Pre-Arrest and Intra-Arrest Prognostic Factors Associated with Survival Following Traumatic Out-of-Hospital Cardiac Arrest – A Systematic Review and Meta-Analysis
CCCF ePoster library. Tran A. 11/12/19; 283454; EP64
Alexandre Tran
Alexandre Tran
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Topic: Systematic Review, Meta-Analysis, or Meta-Synthesis

Tran, Alexandre1; Fernando, Shannon2; Rochwerg, Bram3; Vaillancourt, Christian2; McCredie, Victoria4; Inaba, Kenji5; Kyeremanteng, Kwado6; Nolan, Jerry7; Petrosoniak, Andrew4; Perry, Jeffrey2
1 Department of Surgery, University of Ottawa, Ottawa, Canada; 2 Department of Emergency Medicine, University of Ottawa, Ottawa, Canada; 3 Division of Critical Care, McMaster University, Hamilton, Canada; Division of Critical Care, 4 University of Toronto, Toronto, Canada; 5 Department of Surgery, University of Los Angeles California, Los Angeles, USA; 6 Division of Critical Care, University of Ottawa, Ottawa, Canada; 7 Division of Critical Care, University of Bristol, Bristol, United Kingdom

INTRODUCTION: While many health systems strictly regulate the in-hospital care for trauma patients, there is considerable variability in management of patients suffering traumatic out-of-hospital cardiac arrests (OHCA). This is largely driven by the lack of data regarding prognostication of outcome for these patients to guide ongoing pre-hospital resuscitation. 

OBJECTIVES: We sought to summarize the prognostic association of various pre- and intra-arrest factors associated with return of spontaneous circulation (ROSC) and survival to discharge following a traumatic OHCA. ​

METHODS: We searched six databases from inception through March 2019. We included English-language studies (observational and randomized controlled trials) investigating prognostic factors and survival following traumatic OHCA. Primary outcomes include return of ROSC and survival to hospital discharge. Pooled unadjusted odds ratios are presented as Forest Plots using a random-effects method. Due to clinical and statistical heterogeneity, adjusted odds ratios are presented descriptively.
RESULTS: We included 41 studies (29,349 patients) primarily from civilian cohorts. The overall rate of survival to hospital admission (achieved ROSC) was 14.8% (3,606 of 24,360 patients) and the overall rate of survival to hospital discharge was 5.0% (1,391 of 28,091). Significant predictors of ROSC include an initially shockable cardiac rhythm (OR 2.19, 1.59 to 3.00) and a witnessed arrest (OR 1.67, 1.33 to 2.08). Significant predictors of survival to hospital discharge include an initially shockable rhythm (OR 7.39, 5.09 to 10.73), a witnessed arrest (OR 2.12, 1.37 to 3.26) and receipt of bystander CPR (OR 1.86, 1.26 to 2.76). The use of epinephrine (OR 0.55, 0.36 to 0.85) and pre-hospital intubation (OR 0.72, 0.54 to 0.96) was associated with worse survival. Among studies controlling for confounding factors, the only consistent and powerful predictor of survival to hospital admission and discharge was the presence of a shockable rhythm. Patients with an initially shockable cardiac rhythm demonstrated 17.1% survival compared to 2.6% for patients in asystole or pulseless electrical activity. Mechanism of injury was not found to be a significant predictor of ROSC or survival to discharge during adjusted or unadjusted analyses. 
CONCLUSION: These findings highlight the dismal outcomes following traumatic OHCA. As in the non-traumatic cardiac arrest literature, the presence of a shockable rhythm remains the most important prognostic determinant, demonstrated in this meta-analysis for both adjusted and unadjusted odds ratios. Despite the longstanding dogma regarding the importance of injury mechanism, there is no existing evidence identified by this review to support that belief. There exists a clear need for robust prognostic modeling research to appropriately guide indications for patient transport to hospital and ongoing resuscitation for patients following OHCA.  

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