Clinical paperDiagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study
Introduction
Out of hospital circulatory arrest (OHCA) is common, occurring in approximately 89 per 100,000 individuals in the Unites States.1 After successful resuscitation, past medical history, prodromal and ongoing symptoms are often unknown due to obtundation and intubation.2 In patients without an obvious cause for OHCA on hospital arrival, termed idiopathic OHCA, guideline-based standard of care includes electrocardiogram (ECG), chest radiography, metabolic evaluation, head CT, and echocardiography.3, 4, 5, 6 More recently, the European Society of Cardiology guidelines suggest that chest CT should also be considered when this initial evaluation are not consistent with a cardiac cause.7 Additional evaluations including imaging are ordered at the discretion of the treating physicians, including CT scans.8, 9, 10 While this approach allows for tailored clinical evaluation, heterogenous patient evaluation can adversely affect diagnosis and treatment decisions in these critically ill individuals.
The CT Feasibility In Resuscitated patients for Sudden death Triage (CT FIRST) observational study prospectively enrolled 104 patients to undergo a head-to-pelvis sudden death CT (SDCT) scan and identified a cause for OHCA in 39% of patients as well as a high proportion of patients with resuscitation complications.11, 12, 13 However, the incremental benefit and safety of routine SDCT scanning compared to a contemporary standard of care (SOC) cohort has not been explored.
The current study was a planned prospective pre-/post-analysis of successfully resuscitated patients with idiopathic OHCA. The study compared the standard of care alone (Pre-cohort or SOC-cohort) to the addition of an SDCT scan within 6 hours of hospital arrival (Post-cohort or SDCT-cohort) in addition to the standard of care. The primary endpoint of this study was diagnostic SDCT scan yield. Secondary outcomes included and time to diagnosis, SDCT scan safety, and patient survival and neurologic outcome at hospital discharge.
Section snippets
Methods
The CT FIRST study design was a prospective observational pre- and post-cohort study of patients successfully resuscitated from an idiopathic OHCA event (NCT 03111043. https://clinicaltrials.gov/ct2/show/NCT03111043). The pre-cohort (SOC alone) cohort included patients successfully resuscitated from OHCA from January 2014 to December 2015 and treated with standard post-arrest care in two academic hospitals. The post- or SDCT-cohort included patients that underwent a head-to-pelvis SDCT scan in
Results
The cohort diagram outlines subject inclusion in Fig. 1. For the SOC-cohort, of the 273 patients admitted after resuscitation from OHCA, 143 met criteria for idiopathic OHCA and could have undergone SDCT scanning. These included 29 (20%) of otherwise eligible patients with low eGFR of 1–30 ml/min/1.73 m2. For the SDCT-cohort, of the 307 patients admitted after resuscitation from OHCA, 111 patients underwent SDCT. After exclusion of 7 patients, 104 patients were included in the SDCT-cohort.
Discussion
The CT FIRST observational cohort study showed that adding an early SDCT scan to the standard of care increased the identification of causes for OHCA and a significantly shortened time to OHCA diagnosis to 3 hours compared to 14 hours. Identification of time critical diagnoses was similar although SDCT scanning decreased the number of delayed (>6 hours) time-critical diagnoses by 81%. There was no significant difference on survival to hospital discharge for the SDCT-cohort. These data suggest
Conclusions
In this study comparing two cohorts, SDCT scan protocol added to post-OHCA standard of care early after resuscitation safely improved the time and overall diagnostic ability to determine causes for OHCA compared to the standard of care alone. Identification of time-critical diagnoses was similar but delayed identification of time-critical diagnosis was reduced with SDCT scanning. However, this did not result in improved survival. Implementation of SDCT scanning to the critically ill
Conflicts of Interest
The authors have no conflicts of interest for the current manuscript. KRHB reports grant money to University of Washington to conduct research conceived and sponsored Bayer, Sanofi, Eli Lilly, Kestra and has received funding personally from Bayer and Janssen for consulting. JLP reports grant money to University of Washington to conduct research conceived and sponsored Bayer, Sanofi, Eli Lilly. J MOG, PJK, CM, MRS, DJC, RME, CRC, JLP, RB, NJ, MLG report no conflict of interest. The study was
CRediT authorship contribution statement
Kelley R.H. Branch: Conceptualization, Methodology, Validation, Resources, Data curation, Writing – original draft, Supervision. Medley O. Gatewood: Methodology, Validation, Investigation, Data curation, Writing – review & editing. Peter J. Kudenchuk: Conceptualization, Writing – review & editing. Charles Maynard: Methodology, Data curation, Formal analysis, Writing – review & editing. Michael R. Sayre: Methodology, Writing – review & editing. David J. Carlbom: Methodology, Writing – review &
Acknowledgements
We would like to thank Deborah Fly, RN and Michelle Olsufka, RN and the additional staff of the Medic One foundation for their assistance and expertise with data review, abstraction, and data entry.
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