24 Nov

In-hospital Cardiopulmonary Resuscitation during Asystole: Methods

Facilities and Code Procedures
North Shore University Hospital (NSUH) is a 650-bed tertiary care facility in Manhasset, NY. At NSUH, basic CPR is initiated by personnel on the unit where the arrest occurs. A “code” (999) is announced on the overhead page system and a cardiac arrest team (CAT) is notified by pocket beepers. Those arrests which occur in the emergency room (ER) and critical care areas are witnessed and CPR is begun immediately. Those which occur on the wards may not be witnessed, and therefore the time before initiation of CPR cannot be accurately determined in all cases. For purposes of this study, codes precipitated by respiratory arrest or syncopal episode were excluded.

The CAT includes medical and surgical residents and anesthesiologists assigned to carry a beeper on a rotating schedule. Critical care areas (MICU, CCU, SICU) each have a cardiac arrest beeper, and one critical care nurse from each area responds to every arrest. The members of the CAT are certified in Advanced Cardiac Life Support (ACLS) and, in all cases, a senior resident, at the PGY III Level, or higher, is in control of the CPR efforts. Cardiac arrest resuscitation carts are stationed in every patient area of the hospital. Documentation of each cardiac arrest is made by the nurse on a standard cardiac arrest report sheet. A copy of this record is collected for data analysis. Link

Sample
CPR was attempted in 630 cardiac arrests occurring at NSUH during the period July 1984 through June 1986. There were 1,060 in-hospital deaths during this period. Of the 630 arrests, 512 were the first and only in-hospital resuscitation for the patient. The remaining 118 arrests occurred in 49 additional patients. Among all single-resuscitation patients, 32.6 percent survived CPR and were alive 24 h after the arrest. Of these, 45.1 percent survived to be discharged, representing 14.7 percent of the total single-resuscitation sample. In 123 (24.0 percent) of these CPR attempts, the initial rhythm recorded was asystole (ie, a flat ECC). In each case, the initial rhythm was determined by a senior resident, using a 12-lead ECG. Twenty-eight (22.8 percent) patients with asystole were alive 24 h after initiation of CPR. Thirteen were discharged from the hospital, representing 46.4 percent of the 24-h survivors and 10.6 percent of all asystole patients. Table 1 provides descriptive statistics for the 123 patients whose first and only in-hospital resuscitation followed an initial rhythm of asystole. It should be noted that the majority of patients with a diagnosis of “other” had cancer, as did a large number of those who had some other primary diagnosis.
Table 1—Descriptive Statistics* by Status 24 h After CPR Initiation

Total (%) Alive, N (%) Died, N (%)
Gender
M 74 (60.7) 15 (20.3) 59 (79.7)
F 48 (39.3) 13 (27.1) 35 (72.9)
Primary Diagnosis!
Cardiac 56 (50.5) 15 (26.8) 41 (73.2)
Respiratory 21 (18.9) 8 (38.1) 13 (61.9)
Renal 6 (5.4) 1 (16.7) 5 (83.3)
Infection 7 (6.3) 1 (14.3) 6 (85.7)
GI 14 (12.6) 6 (42.9) 8 (57.1)
Neurologic 6 (5.4) 0 (0.0) 6 (100.0)
Other 19 (17.1) 1 (5.3) 18 (94.7)
Arrest locations
ER 52 (42.6) 8 (15.4) 44 (84.6)
ICUs 22 (18.1) 9 (40.9) 13 (59.1)
Wards 48 (39.3) 11 (22.9) 37 (77.1)
Therapeuticinterventions^
Intubation 112 (91.8) 24 (21.4) 88 (78.6)
Pacemaker§ 60 (50.4) 8 (13.3) 52 (86.7)
Defibrillations 59 (59.6) 10 (16.9) 49 (83.1)
IV Drugst
CaCl2 81 (66.4) 13 (16.0) 68 (84.0)
Epinephrine 100 (82.0) 19 (19.0) 81 (81.0)
NaHC03 110 (90.2) 23 (20.9) 87 (79.1)
Atropine 101 (82.8) 24 (23.8) 77 (76.2)
Lidocaine 30 (24.6) 12 (40.0) 18 (60.0)
Bretylium 10 (8.2) 2 (20.0) 8 (80.0)
Other IV drug 21 (17.2) 5 (23.8) 16 (76.2)
Dripst
Dopamine 39 (32.5) 10 (25.6) 29 (74.4)
Norepinephrine§ 43 (35.5) 17 (39.5) 26 (60.5)
Isuprel 75 (62.5) 17 (22.7) 58 (77.3)
Lidocaine§ 21 (17.5) 10 (47.6) 11 (52.4)
Other drip 17 (14.0) 8 (47.1) 9 (52.9)
Duration of
CPR min, mean 29.0 (2-90)|| 34.5 (25.5)# 27.3 (18.6)#
Age, yr, mean 70.2 (18-99)|| 67.0 (15.1)# 71.2 (13.9)#

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