strafied according to cardiac

aeology and shockable arrhythmia.

% survival
1-hour survival in 302 episodes

Non-
VF/VT Survival
Survival

Total VF/VT
Dead
CARDIAC
Dead
 NON
VF/VT
Dead
Total

Total
% survival

Total

VF/VT
CARDIAC % survival
Survival

% survival

Recog.
Non- Not recog.
Survival Crude

p
VF/VT
Dead
Dead

benefit

Total

-CARDIAC

Total
% survival

VF/VT
% survival Survival

49
Non- 9
Survival

NON
VF/VT
Dead

Dead
12
3

Total

-CARDIAC
% survival
61
Total 12
Hospital discharge in 285 paents

% survival
VF/VT
Survival

80 %
Non- 75 %
Survival 5%
0.7
Dead
 2
8

100 %
63 %
26 37 %
6 1.00
31
5

35
18 20
6

53*
14

61
24 51
11

21
46

43 %
25 % 61 %
18 %
45 %
0.14 16 %
0.5
74
60

72 %
23 %
2 49 %
5 8
< 0.01 1

Recog.
Not recog.
Crude
0
3 p 52
22

benefit
 22*
2
2
5
60
23

50
57
2
7
13 %
4%
9%
0.67

72
59
0%
29 %
-29 %
1

31 %
3%
0
28 %
2

< 0.01

effect within the regarding the treatment effect within the cohort
The 1-hour survival among 302 episodes (upper table), and cohort is equal for estimation above. The appendix contains
based on
survival to hospital discharge among 285 patients (lower all
the extended information
table), stratified according to cardiac or non-cardiac
aetiology, shockable or non-shockable presenting rhythms propensity
and whether the causes of arrest were recognized or not. scores to met.
was investigated using the test condate function based on
*The causes identified among these survivors are tabulated assess if
in Table 4. this the about propensity score matching and treatment
individuals. It uses
assumption effect estimation.
the same variables
ET: Emergency team; VF/VT: ventricular was
fibrillation/ventricular tachycardia; Recog.: recognized, p: p- as for the treatment
value from two-sided Fischers exact test. effect 14,15
treatment effect estimator. It is a test of the null-
that the
treatment hypothesis A p value of 0.05 or less was
Heterogeneity considered statistically significant.
94 D. Bergum et al. / Resuscitation 97 (2015) 9196
Cardiac tamponade episode may have more
1 than one cause.
Table 4

2
Causes recognized in survivors from non- Hyperkalaemia
cardiac non-shockable arrest. 1
Probabilities of recognizing
1-Hour survival: 56 causes in 53 episodes 2 causes, adjusted for
Number Survival to hospital discharge: episode variables
% 22 causes in 22 patients
Number
%

Hypoxia
35
Hypoxia
63 0 2 4 6 density
Hypovolaemia 17
7 77
0
Pulmonary embolus .5
13 1
Pulmonary embolus 3
6 14 Probabilities/Propensity
Cerebral seizures scores
11
Cerebral seizure 2
4 9
Category
7 Causes recognized by the
Cerebral infarction/haemorrhage emergency team in survivors Episodes with causes
2 from non-cardiac, non- recognized by the
shockable cardiac arrests emergency team Episodes
(marked with * in Table 3). One without causes recognized
4 by the emergency team
recognized. difference in this episodes),
The was subgroup of CPR and
Results
correspondin unevenly survivors are further life
g coefficient distributed presented in support was
Two-hundred and regarding within the Table 4. actively
eighty-five patients survival to cohort. By terminated
experienced 302 IHCA hospital dis- stratificatio based on
The probability
episodes (17 patients charge was n on information
density plot in
experienced two 0.19 meaning cardiac/non about
Fig. 1 shows
episodes). Overall a 19% -cardiac underlying
the influence of
survival to discharge increased causes and critical
episode
was achieved in survival shockable/ condition,
variables on
71/285 patients (25%), (Table 2). The non- comorbidity or
the conditional
as recently estimates are shockable the immediate
probabilities
published. Table 1 statistically rhythms, cause of
12
(the estimated
significant the largest arrest.
shows overall survival propensity
and roughly survival
and episode vari-ables scores) that
correspond to difference
for patients with and the causes of In the 198 of
the was found
without recognized arrest could be 302 episodes
unadjusted among
causes of arrest. The recognized by where the ET
differences patients
crude unadjusted the ET. The correctly
reported with non-
difference in 1-hour groups are identified a
above. cardiac
survival according to clearly cause of arrest
aetiologies
whether or not the overlapping (66% rate-of-
and non-
causes were The results and the recognition),
shockable
recognized, were from the test probabil-ity several
initial
33%. The corre- condate mainly above sources of
rhythms
sponding difference analysis were 0.5, indicating patient data
(Table 3).
regarding survival to statistically proper balance were utilized
This
hospital discharge wassig-nificant, of the variables (Fig. 2). The
applied
23% (Table 1). both between the sources
both for 1-
regarding 1- two groups. predominantly
hour
hour survival utilized (i.e. in
The treatment effect episode
and to more than 50%
estimates are survival One-hour
hospital of episodes)
presented in Table 2. and survival was
discharge were patient
Regarding the 1-hour survival to never achieved
(Appendix). records and
episode survival, the hos-pital in 132
This means pre-arrest
coefficient was 0.285 discharge. episodes. In 22
that the clinical
which means a 28.5% The actual of these
estimated symptoms.
increased survival if causes episodes (7%
survival
causes were recognized of all 302
Discussion correspond to symptoms. probability of 21
deaths. IHCA
the ALS surviving a in which the
guidelines cardiac and
The main finding in We wish to underlying
recommendat shockable
this study was that 1- emphasize cause carries a
ions to look arrest is
hour episode survival that our very poor
for potentially 18,19
and survival to findings do high. prognosis will,
reversible
hospital discharge was not indicate Among even if
4H4T
substantially 16,17
that other patients recognized and
causes. causes suffering a properly
Fig. 1. Estimated
A similar than those cardiac and treated,
probabilities (propensity analysis of listed in non-shockable weaken the
scores) that the causes of survival after Table 4 are IHCA, we relation
arrest could be recognized IHCA related less found critical between
by the emergency team, for to the
the two groups of in-
important todecompensate recognition of
hospital cardiac arrest recognition of rec-ognize. d heart failure causes and
patients whose causes causes has The and cardiac survival, e.g.
were recognized (dark grey not been patients tamponade. septic shock,
curve) and not recognized described in Such ruptured aortic
with a
(light grey curve),
conditional on observed the literature. cardiac and conditions aneurysm and
variables; first documented Our findings shockable have a grave central
rhythm, witnessed arrest, suggest that CA already prognosis even pulmonary
monitored arrest, delay to a structured profit from if correctly embolus.
CPR, delay to defibrillator
attached, whether
search for effective recognized
epinephrine (adrenalin) was underlying diagnosis and treated. In a
administered or not, CPR causes of and For example,
duration and age. ALS: retrospective
IHCA during treatment in cardiac
Advanced life support. Finnish-
ALS should due to the tamponade Swedish
be rapid sudden rupture
material of 104
better for cardiac encouraged, applica-tion of the free IHCAs with
arrest patients whose especially in of a ventricular wall
initial PEA,
causes were recog- episodes of defibrillator. has been Saarinen and
nized by the non- As the ETs shown to be co-workers
emergency teams, shockable follow the dominating
observed that
also after adjusting for rhythms. A current ALS cause if CA is being alive
relevant variables via systematic guidelines, the presenting after 30 days
propensity score search for VF/VT will symptom.20 was more likely
matching. The benefit causes may not be Survival is low, if treatment
was most pronounced be based on missed. If even with measures
among patients with knowledge not prompt included in the
non-cardiac causes about the relapsing recognition ALS algorithm
and non-shockable most into arrest and treatment. matched the
presenting rhythms. common after defi- Untreated causes of PEA
The causes identified causes brillation, cardiac identified.
in this subgroup identified, on the tamponade is While this did
(hypoxia, information immediate mainly found in not
hypovolaemia, from patient cause of autopsies as a independently
thrombosis/pulmonary records on arrest has frequent cause predict survival
embo-lus, cardiac scene, and been of sudden in the
tamponade and on pre-arrest reversed cardiac multivariate
hyperkalaemia) clinical and the analysis age
D. Bergum et al. / Resuscitation 97 (2015) 9196
95

Sources of patient data utilized by emergency teams

No ROSC n=67
36

29

16

13

13

ROSC, died in hospital n=61

29
31

12

10
7

Survival to discharge n=70

32

37

23

14

11
7
5
0
10
20
30

40
50
60
70

80
90

100

110
120

Cardiac arrest episodes

Pat.records

Clin.sym.

ECG

Cor.ang.
Bioch.

Echo.

Imaging
Fig. 2. The sources of patient data utilized by the emergency team in episodes where the causes of arrest were
correctly recognized (198 out of 302 episodes; 66%). The sources are not mutually exclusive, and the number thus
exceeds both the number of episodes and patients. ROSC: return of spontaneous circulation; Pat.rec.: patient
records; Clin.sym.: clinical symptoms; ECG: electrocardiogram; Cor.ang.: coronary angiography; Bioch.:
biochemical results; Echo.: echocardiography; Imaging: Medical imaging results.
discharge among of causes beyond
the unrecognized the provision of high
turned out to be the only significant factor
22
might at best quality CPR; namely
their study sample was small. As suggested increase by 19% the non-shockable.
in the present study, if causes of CA are (coef 0.19 in Table Finally, the sources
recognized, this may also represent a benefit. 2), i.e. from 10 to 12 of information were
This benefit may be related to individual patients, although often simple; pre-
adjustments of therapeutic measures already these numbers arrest symptoms
present in the ALS algorithm or new cause- obviously depend on and patient records.
directed treatments applied during ALS. additional factors A larger prospective
like comorbidity. study would be
needed to confirm
One may ask to what extent survival can be
that a structured
further increased by systematically searching This is the first study
approach towards
for causes during CPR. The unadjusted 1-hour that attempts to
identifying and
episode survival where the causes were not quantify the
treating the insult
recognized was 33% (34 of 104 episodes in potential impact of
actually would
Table 1). If we assume causality between recognition of IHCA
improve survival. In
recognition of causes and the achievement of causes on survival.
the meantime,
ROSC, and apply the estimated survival Furthermore the
however, it makes
benefit of 29% (coef 0.285 in Table 2), a 1- study suggest which
sense to sys-
hour survival of approximately 9 more patients IHCA episodes that
tematically search
could have been achieved. Based on the may benefit most
for the potential
same reasoning as above, survival to hospi-tal from the recognition
causes of arrest of course without episodes where the trigg-ering causes
compromising CPR performance. underlying were recognized by
conditions have a the ET had a higher
high mortality, and 1-hour survival and
This study has several limitations. This was
the group of non- survival to hospital
not a randomized clinical trial and the
cardiac VF/VT which discharge. The
association between cause recognition and
is rarely seen. survival benefit was
survival may have been confounded by
most pronounced
unobserved clinical fac-tors. Underlying
among patients with
conditions with higher probabilities of survival
The study originates
a non-cardiac cause
may also be easier to recognize by the ET from a single clinical
and a non-
during ALS. Thus, recog-nition of causes by centre, which limits
shockable
the ET may not have been a causal event the generalizability,
presenting rhythm.
leading to increased survival, but rather however the patient
The information
reflecting the patients character-istics. and episode
sources most
character-istics are
frequently utilized by
in general
Exactly when during ALS efforts the ETs the ET to identify
comparable to what
suspected a certain cause of arrest could not causes of arrest
is being reported in
be determined in this study. It may have been were patient records
international
the achievement of ROSC in the first place 12
and pre-arrest
that made it possible for the ETs to gather studies. clinical symptoms.
additional patient information and reason
about the causes of arrest. This may be The strengths of the
supported by the results demonstrated in study are the
Table 1 where a high proportion of patients Conflicts of
prospective design
among those without a recognized cause of and identi-fication of interest statement
arrest never achieved ROSC (67%). IHCA episodes, the
thorough The authors declare
Patients with a restricted treatment level investigation of CA no conflicts of
because of severe comorbidity may have causes, and interest.
received fewer diagnostic measures ahead of consistent data
the CA episode. Causes in these patients may about CPR efforts
thus have been difficult to detect because few during the first
diagnostic results were available from patient minutes of ALS. Acknowledgement
records. Such patients are also likely to have s
lower survival probabilities from the onset.
This may have contributed to the results
We are thankful for
indicating that inability to detect causes of
to The Norwegian
arrest during ALS is associated with lower Conclusions Air Ambulance
survival probability.
Founda-tion and its
supporting members
Patients suffering an
The sample size is too small to investigate for the research
in-hospital cardiac
every possible sub-group. This applies grants provided to
arrest where the
especially to the group of cardiac non-VF/VT this study.
96 D. Bergum et al. / Resuscitation 97 (2015) 9196
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