Outcome of out-of-hospital postcountershock asystole and pulseless electrical activity versus primary asystole and pulseless electrical activity

OBJECTIVE: In the prehospital setting, countershock terminates ventricular fibrillation (VF) in about 80% of cases. However, countershock is most commonly followed by asystole or pulseless electrical activity (PEA). The consequences of such a countershock outcome have not been well studied. The purpose of this investigation was to compare the outcome of prehospital VF victims shocked into asystole or PEA with that of patients whose first documented rhythm was asystole or PEA (primary asystole or PEA). DESIGN: Observational, retrospective study conducted over 5 yrs (1995-1999). SETTING: A municipal hospital with a catchment area of >200,000. PATIENTS: Consecutive adult patients with out-of-hospital nontraumatic cardiopulmonary arrest of cardiac origin. Patients found in VF who developed asystole or PEA after countershocks (group 1) and patients found in asystole or PEA (primary asystole or PEA) (group 2) were included if the reported downtime was <10 min. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Study end points included restoration of circulation (defined as a pulse for any duration), survival to hospital admission, and survival to hospital discharge. Ratios were determined, 95% confidence intervals were calculated, and observed differences were compared. For group 1 patients (n = 101), 61% of patients had a bystander-witnessed collapse and 34% received bystander cardiopulmonary resuscitation. For group 2 patients (n = 140), collapse was bystander witnessed in 71% and 45% received bystander cardiopulmonary resuscitation. These differences were not statistically significant. Restoration of circulation was significantly more frequent in group 2 than group 1 (42% vs. 16%, p <.001) as was survival to hospital admission (36% vs. 11%, p =.001). Survival to hospital discharge was greater in group 2 patients, but the difference failed to achieve statistical significance (10% vs. 3%, p =.062). CONCLUSIONS: Countershock of prolonged VF followed by a nonperfusing rhythm has a worse prognosis than primary asystole or PEA and may be related to myocardial electrical injury.