End-Tidal CO2 as a Predictor of Cardiac Arrest Survival

May 16, 2012 by  
Filed under Acute Med, All Updates, EMS, ICU, Resus



In one of largest studies to date of prehospital capnography in cardiac arrest, an initial EtCO2 >10 mmHg (1.3 kPa) was associated with an almost five-fold higher rate of return of spontaneous circulation (ROSC). In addition, a decrease in the EtCO2 during resuscitative events of >25% was associated with a significant increase in mortality, independent of other variables known to affect outcome.

The authors conclude: “EtCO2 values should be included as important variables in protocols to terminate or continue resuscitation in the prehospital setting“.


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.

End-Tidal CO2 as a Predictor of Survival in Out-of-Hospital Cardiac Arres
Prehosp Disaster Med. 2011 Jun;26(3):148-50

Comments

2 Responses to “End-Tidal CO2 as a Predictor of Cardiac Arrest Survival”

  1. Christopher on May 16th, 2012 09:23

    We recently amended our field discontinuation guidelines to be a bit more specific. previously it was largely up to the Paramedic. Now, if we would like to use our own judgement and not phone up a doc, 25 minutes of ACLS must be attempted prior to applying objective criteria including EtCO2 readings and a terminal rhythm.

  2. Mike on May 23rd, 2012 12:34

    With the emphasis on minimal ventilations and maximal (near continuous) compressions, we can maintain an ETCO2 >10 mmHg on most boulders or ceramic garden gnomes. In other words, 10 mmHg may be too low to be of any clinical use if you are doing good work on the CPR front.
    We had used <10 as a cut-off, but now we are using 20 even in pt’s that have been asystolic for 20 minutes or more.