UMEM Educational Pearls

 

Background: Prior evidence^1,2 has suggested that early “pan-scan” after ROSC provides clinically-relevant information that assists in the care of the patient in question, when the cause of OHCA is unclear.

The recent CT FIRST trial looked at patients pre- and post- implementation of a protocol for head-to-pelvis CT within 6 hours of ROSC for adult patients without known cause or evidence of possible cardiac etiology, stable enough for scan. *Patients with GFR <30 were excluded from assignment to CT, although were included in the post/CT cohort if their treating doctors ordered CT scans based on perceived clinical need. To balance this, a similar number of patients with GFR <30 were included in the pre/“standard of care” cohort.

• Pre/SOC cohort (143 pts) vs. Post/SOC+CT cohort (104 pts)
• CT protocol: Dry head CT, CTA chest, venous phase CT abd/pelvis
• In pre/SOC group, CTs ordered by treating docs in 52% (one or mix of the above CTs)

Outcomes After Protocol (Pre- vs. Post-):

• Increased identification of OHCA diagnosis (75% vs. 92%, p = 0.001)
  • In SOC + CT group, diagnosis only found by CT in 13%
  • In SOC group, diagnosis only found by CT in 17%

• Faster OHCA diagnosis (14.1h vs. 3.1h, p= 0.0001)
   
• Fewer delays in time-critical diagnoses* (62% vs. 12%, p= 0.001)  *both OHCA dx and resuscitation-related injury
   
• No difference in ultimate diagnosis of time-critical diagnoses, rates of AKI, or survival to hospital discharge, allergic contrast reactions (0), scan complications (0), inappropriate treatments based on CT findings (0)

 

Bottom Line: Early pan-CT allows for earlier definitive diagnosis and stabilization without increase in adverse events. While this earlier diagnosis does not seem to yield better survival, earlier stabilization may provide some benefits in terms of resource allocation and disposition, a notable benefit during our current crisis of staffing shortages and ED boarding. 

 

References

1. Adel J, Akin M, Garcheva V, et al. Computed-Tomography as First-line Diagnostic Procedure in Patients With Out-of-Hospital Cardiac Arrest. Front Cardiovasc Med. 2022 Feb 3;9:799446. doi: 10.3389/fcvm.2022.799446.
2. Branch KRH, Strote J, Gunn M, et al. Early head-to-pelvis computed tomography in out-of-hospital circulatory arrest without obvious etiology. Acad Emerg Med. 2021 Apr;28(4):394-403. doi: 10.1111/acem.14228.
3. Branch KRH, Gatewood MO, Kudenchuk PJ, et al. Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study. Resuscitation. 2023 Jul;188:109785. doi: 10.1016/j.resuscitation.2023.109785.