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End-Tidal CO2 as a Predictor of Survival in Out-of-Hospital Cardiac Arrest

  • Marc Eckstein (a1) (a2), Lorien Hatch (a1), Jennifer Malleck (a1), Christian McClung (a1) and Sean O. Henderson (a1) (a3)...


Objective: The objective of this study was to evaluate initial end-tidal CO2 (EtCO2) as a predictor of survival in out-of-hospital cardiac arrest.

Methods: This was a retrospective study of all adult, non-traumatic, out-of-hospital, cardiac arrests during 2006 and 2007 in Los Angeles, California. The primary outcome variable was attaining return of spontaneous circulation (ROSC) in the field. All demographic information was reviewed and logistic regression analysis was performed to determine which variables of the cardiac arrest were significantly associated with ROSC.

Results: There were 3,121 cardiac arrests included in the study, of which 1,689 (54.4%) were witnessed, and 516 (16.9%) were primary ventricular fibrillation (VF). The mean initial EtCO2 was 18.7 (95%CI = 18.2–19.3) for all patients. Return of spontaneous circulation was achieved in 695 patients (22.4%) for which the mean initial EtCO2 was 27.6 (95%CI = 26.3–29.0). For patients who failed to achieve ROSC, the mean EtCO2 was 16.0 (95%CI = 15.5–16.5). The following variables were significantly associated with achieving ROSC: witnessed arrest (OR = 1.51; 95%CI = 1.07–2.12); initial EtCO2 >10 (OR = 4.79; 95%CI = 3.10–4.42); and EtCO2 dropping <25% during the resuscitation (OR = 2.82; 95%CI = 2.01–3.97).

The combination of male gender, lack of bystander cardiopulmonary resuscitation, unwitnessed collapse, non-vfib arrest, initial EtCO2 ≤10 and EtCO2 falling > 25% was 97% predictive of failure to achieve ROSC.

Conclusions: An initial EtCO2 >10 and the absence of a falling EtCO2 >25% from baseline were significantly associated with achieving ROSC in out-of-hospital cardiac arrest. These additional variables should be incorporated in termination of resuscitation algorithms in the prehospital setting.


Corresponding author

Correspondence: Marc Eckstein, MD, MPH Department of Emergency MedicineLAC/USC Medical Center1200 N. State Street, Room 1011Los Angeles, CA 90033Tel: 213-978-3741 E-mail:


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Sasson, C, Rogers, MA, Dahl, J, Kellermann, AL: Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circul Cardiovasc Qual Outcomes 2010;6381.
Grmec, S, Krizmaric, M, Mally, S, Kozelj, A, Spindler, M, Lesnik, B: Utstein style analysis of out-of-hospital cardiac arrest-bystander CPR and end expired carbon dioxide. Resuscitation 2007;72:404414.
Grmec, S, Lah, K, Tusek-Bunc, K: Difference in end-tidal CO2 between asphyxia cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest in the prehospital setting. Crit Car 2003;7:R140R144.
Mauer, D, Schneider, T, Elich, D, Dick, W: Carbon dioxide levels during pre-hospital active compression-decompression versus standard cardiopulmonary resuscitation. Resuscitation 1998;39:6774.
Cantineau, JP, Lambert, Y, Merckx, P, Reynaud, P, Porte, F, Bertrand, C, Duvaldestin, P: End-tidal carbon dioxide during cardiopulmonary resuscitation in humans presenting mostly with asystole: A predictor of outcome. Crit Care Med 1996;25:791796.
Koetter, KP, Maleck, GH: End-tidal carbon dioxide monitoring in cardiac arrest. Am J Emerg Med 1998;5:88.
Entholzner, EK, Mielke, LL, Breinbauer, BM, Kling, M, Hargasser, SR, Hipp, RFJ, Kochis, E: End-tidal carbon dioxide during preclinical CPR: Correlation with primary outcome. Am J Emerg Med 1996; 14:109.
Salen, P, O'Connor, R, Sierzenski, P, Passarello, B, Pancu, D, Melanson, S, Arcona, S, Reed, J, Heller, M: Can cardiac sonography and capnography be used Independently and in Combination to Predict Resuscitation Outcomes? Acad Emerg Med 2001;8:610615.
Eckstein, M, Stratton, SJ, Chan, LS: Cardiac arrest resuscitation evaluation in Los Angeles: CARE-LA. Ann Emerg Med 2005;45:504509.
Asplin, BR, White, RD: Prognostic value of end-tidal carbon dioxide pressures during out-of-hospital cardiac arrest. Ann Emerg Med 1995;25:756761.
Falk, JL, Rackow, EC, Weil, MH: End-tidal carbon dioxide concentration during cardiopulmonary resuscitation. N Engl J Med 1988;318:607611.
Levine, RL, Wayne, MA, Miller, CC: End tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med 1997;337:301306.
Sanders, AB, Kern, KB, Otto, CW, Milander, MM, Ewy, GA: End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation: A prognostic indicator for survival. JAMA 1989;262:13471351.
Capnography as a Predictor of the Return of Spontaneous Circulation. Available at Accessed 24 August 2009.
Levine, RL, Wayne, MA, Miller, CC: End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med 1997;337:301307.
Sehra, R, Underwood, K, Checchia, P: End Tidal CO2 Is a Quantitative Measure of Cardiac Arrest. Pacing and Clinical Electrophysiology 2003;26:515517.


End-Tidal CO2 as a Predictor of Survival in Out-of-Hospital Cardiac Arrest

  • Marc Eckstein (a1) (a2), Lorien Hatch (a1), Jennifer Malleck (a1), Christian McClung (a1) and Sean O. Henderson (a1) (a3)...


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