Outcome in patients admitted to the emergency department under ongoing resuscitation: a wake-up call

Introduction: Out-of-hospital cardiac arrest has become the focus of scientific attention in recent years. Countries such as Denmark and the Netherlands have achieved considerable success with the implementation of preclinical measures to improve the quality of cardiopulmonary resuscitation (CPR). In Germany, however, the research focusses on the potential of vaECMO and extracorporeal CPR (eCPR), which has shown promising results in international studies in the treatment of ongoing CPR. The aim of this study is to investigate the care and outcome of patients (pts) under ongoing CPR from the perspective of the central emergency department (ED) in a tertiary care center.

Methods: We retrospectively analysed data of pts with the ICD I46.0, I46.1, I46.9, U69.13, R96.0 and R99 in 2022 from the data warehouse of AK St. Georg - Hamburg. The data was screened for pts matching the criteria for ongoing CPR eligible to eCPR (refractory cardiac arrest despite provision of appropriate CPR for > 15 min without stable ROSC, defined as > 20 min without chest compression and persistent circulation) around admission. Baseline characteristics, CPR, diagnostic and outcome data were extracted from the hospital information system. All data was analysed descriptively. Primary outcome was defined as survival of the primary hospital admission with favourable neurological outcome (cerebral performance category [CPC]-score ≤2). Results: 195 pts were transferred either after OHCA or under ongoing resuscitation to the ED or were resuscitated during their stay there. 77 pts matched the criteria for ongoing CPR eligible to eCPR, with an average age of 63 y. The leading cause of CPR was cardiac with 40%, thereof 12% STEMI. The time between the alarm to the arrival in the ED was 61 min and the preclinical CPR lasted 49 min (45 min professional, 4 min bystander) in average. 74% were witnessed collapses and 41% had a no-flow-time (NFT) > 5 min. 55% (42) deceased in the ED, 45% (35) were dismissed to the cath-lab or the intensivcare unit. Following 42% (32) were transferred to eCPR. Weekdays (8am-6pm), eCPR was established with an average door-to-ECMO-time of 12 min and during on-call service within 15 min. 5 pts (6,5%) were alive at (4) or dismissed before day 30 (1); only two pts had an CPC < 2 (2,6%), the other 3 had a CPC of 4 (3,9%). The 30-d-mortality was 87,5% for eCPR and 97,8% for non-eCPR respectively. The two pts with an CPC < 2 were 67 and 61 y old, had both undergone eCPR after a witnessed collapse and in average an NFT of 2 min (0 and < 4 min), preclinical CPR of 14 min (2 and 25 min) and a door-to-ECMO-time of 22 min (30 and 14 min).

Conclusion: Our analysis shows the continued poor outcome in pts under ongoing CPR in the ED of a tertiary care center with an existing eCPR program. The data shows slightly improved survival of pts under eCPR with persistently high mortality and poor neurological outcome despite very good door-to-ecmo times. It was striking that the surviving pts with a CPC < 2 were characterized by a short prehospital CPR. From our point of view, this shows that an eCPR program alone cannot achieve a resounding success in reducing OHCA mortality. This may require the implementation of a load-and-go principle in the rescue service and other pre-hospital measures (AED network, first responders, dispatcher call, training in schools, etc.). Without these measures, it will probably not be possible to reduce the high OHCA mortality rate in Germany.