Purpose: In Japan, emergency medical service (EMS) providers transport all patients with out-of-hospital cardiac arrest (OHCA) to hospitals and cannot make in-field decisions regarding the termination of cardiopulmonary resuscitation (CPR). In 2019, we developed a termination of resuscitation (TOR) rule (Goto-TOR rule) applicable to refractory OHCAs based on data from the All-Japan Utstein Registry pertaining to the years 2011−2015, during which time CPR was performed according to the 2010 guidelines. The Goto-TOR rule recommends CPR termination when patients meet all of the following criteria: initial asystole, unwitnessed arrest, age ≥81 years, no bystander interventions before EMS arrival, and no return of spontaneous circulation after EMS-initiated CPR for 14 min. This study aimed to validate the Goto-TOR rule using recent data and comparatively assess the rule with the Shibahashi-TOR rule, which was also developed in Japan in cases with no shockable initial rhythm, unwitnessed arrest, and age ≥73 years.
Materials and methods: We analysed the records (All-Japan Utstein Registry data pertaining to 2016−2019) of 466,452 patients (age ≥18 years) who were treated by EMS providers for OHCA. The primary endpoints were specificity and positive predictive value (PPV) for predicting 1-month mortality.
Results: The overall 1-month survival rate was 6.1% (28,681/466,452). The specificity and PPV of the Goto-TOR vs. Shibahashi-TOR rules for predicting 1-month mortality were 99.5% (95% confidence interval, 99.5%–99.6%) and 99.7% (99.6%–99.7%) vs. 92.1% (91.8%–92.4%) and 98.8% (98.7%–98.8%), respectively.
Conclusions: The Goto-TOR rule for in-field decision making was successfully validated using recent data of CPR performed according to the 2015 guidelines. With high specificity and PPV >99.5% for predicting 1-month mortality, the Goto-TOR rule was superior to the Shibahashi-TOR rule in Japanese EMS systems. However, prospective validation studies and the establishment of prehospital EMS protocol are required before implementing this rule in Japan.

External validation of in-field termination-of-resuscitation rules for refractory out-of-hospital cardiac arrests in Japan

Implementation of the Guidelines - How do we put the new ERC Guidelines into practice?

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