Lindsay Laws, MD
Neurocritical Care Fellow
Johns Hopkins University School of Medicine
Baltimore, MD
Disclosure information not submitted.
Sung-Min Cho, DO, MHS
Assistant Professor
Johns Hopkins Hospital, United States
Disclosure information not submitted.
Ajit Munjuluru
Manager of Business Intelligence
Johns Hopkins, United States
Disclosure information not submitted.
Romergryko Geocadin, MD
Professor
Johns Hopkins Hospital, United States
Disclosure information not submitted.
Daniel Swedien, MD
Assistant Professor
Johns Hopkins Hospital, United States
Disclosure information not submitted.
Title: Evidence of Early Autonomic Dysfunction May Predict Worse Outcomes After Cardiac Arrest
Introduction: Cardiac arrest is devastating and neurologic injury is a strong predictor of functional outcome. However, early neurologic assessment does not reliably predict outcome. Evidence of early autonomic nervous system (ANS) dysfunction due to central neurologic injury has not been robustly investigated as a prognostication tool. We hypothesize that early ANS dysregulation in the emergency department (ED) after resuscitation from cardiac arrest, manifest by hypothermia and labile heart rate, corresponds with worse outcomes.
Methods: We performed a retrospective analysis of an institutional database of patients with cardiac arrest from 2016 to 2020. Patients with out-of-hospital medical arrests who had return of spontaneous circulation (ROSC) and vital signs recorded in the ED were included. Traumatic arrests were excluded. We evaluated initial temperature, and heart rate standard deviation (HRSD) in the ED after ROSC, as an indicator of heart rate lability. We compared patients with a favorable outcome, defined by hospital discharge to home or a rehabilitation facility, to those with a poor outcome, who discharged to a skilled nursing facility, acute care facility, or who died.
Results: One hundred fifty-one patients were included. Of those, 137 had temperature recordings, 140 had HR recordings, and 130 had both. Median age was 58 (IQR 46.5-67) and 63% were male. Patients with favorable outcomes (10%) had higher temperatures at initial presentation than patients with poor outcomes (35.9°C vs. 35.4°C, p=0.03). HRSD was lower in patients with favorable outcomes (12bpm vs. 17bpm, p=0.04). In patients with initial temperatures ≤35.5°C, HRSD was also significantly lower in patients with favorable outcomes vs. poor (8bpm vs. 17bpm, p=0.03), but this was not true for patients with temperatures >35.5°C (14bpm vs. 17bpm, p=0.4). No patients who discharged to home or rehab had a temperature in the lowest quartile (22.8ºC-35.4°C) and HRSD in the highest quartile (21bmp-82bpm) whereas 9% of patients who died did.
Conclusions: In patients resuscitated from cardiac arrest, low initial temperature and heart rate instability in the ED correlate with worse outcomes. The combination of hypothermia and high HRSD may provide early objective neurologic assessment by indicating central ANS injury and portend a worse prognosis.