ORIGINAL RESEARCH Open Access
Fac o s de e mining le el o hospi al ca e
and i s associa ion wi h ou come a e
esusci a ion om p e-hospi al pulseless
elec ical ac i i y
Sini SAARINEN
1*
, A i SALO
2
, James BOYD
2
, Päi i LAUKKANEN-NEVALA
3
, Ca ha ina SILFVAST
4
,
Ilkka VIRKKUNEN
3
and Tom SILFVAST
5
Abs ac
Backg ound: Pa ien s esusci a ed om ou -o -hospi al ca diac a es (OHCA) wi h pulseless elec ical ac i i y (PEA)
as ini ial ca diac hy hm a e no always ea ed in in ensi e ca e uni s (ICUs): some a e admi ed o high dependency
uni s wi h a ious le el o ca e, o he s o o dina y wa ds. Aim o his s udy was o desc ibe he ac o s de e mining
le el o hospi al ca e a e OHCA wi h PEA, pos - esusci a ion ca e and su i al.
Me hods: Adul OHCA pa ien s wi h PEA (n= 221), who we e esusci a ed in sou he n Finland be ween 2010 and 2013
we e included, p o ided pa ien su i ed o hospi al admission. The pa ien s we e di ided in o ou g oups acco ding
o he le el o hospi al ca e p o ided: o dina y wa d and Le el 1–3ICUs.Di e encesinpa ien cha ac e is ics,
pos - esusci a ion ca e and su i al we e compa ed be ween he g oups.
Resul s: Mos pa ien s (62.4%) we e ea ed a Le el 2 ICUs. Longe ime o ROSC and ad anced age dec eased
admission a e o Le el 2 o 3 pos - esusci a ion ca e, whe eas good p e-a es CPC (1–2) inc eased he admission a e
o Le el 2/3 ICUs independen ly. T ea men wi h a ge ed empe a u e managemen (TTM) (4.1%) o ea ly co ona y
angiog aphy (3.2%) we e e y a e. P ognos ic decisions we e made ea lie in he lowe ea men in ensi y
g oups (p< 0.01). One-yea su i al a e was 24.0, 17.1% su i ed wi h good neu ological ou come. Neu ological ou come
was be e wi h mo e in ensi e ca e. A e adjus men , le el o ca e was no independen p edic o o ou come: only
e u n o spon aneous ci cula ion (ROSC) ime, ca diac a es cause and p e-a es pe o mance a ec ed independen ly o
1-yea su i al, age and ROSC o neu ologic ou come.
Conclusions: PEA a e usually admi ed o Le el 2 ICUs o pos - esusci a ion ca e in he capi al a ea o Finland. Age, ROSC
and p e-a es CPC we e independen p edic o s o le el o pos - esusci a ion ca e. TTM and ea ly CAG we e a e and
p o ided only o Le el 3 ICU pa ien s. P ognos ica ion was ea lie in lowe le el o ca e uni s. Good neu ologic su i al
was mo e common wi h mo e in ensi e le el o pos - esusci a ion ca e. A e adjus men , le el o ca e was
no independen p edic o o su i al o neu ologic ou come: only ROSC, ca diac a es cause and p e-a es
pe o mance p edic ed 1-yea su i al; age and ROSC neu ologic ou come.
Keywo ds: Hea a es , Ca diopulmona y esusci a ion, Pulseless elec ical ac i i y, Pos - esusci a ion ca e
* Co espondence: [email p o ec ed]
1
FinnHEMS Resea ch and De elopmen Uni and Eme gency Medical Se ice,
FinnHEMS 30, Tampe e Uni e si y Hospi al, Uni e si y o Tampe e, PO Box
2000, FI-33521 Tampe e, Finland
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SAARINEN e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine
(2018) 26:98
h ps://doi.o g/10.1186/s13049-018-0568-0
Backg ound
The p opo ion o pulseless elec ical ac i i y (PEA) as
ini ial ca diac hy hm has inc eased du ing las decades,
cu en ly accoun ing o 19 o 35% o ou -o -hospi al
ca diac a es (OHCA) [1][2][3][4]. Al hough pa ien s
esusci a ed om PEA ha e a wo se p ognosis han
hose esusci a ed om en icula ib illa ion (VF) o
pulseless en icula achyca dia (VT) [5], imp o emen s
in PEA pa ien s’su i al a e ha e been epo ed [2][6]
[7] wi h 5.7–15.7% su i al o hospi al discha ge [1][2]
[8][9][10][11]. Imp o emen has been no ed bo h in
p e-hospi al su i al [6][12] as well as in-hospi al su -
i al [6]. In es iga o s ha e specula ed ha use o a -
ge ed empe a u e managemen (TTM) is one o he
easons o inc eased in-hospi al su i al [5].
The Eu opean Resusci a ion Council (ERC) ecommends
pos - esusci a ion ca e in he in ensi e ca e uni s (ICUs)
and sugges s ha all esusci a ed pa ien s, i espec i e o
he ini ial ca diac hy hm, should be ea ed wi h TTM
[13], and ea ly co ona y angiog aphy (CAG) should also be
conside ed [14]. Howe e , due o limi ed ICU esou ces
and a less a ou able p ognosis, all OHCA pa ien s wi h
PEA a e no admi ed o ICU: ou ea lie s udy e ealed
ha 16% o No dic ICUs do no usually admi pa ien s wi h
ini ial PEA o asys ole (ASY) [15]. Pa ien s no admi ed o
ICUs a e ea ed in high dependency uni s wi h a ious
le els o ca e o in o dina y wa ds. Fu he , he de ini ion o
an ICU a ies a ound he wo ld. The e o e, he ask o ce
o he Wo ld Fede a ion o Socie ies o In ensi e and C i -
ical Ca e Medicine (WFSICCM) ecen ly p oposed a
ca ego iza ion o ICUs o Le el 1 o Le el 3 ICUs based on
he ca e hey p o ide (Table 1)[16].
To ou knowledge, ac o s associa ed wi h selec ion o
di e en le els o ca e among PEA pa ien s has no been
desc ibed ea lie . The aim o ou s udy was o desc ibe
which clinical ea u es we e di e en be ween PEA pa-
ien s selec ed o Le el 1, 2 o 3 ICU ea men o ea -
men in he o dina y wa ds. We p esumed ha pa ien s
admi ed o Le el 3 ICUs we e conside ed mo e likely o
su i e. In addi ion, wo senio physicians, who we e
blinded o he su i al ou come, es ima ed whe he any
o PEA pa ien s ea ed in he o dina y wa ds could ha e
bene i ed om in ensi e ca e.
Me hods
The pa ien s (n= 221) included in his e ospec i e obse -
a ional s udy we e esusci a ed by he Helsinki Eme gency
Medical Se ices (EMS’s) in Helsinki, Finland, o by he
helicop e EMS (HEMS) o he Helsinki uni e si y hospi al,
FinnHEMS 10, in Sou he n Finland be ween 1 Ma ch 2010
and 31 Decembe 2013. Bo h EMS’s a e physician s a ed,
wi h mos physicians specialized in anaes he ics and in en-
si e ca e. All adul OHCA pa ien s wi h PEA as ini ial ca -
diac hy hm we e included, p o ided e u n o spon aneous
ci cula ion (ROSC) was achie ed on he scene and he pa-
ien su i ed o hospi al admission (n= 224).
Pa ien s we e iden i ied om Helsinki EMS’s ca diac
a es egis y and FinnHEMS10 p e-hospi al da abase.
Da a on hospi al ea men we e e ie ed om hospi al
pa ien eco ds. Ce eb al Pe o mance Ca ego y (CPC)
-classi ica ion [17] was used o e alua e p e-a es ce e-
b al pe o mance. CPC-classi ica ion is a i e-s age scale
o neu ological s a e, in which classes 1–2 co espond o
su icien ce eb al unc ion o independen ac i i ies o
daily li e, while classes 3–4 e lec dependency on o he s,
class 5 means dea h. Neu ological ou come is conside ed
a o able wi h CPC sco e 1 o 2. Pa ien s pe o mance
was also e alua ed wi h Eas e n Coope a i e Oncology
G oup (ECOG) Pe o mance S a us (0 = ully ac i e, 1 =
physically s enuous ac i i y es ic ed, able o do ligh
wo k, 2 = independen on sel -ca e, unable o wo k, 3 =
limi ed sel -ca e, in bed mo e han 50% o waking hou s,
4 = comple ely disabled, con ined o bed, 5 = dead) [18].
In addi ion, p e-a es pe o mance was ca ego ized as
in he FINNRESUSCI s udy [19] in o ou classes (1 =
able o wo k o in equi alen condi ion, 2 = unable o
wo k bu independen in ac i i ies o daily li e, 3 = e-
qui ing some help in daily ac i i ies, 4 = dependen on
o he s o pe o ming daily ac i i ies).
Pa ien s we e di ided in o ou g oups acco ding o he
le el o ca e p o ided as ca ego ized by he WFSICCM
Task Fo ce: pa ien s ea ed a Le el 1–2 ICUs, Le el 3
Table 1 Classi ica ion o ICUs as pu posed by WFSICCM. Modi ied om Ma shall e al. 2017 [16]
Le el 1 Le el 2 Le el 3
Capaci y Sho - e m suppo o mild o gan
dys unc ion
Basic suppo o o gan dys unc ion Complex managemen o o gan dys unc ion
T ea men Non-in asi e espi a o y suppo Mechanical en ila o suppo , pha macologic
hemodynamic suppo , in e mi en RRT
Ad anced en ila o and hemodynamic suppo ,
con inuous RRT
Moni o ing Non-in asi e In asi e Ad anced in asi e
Pe sonnel Nu se pa ien a io 1:4 o 1:3
Physicians wi h some expe ience on
c i ical ca e a ailable du ing day
Nu se pa ien a io 1:3 o mo e
Physicians wi h some ICU aining du ing day,
a ailable a nigh
Nu se pa ien a io 1:1 o 1:2
Physicians wi h ICU aining on call 24/7
ICU in ensi e ca e uni , RRT enal eplacemen he apy, WFSICCM Wo ld Fede a ion o Socie ies o In ensi e and C i ical Ca e Medicine
SAARINEN e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2018) 26:98 Page 2 o 9
ICUs and hose ea ed in he o dina y wa ds (Table 1)
[16]. In Finland, usually only Le el 3 ICUs a e called
ICUs and Le el 1–2 ICUs a e o en called high de-
pendency uni s.
S a is ical analyses
The p e-a es cha ac e is ics, esusci a ion de ails, pos -
esusci a ion ca e and su i al o hese ou pa ien co-
ho s (Wa d, Le el 1 ICU, Le el 2 ICU, Le el 3 ICU)
we e compa ed. As age was symme ically dis ibu ed,
mean ages o he g oups wi h s anda d de ia ion was e-
po ed, and 1-way Ano a - es was used o compa e
g oup means o age. Mul iple compa isons be ween
g oup mean ages we e analysed wi h Tukey HSD es .
No mal dis ibu ion o esponse, ROSC and en ila o
imes we e un ealis ic based on Shapi o-Wilk’s es , hus
medians wi h in e qua ile anges (IQRs) we e epo ed
and independen samples K uskal-Wallis es was used
o g oup compa ison. Pea son’s chi-squa e es was
used o gende and cause o CA, which had nominal
measu emen scale. To all o he a iables o baseline
cha ac e is ics, pos - esusci a ion and su i al da a wi h
o dina y scale, Man el-Haenszel es o end was used.
To e alua e independen ac o s de e mining he Le el
o ca e, baseline ac o s and ca diopulmona y esusci a-
ion (CPR) de ails we e included in a logis ic eg ession
model o adjus men . Fo his model, wa d and Le el 1
ICU g oups we e combined, as well as Le el 2 and 3
ICUs. Pa ien s ully awake on hospi al admission we e
excluded om he logis ic eg ession model. Fo com-
pa ison o pos - esusci a ion ca e and su i al, wa d and
Le el 1 ICU g oups we e combined. Ano he logis ic e-
g ession model was c ea ed o adjus ac o s de e mining
good neu ologic su i al. Fo 1-yea su i al p opo -
ional haza ds eg ession model was i ed. The pos - e-
susci a ion ca e and su i al models included baseline
cha ac e is ics, CPR de ails and Le el o ca e as inde-
penden ac o s. Reducing o ac o s in hese models was
made by backwa d s epwise selec ion, based on he
p obabili y o he likelihood- a io s a is ic.
Based on he da a a ailable on hospi al admission (p e--
a es diagnoses, symp oms be o e OHCA, ce eb al pe -
o mance, independency on o he s and esusci a ion
de ails: wi nessed CA, bys ande CPR, EMS esponse ime
and ime o ROSC), wo senio anaes hesia and in ensi e
ca e physicians (T.S and I.V) independen ly es ima ed
each pa ien ea ed in o dina y wa ds o in Le el 1 ICUs
whe he in hei opinion he e was an indica ion o mo e
in ensi e (Le el 2 o 3 ICU) ea men o no . The physi-
cians we e blinded o in o ma ion abou he ea men
uni chosen, me hods used, su i al and neu ological ou -
come. Es ima ion was ca ied ou wi hou p e-de ined c i-
e ia o ICU-admission, since o ou knowledge, no
gene al p e-de ined c i e ia o PEA pa ien s’admission is
being used in Finland a he momen . Only hose pa ien s
who bo h o he physicians independen ly hough would
ha e bene i ed om mo e in ensi e ca e (Le el 2–3) we e
included in his analysis. The in e - a e ag eemen was
es ima ed by Cohen’skappa.P- alues o < 0.05 we e con-
side ed o indica e signi icance. SPSS S a is ics (IBM, Ve -
sion 25) was used o da a analysis.
Pe mission o conduc he s udy was g an ed by he
Helsinki Uni e si y Hospi al Resea ch and De elopmen
Di ision. Because his s udy used p e iously collec ed
da a, he esea che s we e no equi ed o submi he
s udy p o ocol o e hical boa d e iew.
Resul s
Selec ion o pos - esusci a ion ca e uni
Du ing he s udy pe iod, 224 adul pa ien s we e esusci-
a ed om OHCA wi h PEA and admi ed o hospi al
wi h sus ained ROSC. Th ee pa ien s aken di ec ly o
ope a ion oom o su gical in e en ion ( up u ed ao ic
aneu ysm) we e excluded, hus 221 pa ien s o med he
s udy popula ion. The mos common uni s o pos - e-
susci a ion ca e we e Le el 2 ICUs (n= 138, 62.4%),
ollowed by Le el 3 ICUs (n= 39, 17.6%), o dina y wa ds
(n= 28, 12.7%) and Le el 1 ICU (n= 16, 7.2%).
The mean age o all pa ien s was 64.0 ± 15.1 yea s
(Table 2). Mean age di e ed signi ican ly be ween he
g oups: compa ed o Le el 3 ICU pa ien s, wa d pa ien s
we e on a e age 13.4 yea s olde (95%CI 4.1–22.6, p<
0.01), Le el 1 ICU pa ien s we e 18.9 yea s olde (95%CI
7.8–30.0, p < 0.01) and Le el 2 pa ien s we e 6.8 yea s
olde (CI95% 0.02–13.6, p= 0.049). In addi ion, Le el 1
ICU pa ien s we e on a e age 12.0 yea s olde (CI95%
2.2–22.0) han Le el 2 ICU pa ien s (p=0.01).Gende dis-
ibu ion o he pa ien s did no di e be ween he g oups.
The p e alence o p e-a es diagnoses o co ona y
a e y disease and ca diac ailu e di e ed be ween he
g oups (p= 0.02 and p = 0.01 o end, espec i ely):
co ona y a e y disease had he highes p e alence in he
Le el 1 ICU g oup, ca diac ailu e in he Wa d g oup.
Bo h diagnoses we e he a es among Le el 3 ICU pa-
ien s (Table 2). The cause o OHCA also di e ed be-
ween he g oups, Le el 3 ICU pa ien s had less hypoxic
and neu ological causes (p= 0.048). No di e ence was
ound be ween he g oups in he numbe o p e-a es
diagnoses o hype ension, diabe es, memo y impai -
men /diso de o o he b ain disease and enal ailu e.
Da a on esusci a ion de ails (wi nessed OHCA, by-
s ande CPR, EMS esponse ime and ime o ROSC)
did no di e be ween he g oups. Fac o s desc ibing pa-
ien s’pe o mance and dependence on o he s we e all
signi ican ly di e en be ween he g oups (Table 2).
Pa ien s in he Le el 3 ICU g oup we e mos commonly
in classes which s and o independency and good pe -
o mance (Table 2).
SAARINEN e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2018) 26:98 Page 3 o 9
Table 2 Baseline and clinical cha ac e is ics acco ding o in ensi y o pos - esusci a ion ca e, n (%)
All
n= 221
Wa d
n=28
Le el 1 ICU
n=16
Le el 2 ICU
n= 138
Le el 3 ICU
n=39
p
Age (y), mean ± SD 64.0 ± 15.1 70.1 ± 15.2 75.6 ± 7.8 63.5 ± 14.9 56.7 ± 14.2 < 0.001
Male 143 (64.7) 20 (71.4) 9 (56.3) 92 (66.7) 22 (56.4) 0.48
P e-a es diagnoses
Hype ension 102 (46.4) 13 (46.4) 9 (56.3) 60 (43.8) 20 (51.3) 0.96
Co ona y a e y disease 44 (20.0) 8 (28.6) 5 (31.3) 29 (21.2) 2 (5.1) 0.02
Diabe es 57 (25.9) 5 (17.9) 9 (56.3) 37 (27.0) 6 (15.4) 0.43
Hea ailu e 28 (12.7) 7 (25.0) 3 (18.8) 16 (11.7) 2 (5.1) 0.01
Renal ailu e 15 (6.8) 3 (10.7) 1 (6.3) 9 (6.6) 2 (5.1) 0.39
Memo y impai men 20 (9.1) 3 (10.7) 4 (25.0) 11 (8.0) 2 (5.1) 0.17
O he b ain disease¤ 37 (16.8) 6 (21.4) 4 (25.0) 23 (16.8) 4 (10.3) 0.18
P e-a es pe o mance 0.02
1 138 (62.7) 15 (53.6) 6 (37.5) 89 (65.0) 28 (71.8)
2 26 (11.8) 3 (10.7) 0 (0.0) 19 (13.9) 4 (10.3)
3 54 (24.5) 10 (35.7) 10 (62.5) 28 (20.4) 6 (15.4)
4 2 (0.9) 0 (0.0) 0 (0.0) 1 (0.7) 1 (2.6)
P e-a es pe o mance ECOG 0.001
0 88 (40.2) 7 (25) 3 (18.8) 53 (39.0) 25 (64.1)
1 52 (23.7) 8 (28.6) 3 (18.8) 37 (27.2) 4 (10.3)
2 26 (11.9) 3 (10.7) 0 (0.0) 18 (13.2) 5 (12.8)
3 53 (24.2) 10 (35.7) 10 (62.5) 28 (20.6) 5 (12.8)
P e-a es CPC < 0.001
1 114 (52.1) 10 (35.7) 5 (31.3) 69 (50.7) 30 (76.9)
2 57 (26.0) 8 (28.6) 1 (6.3) 41 (30.1) 7 (17.9)
3 48 (21.9) 10 (35.7) 10 (62.5) 26 (19.1) 2 (5.1)
Accomoda ion ype 0.02
Home, independen 152 (71.0) 18 (66.7) 6 (37.5) 99 (74.4) 29 (76.3)
Home, assis ed 36 (16.8) 5 (18.5) 4 (25.0) 18 (13.5) 9 (23.7)
Nu sing home 26 (12.1) 4 (14.8) 6 (37.5) 16 (12.0) 0 (0.0)
Resusci a ion de ails
Wi nessed CA 193 (88.1) 26 (92.9) 14 (87.5) 115 (84.6) 38 (97.4) 0.79
Bys ande CPR 70 (34.0) 9 (33.3) 2 (15.4) 44 (34.4) 15 (39.5) 0.41
Response ime, median IQR 6 (0–9) 7 (1–9) 7 (0–9) 5 (0–9) 5 (0–8) 0.67
ROSC ime, median (IQR) 18 (12–23) 17 (12–23) 22 (16–25) 18 (12–22) 17 (13–25) 0.63
Cause o CA 0.048
Ca diac 66 (30.3) 8 (28.6) 6 (37.5) 40 (29.6) 12 (30.8)
Hypoxia 61 (28.0) 10 (35.7) 6 (37.5) 36 (26.7) 9 (23.1)
In oxica ion 16 (7.3) 0 (0.0) 0 (0.0) 11 (8.1) 5 (12.8)
Neu ological 21 (9.6) 4 (14.3) 4 (25.0) 12 (8.9) 1 (2.6)
O he 24 (11.0) 2 (7.1) 0 (0.0) 20 (14.8) 2 (5.1)
Unknown 30 (13.8) 4 (14.3) 0 (0.0) 16 (11.9) 10 (25.6)
ICU in ensi e ca e uni , CPC ce eb al pe o mance ca ego y, CA ca diac a es , CPR ca diopulmona y esusci a ion, ROSC e u n o spon aneous ci cula ion, SD
s anda d de ia ion, IQR in e qua ile ange, ECOG Eas e n Coope a i e Oncology G oup
Response and ROSC imes a e p esen ed in minu es, as median (IQR)
¤diagnoses o p e ious in ac anial haemo hage, s oke, con usion, se e e congeni al disabili y, b ain a ophy, encephali is, and b ain umou
See Me hods o de ails o pe o mance, ECOG and CPC classi ica ions. P- alues < 0.05 indica e signi ican di e ence be ween a leas wo Le els o ca e (age,
esponse-and ROSC imes) o signi ican end in esul s when Le el o ca e inc eases (o he a iables). Thus P- alue < 0.05 in headings o p e-a es
pe o mance, ECOG, CPC, accommoda ion ype and cause o ca diac a es indica es ha he e is signi ican di e ence be ween g oups in a leas one o he
alues ( o example in amoun o CPC 1, CPC 2 o CPC 3) and he e is a end acco ding o inc easing Le el o ca e. I he esul ing p- alue is > 0.05, i means
he e is no signi ican di e ence be ween any o he alues. P obabili y es used a e explained in de ail in he Me hods sec ion
SAARINEN e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2018) 26:98 Page 4 o 9
In he logis ic eg ession model, pa ien s ully awake
on hospi al admission (n= 10) we e excluded. Wa d and
Le el 1 ICU we e compa ed o Le el 2 and 3 ICUs. A e
adjus men o o he baseline ac o s (Table 2), longe
ime o ROSC and ad anced age dec eased he admis-
sion a e o Le el 2 o 3 pos - esusci a ion ca e, whe eas
good p e-a es CPC (1–2) inc eased Le el 2/3 ICU ad-
mission a e (Table 3).
Acco ding o he blinded assessmen , in he opinion o
bo h physicians, 16 pa ien s (36.4%) admi ed o wa d o
Le el 1 ICU could ha e bene i ed om Le el 2–3 in en-
si e ca e. The wo physicians’opinions di e ed om
each o he in 10 (22.7%) pa ien s, indica ing mode a e
ag eemen (Cohen’s kappa = 0.548).
Pos - esusci a ion ca e
Nine pa ien s (4.1%) we e ea ed wi h TTM, all in Le el
3 ICUs (Table 4). Ea ly CAG was p o ided o 7 pa ien s
(3.2%) and la e du ing hospi al s ay o 6 pa ien s
(2.7%). Co ona y a e y bypass g a su ge y and enal
eplacemen he apy we e e y a ely p o ided. The me-
dian ime on en ila o was longes 35 h (18-67 h) in
Le el 3 ICU g oup. Le el 3 pa ien s had he longes en-
ila o ea men imes, bu no di e ence exis ed be-
ween Le el 2 and Le el 3 en ila o ea men imes (p
= 0.06). The decision whe he o con inue ac i e pos - e-
susci a ion ca e o a coma ose pa ien was made ea lie
in he lowe ea men in ensi y g oups (p< 0.01). P og-
nos ic decisions we e made < 24 h a e OHCA in 87
(61.7%) pa ien s and up o 93.5% in wa d o Le el 1 ICU
ea ed pa ien s (Table 4).
Su i al and neu ological ou come
O all s udy pa ien s, 72 (32.6%) su i ed o hospi al dis-
cha ge, 62 (28.1%) su i ed 90 days and 53 (24.0%) su -
i ed 1 yea a e OHCA. Pa ien s ea ed in Le el 3 ICU
had highes 90-days and 1-yea su i al a es (Table 5),
bu no signi ican di e ence was ound in 90-days and
1-yea su i al be ween he g oups. Good neu ological
su i al (CPC 1–2) 1 yea a e OHCA was epo ed in
37 (17.1%) pa ien s. PEA pa ien s ea ed in uni s p o-
iding mo e in ensi e pos - esusci a ion ca e had be e
neu ological ou come: 11 (28.2%) Le el 3 ICU pa ien s,
22 (16.1%) Le el 2 ICU and 4 (9.8%) wa d/Le el 1 ICU
pa ien s had CPC 1–2 1 yea a e OHCA (p= 0.02).
A e adjus men o baseline cha ac e is ics and CPR
de ails, Le el o ca e (wa d/Le el1 o Le el 2 o Le el 3)
did no independen ly a ec on 1-yea su i al o neu o-
logical ou come. Independen p edic o s o 1-yea mo -
ali y we e long ime o ROSC, neu ological eason o
OHCA compa ed o ca diac eason and poo p e-a es
pe o mance. Fo poo neu ological ou come o dea h,
ad anced age and long ime o ROSC we e independen
p edic o s (Table 6).
Discussion
In his s udy on he le el o pos - esusci a ion ca e and
i s’associa ion wi h ou come, we ound ha age, ROSC
and p e-a es CPC we e independen p edic o s o se-
lec ion o pos - esusci a ion ca e le el. Good neu ologic
su i al was mo e common wi h mo e in ensi e pos - e-
susci a ion ca e. A e adjus men , le el o ca e was no
independen p edic o o su i al o neu ologic ou -
come: only ROSC, ca diac a es cause and p e-a es
pe o mance a ec ed independen ly o 1-yea su i al,
age and ROSC o neu ologic ou come.
To ou knowledge, ac o s in luencing PEA pa ien s’
admission o pos - esusci a ion ca e uni s ha e no been
desc ibed ea lie . Among ou PEA pa ien s, Le el 2
ICUs we e he common uni s o pos - esusci a ion ca e
and Le el 3 ICU ca e was p o ided o only 17.6% o pa-
ien s. Pa ien s selec ed o mo e in ensi e ca e we e
younge , had less co ona y a e y disease and ca diac
ailu e, less neu ologic and hypoxic cause o CA and
mo e a ou able p e-a es pe o mance and CPC. A
a ou able CPC ca ego y, sho ime o ROSC and young
age we e independen ac o s associa ed wi h admission
o mo e in ensi e le el o ca e.
We assumed ha pa ien s admi ed o ca e a wa ds o
Le el 1 ICUs we e conside ed o ha e ei he despe a e
p ognosis, which canno be imp o ed wi h mo e in ensi e
ca e, o so good p ognosis, ha ou come is good e en wi h-
ou Le el 2 o 3 ca e. As his was assumed o con use he
analysis o ac o s a ec ing admission o di e en le els o
ca e, pa ien s awake a hospi al admission we e excluded.
Ou esul s suppo he hypo hesis ha pa ien s conside ed
o su i e a e mo e likely admi ed o mo e in ensi e ca e,
since all independen p edic o s ha e been epo ed o as-
socia e wi h inc eased su i al [20][21]. Nu sing home es-
iden s ha e been epo ed o ha e wo se su i al a es [20],
which is in line wi h ou indings on he e ec o CPC on
Le el 2–3 ICU admission. A p e ious s udy o all- hy hm
Table 3 Independen p edic o s o Le el 2–3 admission
(compa ed o wa d/Le el 1) (n= 211)
p OR 95% CI o OR
Age (y) 0.03 0.97 0.94–0.996
ROSC (min) 0.03 0.95 0.91–0.996
CPC
1 0.04 2.69 1.07–6.78
2 0.01 4.50 1.41–14.35
3–41
OR odds a io, CI con idence in e al, ROSC e u n o spon aneous ci cula ion,
CPC ce eb al pe o mance ca ego y
In he model, pa ien s in CPC 1 o 2 we e compa ed o pa ien s in CPC 3–4
( e e ence). OR > 1 indica es ha he p obabili y o Le el 2–3 ICU admission is
highe han ha o e e ence pa ien s. P alues we e calcula ed using
Wald’s es
SAARINEN e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2018) 26:98 Page 5 o 9

wi nessed OHCA showed wo se ou comes in pa ien s
wi h p e-a es diagnoses o hype ension, diabe es, myo-
ca dial in a c ion and conges i e hea ailu e [22]. Ad-
anced age is associa ed wi h wo se ou comes in CA in
pa ien s mo e han 65 yea s o age [20], bu he e is a wide
a ia ion in he e ec o age on ou comes, wi h some
s udies showing no associa ion be ween he wo [23]. O
CPR de ails, wi nessed CA [5][12][24], bys ande CPR
[5][12], sho i s esponse ime [12] and sho ime o
ROSC [21] a e known o be associa ed wi h imp o ed
p ognosis a he popula ion le el.
Acco ding o he opinion o he blinded physicians in his
s udy, mo e han a hi d o he pa ien s ea ed ou side
Le el 2–3 ICUs would possibly ha e bene i ed om in en-
si e ca e. Mode a e ag eemen be ween he wo physicians
indica es ha pa ien selec ion is an ambiguous p ocess: in-
o ma ion abou he pa ien ’s p e-a es condi ion is o en
limi ed, and p ognos ica ion a he ea ly phase o pos - e-
susci a ion ca e is challenging, since eliable p ognosis o
neu ological eco e y is possible only 3 days a e CA [25].
The decision whe he o admi pa ien s esusci a ed om
PEA o an ICU o en needs o be made immedia ely a e
hospi al admission. Fu he , he decision whe he o ans-
e a PEA pa ien o a Le el 3 ICU o o a local hospi al
wi h Le el 1–2 ICU should op imally be made al eady on
he scene. Wi hou p ede ined c i e ia, he expe ience and
opinions o he ea ing physician in luence on he decision
o Le el 2 o 3 ICU admission and may lead o al e na ing
pa ien selec ion. On he o he hand, p ede ined c i e ia
may p e en indi idual a ia ion bu may also exclude po-
en ial su i o s who do no i he c i e ia. Sco ing sys ems
o p edic OHCA pa ien s’ou come and he e o e ad oca e
Le el 2–3 ICU ea men a e no commonly used, al hough
some p edic ion ools ha e been c ea ed [24][26][27].
Thus, implemen ing a eliable and es ed sco ing sys em
could help clinicians in decision making.
TTM (4.1%) and ea ly CAG (3.2%) we e p o ided e y
a ely and only o Le el 3 ICU pa ien s. The ini ial
hy hm in OHCA has been epo ed o g ea ly a ec
pos - esusci a ion ca e: up o 39% o UK ICUs ha e
Table 4 Pos - esusci a ion ca e in ea men g oups, n (%)
All n = 221 Wa d /Le el 1 ICU (n= 44) Le el 2 ICU (n = 138) Le el 3 ICU (n = 39) p
TTM 9 (4.1) 0 0 9 (23.1) < 0.01
CAG
<48h
13 (5.9)
7 (3.2)
1 (2.3)
0
9 (6.5)
4 (2.9)
3 (7.7)
3 (7.7)
0.69
CABG 6 (2.7) 1 (2.3) 4 (2.9) 1 (2.6) 0.93
Time on en ila o (h) 18 (4–41) 3 (0–12) 20 (6–46) 35 (18–67) < 0.01
B ain CT 110 (50.5) 14 (31.8) 72 (53.3) 24 (61.5) 0.01
NSE 64 (29.4) 2 (4.5) 49 (36.3) 13 (33.3) < 0.01
P ognos ica ion < 0.01
< 24 h 87 (61.7) 29 (93.5) 51 (54.8) 7 (41.2)
24-72 h 36 (25.5) 2 (6.5) 26 (28.0) 8 (47.1)
> 72 h 18 (12.8) 0 16 (17.2) 2 (11.8)
ICU in ensi e ca e uni , TTM a ge ed empe a u e managemen , CAG co ona y angiog aphy, CABG Co ona y a e y bypass g a su ge y, CT compu e omog aphy,
NSE neu on speci ic enolase. Time on en ila o is p esen ed as median (IQR). P obabili y es s used a e explained in Me hods sec ion. P- alue < 0.01 o
p ognos ica ion indica es ha he e is signi ican di e ence be ween he g oups in a leas one o he p ognos ica ion ime ca ego ies and he e is a end
acco ding o inc easing le el o ca e
Table 5 Su i al and neu ological ou come acco ding o he le el o pos - esusci a ion ca e, n (%)
Su i al All
n = 221
Wa d /Le el 1 ICU (n = 44) Le el 2 ICU (n = 138) Le el 3 ICU (n = 39) p
90 days 62 (28.1) 11 (25.0) 39 (28.3) 12 (30.8) 0.56
1 yea 53 (24.0) 8 (18.2) 33 (23.9) 12 (30.8) 0.18
CPC a 1 yea 0.02
1 23 (10.6) 0 15 (10.9) 8 (20.5)
2 14 (6.5) 4 (9.8) 7 (5.1) 3 (7.7)
3 12 (5.5) 1 (2.4) 10 (7.3) 1 (2.6)
400 0 0
5 168 (77.4) 36 (87.8) 105 (76.6) 27 (69.2)
ICU In ensi e ca e uni , CPC ce eb al pe o mance ca ego y. P- alue < 0.02 o CPC a 1 yea indica es ha he e is signi ican di e ence be ween he g oups in a
leas some o he ca ego ies (CPC 1–5) and he e is a end acco ding o inc easing le el o ca e
SAARINEN e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2018) 26:98 Page 6 o 9
epo ed hey ne e use TTM o pa ien s esusci a ed
om PEA o ASY [28]. 54–87% o ICUs ha e epo ed
o usually cool pa ien s esusci a ed om VF/VT, bu
only 28–30% usually cool pa ien s esusci a ed om
PEA o ASY [28]. In addi ion, ea ly CAG is p o ided o
37–58% o VF/VT pa ien s compa ed o 7–16% o pa-
ien s esusci a ed om PEA o ASY [29][30]. Howe e ,
CAG is a speci ic ea men o acu e co ona y syn-
d ome, which is mo e common in VF/VT pa ien s. This
s udy does no de ine which o he PEA pa ien s had
possible acu e co ona y synd ome and he eby po en ial
o bene i om CAG. The he e ogenei y o p o ided
pos - esusci a ion ca e e lec s in pa he inconclusi e
e idence ega ding op imal pos - esusci a ion ca e.
RCT-based e idence on e icacy o TTM in non-shock-
able OHCA pa ien s is s ill lacking [31]. In addi ion, e i-
cacy o ea ly CAG among OHCA pa ien s comes om
obse a ional s udies [32]. The use o TTM could in-
c ease he su i al a es: in obse a ional s udies, up o
2.9 imes inc eased odds o su i al wi h good neu o-
logical ou come ha e been epo ed o non-shockable
pa ien s [33][34]. Ca ego ical exclusion o PEA pa ien s
om TTM, because o ini ial ca diac hy hm, can esul
in exclusion o some pa ien s who may bene i om his
ea men .
Compa ed o la ely epo ed PEA pa ien s’hospi al
discha ge a es o 5.9–15.7% [1][2][8][9][10][11], e-
sul s o ou s udy a e encou aging: 32.6% o pa ien s ad-
mi ed o hospi al su i ed o hospi al discha ge and
24% su i ed 1 yea , 17.1% wi h good neu ology. Su i al
a es inc eased by inc easing le el o ca e pos - esusci a-
ion ca e, bu he di e ence was insigni ican be ween
he g oups. Su i al wi h good neu ology inc eased sig-
ni ican ly wi h mo e in ensi e le el o ca e. Howe e ,
a e adjus men , le el o ca e was no independen ly as-
socia ed wi h su i al o neu ological ou come. The e is
a possibili y ha he s udy popula ion was oo small o
show an associa ion be ween wi h he le el o ca e and
ou come. In addi ion, including pa ien s awake on ad-
mission, who p obably did no need ha in ensi e ca e,
in his analysis could con lic he esul s. On he o he
hand, Guide e al. epo ed in a ecen ly published mul-
icen e, clus e - andomized clinical ial, ha among
c i ically ill elde ly pa ien s (o e 75 yea s), p omo ion o
ICU admission did no educe 6-mon h mo ali y no
imp o e unc ional s a us o physical quali y o li e 6
mon hs a e [35]. In ou popula ion, he independen
p edic o s o good ou come (young age, sho ime o
ROSC, ca diac a es cause and good p e-a es pe -
o mance) ha e been epo ed o imp o e ou come also
in ea lie s udies [20][21][36][37].
Two hi ds o he pa ien s who do no su i e o dis-
cha ge a e OHCA die as a esul o hypoxic-ischemic
b ain inju y, and app oxima ely hal o he pa ien s die
a e wi hd awal o li e-sus aining ea men a e a bad
ou come is p edic ed [38][39]; hus, he iming o p og-
nos ica ion is c ucial. The ERC ecommends pos poning
p ognos ic decisions o > 72 h a e OHCA in coma ose
pa ien s [40]. In he p esen s udy, he p ognos ic deci-
sion was made ea ly (< 24 h) in mos o he pa ien s
(62%) and signi ican ly ea lie in he lowe le el o ca e
g oups. Howe e , a mo e de ailed e iew showed ha 62
(28.1%) o pa ien s needed help in ac i i ies o daily li e
o li ed in nu sing homes and 5 had a do no a emp
esusci a ion (DNAR) o de , o which p ehospi al pa a-
medics and physicians we e no awa e o . Resusci a ion
was a emp ed, and ROSC was achie ed in pa ien s wi h
a se e e medical his o y and high dependency on o he s,
in whom a DNAR decision p obably should ha e been
made be o e OHCA. S ill, i is possible, ha among
some pa ien s, he p ognos ic decision and he decision
o wi hd aw li e-sus aining ea men we e made oo
ea ly, based on un eliable indica o s o poo ou come.
This s udy was limi ed by i s e ospec i e na u e. Fu -
he mo e, pa ien s we e esusci a ed and ea ed in
Sou he n Finland, in he capi al a ea and a ound i .
These esul s canno be gene alized o conce n he es
o he coun y. Al hough he hospi als ollow he same
in e na ional guidelines, ICU and high dependency uni
selec ion c i e ia migh a y be ween di e en egions
and hospi als due o egional policies and a ying ICU
capaci y. As da a we e collec ed e ospec i ely, e-
sea che s es ima ed pa ien s’pe o mance and CPC s a-
us acco ding o pa ien s eco ds, which could lead o
alse e alua ion. In addi ion, he e we e ela i ely small
numbe o pa ien s in wa d, Le el 1 and 3 ICU g oups.
Conclusions
Based on he p esen indings, we conclude ha only a mi-
no i y (17.6%) o OHCA pa ien s wi h PEA a e admi ed o
Le el 3 ICUs o pos - esusci a ion ca e in he capi al a ea
o Finland. Age, ROSC and p e-a es CPC we e independ-
en p edic o s o selec ion o pos - esusci a ion ca e le el.
TTM (4.1%) and ea ly CAG (3.2%) we e a e and p o ided
Table 6 Independen p edic o s o 1-yea mo ali y and poo
CPC a 1-yea (n = 221)
1-yea mo ali y p HR 95% CI o HR
ROSC (min) < 0.01 1.04 1.02–1.06
Neu ologic e sus ca diac OHCA < 0.01 1.92 1.19–3.08
Pe o mance class 3–4 e sus class 1 0.03 1.50 1.04–2.20
CPC 3–5 a 1 yea p OR 95%CI o OR
Age (y) < 0.01 1.05 1.02–1.08
ROSC (min) < 0.01 1.17 1.10–1.26
CPC ce eb al pe o mance ca ego y, HR haza d a e, OR odds a io, CI
con idence in e al, ROSC e u n o spon aneous ci cula ion, OHCA ou -o -
hospi al ca diac a es
SAARINEN e al. Scandina ian Jou nal o T auma, Resusci a ion and Eme gency Medicine (2018) 26:98 Page 7 o 9
only o Le el 3 ICU pa ien s. P ognos ica ion was ea lie
in lowe le el o ca e uni s. Good neu ologic su i al was
mo e common wi h mo e in ensi e le el o pos - esusci a-
ion ca e. A e adjus men , le el o ca e was no independ-
en p edic o o su i al o neu ologic ou come: only
ROSC, ca diac a es cause and p e-a es pe o mance a -
ec ed independen ly o 1-yea su i al, age and ROSC o
neu ologic ou come.
Abb e ia ions
ASY: Asys ole; CA: Ca diac a es ; CABG: Co ona y a e y bypass g a su ge y;
CAG: Co ona y angiog aphy; CI: Con idence in e al; CPC: Ce eb al pe o mance
ca ego y; CPR: Ca diopulmona y esusci a ion; CT: Compu e omog aphy;
DNAR: Do no a emp esusci a ion; ECOG: Eas e n Coope a i e Oncology G oup;
EMS: Eme gency medical se ice; ERC: Eu opean Resusci a ion Council; HA: Haza d
a e; HEMS: Helicop e eme gency medical se ice; ICU: In ensi e ca e
uni ; IQR: In e qua ile ange; NSE: Neu on speci ic enolase; OHCA: Ou -o -hospi al
ca diac a es ; OR: Odds a io; PEA: Pulseless elec ical ac i i y; RCT: Randomized
con olled ial; ROSC: Re u n o spon aneous ci cula ion; RRT: Renal eplacemen
he apy; SD: S anda d de ia ion; TTM: Ta ge ed empe a u e managemen ;
VF: Ven icula ib illa ion; VT: Ven icula achyca dia; WFSICCM: Wo ld
Fede a ion o Socie ies o In ensi e and C i ical Ca e Medicine
Funding
S.S. has ecei ed a g an om he FinnHEMS Resea ch and De elopmen
Uni and om Ensihoidon Tukisää iö.
A ailabili y o da a and ma e ials
The da a ha suppo he indings o his s udy a e a ailable om he
co esponding au ho , bu es ic ions apply o he a ailabili y o hese da a,
which we e used unde license o he cu en s udy, and so a e no publicly
a ailable. Da a a e howe e a ailable om he au ho s upon easonable
eques and wi h pe mission o Helsinki Uni e si y Hospi al Resea ch and
De elopmen Di ision.
Au ho s’con ibu ions
SS, TS, IV and PL-N mainly designed he s udy. CS, SS, AS and JB ook pa in
da a collec ion. Da a was analysed by PL-N and SS. All au ho s pa icipa ed in
w i ing he manusc ip and all ha e ead and accep ed he inal manusc ip .
E hics app o al and consen o pa icipa e
Pe mission o conduc he s udy was g an ed by he Helsinki Uni e si y
Hospi al Resea ch and De elopmen Di ision. Because his s udy used
e ospec i ely collec ed da a, he esea che s we e no equi ed o submi he
s udy p o ocol o e hical boa d e iew.
Consen o publica ion
No applicable.
Compe ing in e es s
The au ho s decla e ha hey ha e no compe ing in e es s.
Publishe ’sNo e
Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in
published maps and ins i u ional a ilia ions.
Au ho de ails
1
FinnHEMS Resea ch and De elopmen Uni and Eme gency Medical Se ice,
FinnHEMS 30, Tampe e Uni e si y Hospi al, Uni e si y o Tampe e, PO Box
2000, FI-33521 Tampe e, Finland.
2
Eme gency Medical Se ices, Depa men
o Eme gency Medicine, Uni e si y o Helsinki and Helsinki Uni e si y
Hospi al, Helsinki, Finland.
3
FinnHEMS Resea ch and De elopmen Uni ,
FinnHEMS L d, Van aa, Finland.
4
Uni e si y o Helsinki, Helsinki, Finland.
5
Helsinki Uni e si y Hospi al and Uni e si y o Helsinki, Helsinki, Finland.
Recei ed: 21 May 2018 Accep ed: 11 No embe 2018
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