Published: 2019-11-27

Utility of opening rhythms in predicting time to return of spontaneous circulation in cardiac arrest victims in a resource constrained setting: a single centre prospective observational study

Appu Suseel, Siju V. Abraham, Radha K. R.


Background: Time to ROSC has been shown to be an important and independent predictor of mortality and adverse neurological outcome. In resource limited situations judicious deployment of resources is crucial. Prognostication of arrest victims may aid in better resource allocation. This study aimed to assess the time to Return of Spontaneous Circulation (ROSC) in cardiac arrest victims and its relationship with opening rhythms.

Methods: Consecutive victims of cardiopulmonary arrest who presented to a single center were included in this study if they met the inclusion and exclusion criteria. Time at which opening rhythm was analyzed and time at which ROSC was achieved was noted. This was done for all cases and mean time to ROSC was calculated for each opening rhythm. All those patients who achieved ROSC were followed up till hospital discharge or death.  Primary outcome measured was achievement of ROSC and the secondary outcome was the survival to hospital discharge.

Results: A sample size of 100 was calculated to yield a significance criterion of 0.05 and a power of 0.80 based on prior studies. Out of 100 patients studied. 58% had shockable rhythms and 42% had non-shockable rhythms.  Mean time to ROSC for shockable rhythm was 5.55±3.51 minutes, and for non-shockable rhythm is 17.29±4.18 minutes.  There was a statistically significant difference between opening rhythms in terms of survival to hospital discharge (p=0.0329).

Conclusions: Cardiac arrests with shockable rhythms attained ROSC faster when compared to nonshockable rhythms. Shockable rhythms have a better survival to hospital discharge when compared to shockable rhythms. Opening rhythms may aid the clinician in better utility of resources in a resource constrained setting.


Cardiac arrest, Cardiopulmonary resuscitation, Non-shockable rhythm, Returns of spontaneous circulation, Shockable rhythm

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Jacobs I, Nadkarni V, Bahr J, Berg RA, Billi JE, Bossaert L, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation. Resuscitation. 2004;63(3):233-49.

Travers AH, Rea TD, Bobrow BJ, Edelson DP, Berg RA, Sayre MR, et al. Part 4: CPR overview: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010 Nov 2;122(3):S676-84.

Mader TJ, Nathanson BH, Millay S, Coute RA, Clapp M, McNally B, et al. Out-of-hospital cardiac arrest outcomes stratified by rhythm analysis. Resuscitation. 2012 Nov;83(11):1358-62.

Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(3):S729-67.

Meaney PA, Nadkarni VM, Kern KB, Indik JH, Halperin HR, Berg RA. Rhythms and outcomes of adult in-hospital cardiac arrest. Critical Care Med. 2010 Jan 1;38(1):101-8.

Sayre MR, Koster RW, Botha M, Cave DM, Cudnik MT, Handley AJ, et al. Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation. 2010 Oct 19;122(2):S298-324.

Kjaergaard J, Nielsen N, Winther-Jensen M, Wanscher M, Pellis T, Kuiper M, et al. Impact of time to return of spontaneous circulation on neuroprotective effect of targeted temperature management at 33 or 36 degrees in comatose survivors of out-of hospital cardiac arrest. Resus. 2015 Nov 1;96:310-6.

Wibrandt I, Norsted K, Schmidt H, Schierbeck J. Predictors for outcome among cardiac arrest patients: the importance of initial cardiac arrest rhythm versus time to return of spontaneous circulation, a retrospective cohort study. BMC Emergency Med. 2015 Dec;15(1):3.

Morrison LJ, Kierzek G, Diekema DS, Sayre MR, Silvers SM, Idris AH, et al. Part 3: ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(3):S665-75.

Nadkarni VM, Larkin GL, Peberdy MA, Carey SM, Kaye W, Mancini ME, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA. 2006 Jan 4;295(1):50-7.

Soga T, Nagao K, Sawano H, Yokoyama H, Tahara Y, Hase M, et al. Neurological benefit of therapeutic hypothermia following return of spontaneous circulation for out-of-hospital non-shockable cardiac arrest. Circulation J. 2012;76(11):2579-85.

Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, et al. Outcome, timing and adverse events in therapeutic hypothermia after out‐of‐hospital cardiac arrest. Acta Anaesthesiol Scandinavica. 2009 Aug;53(7):926-34.

Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, et al. Targeted temperature management at 33 C versus 36 C after cardiac arrest. N Engl J Med. 2013 Dec 5;369(23):2197-206.

Oddo M, Ribordy V, Feihl F, Rossetti AO, Schaller MD, Chiolero R, et al. Early predictors of outcome in comatose survivors of ventricular fibrillation and non-ventricular fibrillation cardiac arrest treated with hypothermia: a prospective study. Critical Care Med. 2008 Aug 1;36(8):2296-301.