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End-Tidal CO2 as a Predictor of Survival in Out-of-Hospital Cardiac Arrest
- Marc Eckstein, Lorien Hatch, Jennifer Malleck, Christian McClung, Sean O. Henderson
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- Journal:
- Prehospital and Disaster Medicine / Volume 26 / Issue 3 / June 2011
- Published online by Cambridge University Press:
- 02 September 2011, pp. 148-150
- Print publication:
- June 2011
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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.
Paramedic Knowledge, Attitudes, and Training in End-of-Life Care
- Susan C. Stone, Jean Abbott, Christian D. McClung, Chris B. Colwell, Marc Eckstein, Steven R. Lowenstein
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- Journal:
- Prehospital and Disaster Medicine / Volume 24 / Issue 6 / December 2009
- Published online by Cambridge University Press:
- 28 June 2012, pp. 529-534
- Print publication:
- December 2009
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Introduction:
Paramedics often are asked to care for patients at the end of life. To do this, they must communicate effectively with family and caregivers, understand their legal obligations, and know when to withhold unwanted interventions. The objectives of this study were to ascertain paramedics' attitudes toward end-of-life (EOL) situations and the frequency with which they encounter them; and to compare paramedics' preparation during training for a variety of EOL care skills.
Methods:A written survey was administered to a convenience sample of paramedics in two cities: Denver, Colorado and Los Angeles, California. Questions addressed: (1) attitudes toward EOL decision-making in prehospital settings; (2) experience (number of EOL situations experienced in the past two years); (3) importance of various EOL tasks in clinical practice (pronouncing and communicating death, ending resuscitation, honoring advance directives (ADs)); and (4) self-assessed preparation for these EOL tasks. For each task, importance and preparation were measured using a four-point Likert scale. Proportions were compared using McNemar chi-square statistics to identify areas of under or over-preparation.
Results:Two hundred thirty-six paramedics completed the survey. The mean age was 39 years (range 22–59 years), and 222 (94%) were male. Twenty percent had >20 years of experience. Almost all participants (95%; 95% CI = 91–97%) agreed that prehospital providers should honor field ADs, and more than half (59%; 95% CI = 52–65%) felt that providers should honor verbal wishes to limit resuscitation at the scene. Ninety-eight percent of the participants (95% CI = 96–100%) had questioned whether specific life support interventions were appropriate for patients who appeared to have a terminal disease. Twenty-six percent (95% CI = 20–32%) reported to have used their own judgment during the past two years to withhold or end resuscitation in a patient who appeared to have a terminal disease. Significant discrepancies between the importance in practice and the level of preparation during training for the four EOL situations included: (1) understanding ADs (75% very important vs. 40% well prepared; difference 35%: 95% CI = 26–43%); (2) knowing when to honor written ADs (90% very important vs. 59% well-prepared; difference 31%: 95% CI = 23–38%); and (3) verbal ADs (75% very important vs. 54% well-prepared, difference 21%: 95% CI = 12–29%); and (4) communicating death to family or friends (79% very important vs. 48% well prepared, difference 31%: 95% CI = 23–39%). Paramedics' preparation in EOL skills was significantly lower than that for clinical skills such as endotracheal intubation or defibrillation.
Conclusions:There is a need to include more training in EOL care into prehospital training curricula, including how to verify and apply ADs, when to withhold treatments, and how to discuss death with victims' family or friends.