Goal-directed cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest in the emergency Department: A feasibility study

Aim: To describe the feasibility of prospective measurement of intra-arrest diastolic blood pressure (DBP) and goal-directed treatment of refractory out-of-hospital cardiac arrest (OHCA) in the emergency department (ED). Methods: Retrospective case series performed at an urban, tertiary-care hospital from 12/1/2018 - 12/31/2019. We studied consecutive adults presenting with refractory, non-traumatic OHCA treated with haemodynamic-targeted resuscitation that entailed placement of a femoral arterial catheter, transduction of continuous BP during CPR, and administration of vasopressors (1 mg noradrenaline) and, if applicable, Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), to achieve DBP >= 40 mmHg. Feasibility was measured by the success rate and time to achieve arterial catheterization and BP transduction. Additional outcomes included the change in DBP with vasopressor administration and occurrence of sustained ROSC. Results: Goal-directed treatment was successfully performed in 8/9 (89%) patients. Arterial access required 1.5 (interquartile range (IQR) 1-2) attempts and BP transduction occurred within 10.5 +/- 2.4 minutes of patient arrival. Noradrenaline slightly increased DBP (pre 21.6 +/- 8.3 mmHg, post 26.1 +/- 12.1 mmHg, p < 0.025), but only 4/23 (17%) doses resulted in DBP >= 40 mmHg. REBOA was attempted in 2/8 (25%) patients and placed successfully in both cases. Three (37.5%) patients achieved ROSC, but none survived to hospital discharge. Conclusions: In ED patients with refractory OHCA, measurement of DBP during CPR and titration of resuscitation to a DBP goal is feasible. Future research incorporating this approach should seek to develop haemodynamic-targeted treatment strategies for OHCA patients that do not achieve ROSC with initial resuscitation.