實證醫學競賽 － CAT 摘要

1. 實證醫學競賽 － CAT 摘要 組別：第 ( A ) 組

2. 訂定 PICO • P : unwittnessed cardiac arrest • I : CardiacPulmonaryResusciation • C : termination of CPR • O : survival rate

3. 資料庫來源 • PubMed

4. 搜尋之關鍵字 • unwittnessed cardiac arrest • CardiacPulmonaryResusciation • termination of CPR • survival rate

5. 搜尋之歷程 • #34 Search WHEN TO TERMINATE CPR Limits: Humans, English, All Adult: 19+ years 02:49:03 10 • #32 Search MINIMUM CPR Limits: Humans, English, All Adult: 19+ years 02:47:10 13 • #31 Search MINIMUM DURATION OF CPR Limits: Humans, English, All Adult: 19+ years 02:46:51 2 • #30 Search "CPR" AND "SATISFY" Limits: Humans, English, All Adult: 19+ years 02:46:04 3 • #27 Search CPR HOW LONG' Limits: Humans, English, All Adult: 19+ years 02:42:54 0 • #28 Search cpr how long Limits: Humans, English, All Adult: 19+ years 02:42:54 158 • #25 Search ("Mortality"[Mesh] AND "Cardiopulmonary Resuscitation"[Mesh] AND "Death, Sudden, Cardiac"[Mesh] AND "Heart Arrest"[Mesh]) Limits: Humans, English, All Adult: 19+ years 02:39:50 18 • #24 Search ("Mortality"[Mesh] OR "Cardiopulmonary Resuscitation"[Mesh] OR "Death, Sudden, Cardiac"[Mesh] OR "Heart Arrest"[Mesh]) Limits: Humans, English, All Adult: 19+ years 02:39:00 111287 • #22 Search "CPR" OR "MORTALITY" OR"CARDIAC ARREST" Limits: Humans, English, All Adult: 19+ years 02:37:40 231287 • #21 Search (cardiac arrest CPR time duration) AND (randomized controlled trial[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract] AND trial[Title/Abstract])) Limits: Humans, English, All Adult: 19+ years 02:35:23 4 • #20 Search CPR survival factors time Limits: Humans, English, All Adult: 19+ years 02:32:49 198 • #17 Search CPR survival factors Limits: Humans, English, All Adult: 19+ years 02:28:29 297 • #16 Search duration CPR survival Limits: Humans, English, All Adult: 19+ years 02:23:21 78 • #12 Search duration CPR asystole survival Limits: Humans, English, All Adult: 19+ years 02:22:37 59 • #11 Search CPR asystole survival Limits: Humans, English, All Adult: 19+ years 02:14:38 483 • #10 Search CPR asystole Limits: Humans, English, All Adult: 19+ years 02:14:27 833 • #9 Search duration resuscitation asystole Limits: Humans, English 02:12:21 291 • #8 Search duration rususcitation asystole Limits: Humans, English 02:11:04 1165 • #2 Search duration CPR asystole Limits: Humans, English 01:59:34 112 • #1 Search duration CPR asystole 01:51:31 165

6. 文獻研讀 • 請列出你們認為證據最強的相關文獻一至三篇 • 針對每篇文獻，請摘錄其： • 題目及出處 (e.g. Dosing and safety of cyclosporine in patients with severe brain injury. J Neurosurg. 2008;109(4):699-707) • 研究設計 (study design) • 結果 (若有計算NNT、RR、OR等，請一併列出) • 證據等級 (level of evidence)

7. 第一篇 • Independent evaluation of an out-of-hospital termination of resuscitation (TOR) clinical decision rule. Acad Emerg Med. 2008 Jun;15(6):517-21

8. ABSTRACT • Objectives:determine whether to terminate emergency medical services (EMS) resuscitative efforts for out-of-hospital cardiac arrests (OOHCA). • Methods:retrospective cohort analysis conducted in the state of Arizona. Consecutive, adult, OOHCA were prospectively evaluated from October 2004 through October 2006. A statewide OOHCA database utilizing Utstein-style reporting from 30 different EMS systems was used. Data were abstracted from EMS first care reports and hospital discharge records. The TOR guidelines predict that no survival to hospital discharge will occur • 1) an OOHCA victim does not have return of spontaneous circulation (ROSC), • 2) no shocks are administered, • 3) the arrest is not witnessed by EMS personnel. Data were entered into a structured database. Continuous data are presented as means (±standard deviations [SD]) and categorical data as frequency of occurrence, and 95% confidence intervals (CIs) were calculated as appropriate. The primary outcome measure was to determine if any cohort member who met TOR criteria survived to hospital discharge.

9. Results:There were 2,239 eligible patients; the study group included 2,180 (97.4%) patients for whom the data were complete; mean age was 64 (±11) years, and 35% were female. The majority of patients in the study group met at least one or more of the TOR criteria. A total of 2,047 (93.8%) patients suffered from cardiac arrest that was unwitnessed by EMS; 1,653 (75.8%) had an unwitnessed arrest and no ROSC. With respect to TOR, 1,160 of 2,180 (53.2%) patients met all three criteria; only one (0.09%; 95% CI=0% to 0.5%) survived to hospital discharge. • Conclusions:The authors evaluated TOR guidelines in an independent, statewide OOHCA database. The results are consistent with the findings of the TOR investigation and suggest that this algorithm is a promising tool for TOR decision-making in the field.

10. 第二篇 • Prehosp Emerg Care. 2000 Apr-Jun;4(2):190-5. • Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest. National Association of EMS Physicians Standards and Clinical Practice Committee.

11. The following factors should be considered in establishing termination of resuscitation protocols: • 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. • 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. • 3) In the absence of “DNR" or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. • 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation.

12. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. • 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. • 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers.

13. 第三篇 • Out-of-hospital unwitnessed cardiopulmonary collapse and no-bystander CPR: a practical addition to resuscitation termination guidelines. • Stratton SJ, Rashi P; Los Angeles County Prehospital Care Coordinators.

14. The purpose of this prospective cohort study was to determine if unwitnessed collapse combined with no-bystander cardiopulmonary resuscitation would support a decision to terminate attempted resuscitation. • There were 541 patients analyzed during 6 months, with functional neurological survival the outcome of interest. • There were no functional neurological survivors at hospital discharge among the 180 victims in the unwitnessed, no-bystander CPR subgroup (95% confidence interval [CI] 0.0%-2.1%). Functional neurological survival for witnessed collapse, bystander CPR was 6.0% (95% CI 2.8%-12.5%), for witnessed collapse, no-bystander CPR was 3.8% (95% CI 1.9%-7.7%), and for unwitnessed collapse, bystander CPR 1.3% (95% CI 0.2%-6.9%). • With confirmation by further studies, unwitnessed collapse and lack of bystander CPR may be a practical addition to resuscitation termination guidelines.

15. 由以上paper得知符合某些條件之到院前死亡病人,不論接下的處置存活率都逼近於零由以上paper得知符合某些條件之到院前死亡病人,不論接下的處置存活率都逼近於零

16. 結論

17. 如何應用於臨床？ • 請嘗試以去學術化術語的方式回答家屬的問題。

18. 困境或陷阱 • 臨床應用是否會遭遇困境或有哪些陷阱？

19. 參考資料

20. 參考資料：證據的強度

21. 參考資料：證據等級和臨床建議

22. 參考資料