Prospective use of a clinical decision rule to identify pulmonary embolism as likely cause of outpatient cardiac arrest

D. Mark Courtney, Jeffrey Kline

Research output: Contribution to journalArticle

27 Citations (Scopus)

Abstract

A clinical decision rule (CDR) derived retrospectively found that 57% of outpatients aged 65 years or less, with witnessed arrest + PEA had pulmonary embolism (PE) as cause of cardiac arrest. These retrospectively studied patients also had significant frequency of pre-arrest respiratory distress, altered mental status, and shock. Objectives: (1) To test prospectively the feasibility and diagnostic accuracy of this CDR. (2) To test if the pre-arrest clinical triad of respiratory distress, altered mental status and shock predicts the presence of PE. All EMS personnel (N = 204) in an urban EMS system and Emergency Department physicians (N = 143) at 7 hospitals were included in the CDR and data collection. Inclusion criteria: age 18-70, non-trauma, witnessed arrest, PEA as the first and primary rhythm. Exclusion: defibrillation before or more often than once after PEA. Criterion standards: autopsy or predefined cardiopulmonary imaging for PE. Over 21 months, 44 subjects were enrolled. Thirty-three subjects had a criterion standard (N = 20 autopsy, 13 - other criteria). 18/33 (54%; 95% CI 36-72%) had PE. Of the PE arrests, 88% were witnessed by EMS (N = 8) or ED physicians (N = 8), compared with 47% in the non-PE group (N = 3 EMS and N = 4 ED). Of the PE arrests, 83% had at least two of the three components of the triad versus 33% of the non-PE group (95% CI for difference 20-79). Mortality was 100% in the PE group. Analysis of the EMS cardiac arrest registry indicated that 65% of all patients served by the EMS system, age ≤70 recorded as having pre-hospital PEA arrest were enrolled during the study period. Conclusions: We implemented successfully a CDR in a large, urban prehospital system to detect PE rapidly as most likely cause of cardiac arrest.

Original languageEnglish (US)
Pages (from-to)57-64
Number of pages8
JournalResuscitation
Volume65
Issue number1
DOIs
StatePublished - Apr 2005
Externally publishedYes

Fingerprint

Heart Arrest
Pulmonary Embolism
Outpatients
Embolism
Autopsy
Shock
Physicians
Registries
Hospital Emergency Service
Mortality

Keywords

  • Cardiac arrest
  • Pulmonary embolism
  • Pulseless electrical activity

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Nursing(all)

Cite this

Prospective use of a clinical decision rule to identify pulmonary embolism as likely cause of outpatient cardiac arrest. / Courtney, D. Mark; Kline, Jeffrey.

In: Resuscitation, Vol. 65, No. 1, 04.2005, p. 57-64.

Research output: Contribution to journalArticle

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abstract = "A clinical decision rule (CDR) derived retrospectively found that 57{\%} of outpatients aged 65 years or less, with witnessed arrest + PEA had pulmonary embolism (PE) as cause of cardiac arrest. These retrospectively studied patients also had significant frequency of pre-arrest respiratory distress, altered mental status, and shock. Objectives: (1) To test prospectively the feasibility and diagnostic accuracy of this CDR. (2) To test if the pre-arrest clinical triad of respiratory distress, altered mental status and shock predicts the presence of PE. All EMS personnel (N = 204) in an urban EMS system and Emergency Department physicians (N = 143) at 7 hospitals were included in the CDR and data collection. Inclusion criteria: age 18-70, non-trauma, witnessed arrest, PEA as the first and primary rhythm. Exclusion: defibrillation before or more often than once after PEA. Criterion standards: autopsy or predefined cardiopulmonary imaging for PE. Over 21 months, 44 subjects were enrolled. Thirty-three subjects had a criterion standard (N = 20 autopsy, 13 - other criteria). 18/33 (54{\%}; 95{\%} CI 36-72{\%}) had PE. Of the PE arrests, 88{\%} were witnessed by EMS (N = 8) or ED physicians (N = 8), compared with 47{\%} in the non-PE group (N = 3 EMS and N = 4 ED). Of the PE arrests, 83{\%} had at least two of the three components of the triad versus 33{\%} of the non-PE group (95{\%} CI for difference 20-79). Mortality was 100{\%} in the PE group. Analysis of the EMS cardiac arrest registry indicated that 65{\%} of all patients served by the EMS system, age ≤70 recorded as having pre-hospital PEA arrest were enrolled during the study period. Conclusions: We implemented successfully a CDR in a large, urban prehospital system to detect PE rapidly as most likely cause of cardiac arrest.",
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