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Initial end-tidal carbon dioxide as a predictive factor for return of spontaneous circulation in nonshockable out-of-hospital cardiac arrest patients

A retrospective observational study

Poppe, Michael*; Stratil, Peter*; Clodi, Christian; Schriefl, Christoph; Nürnberger, Alexander; Magnet, Ingrid; Warenits, Alexandra-Maria; Hubner, Pia; Lobmeyr, Elisabeth; Schober, Andreas; Zajicek, Andreas; Testori, Christoph

European Journal of Anaesthesiology (EJA): July 2019 - Volume 36 - Issue 7 - p 524–530
doi: 10.1097/EJA.0000000000000999

BACKGROUND Early outcome prediction in out-of-hospital cardiac arrest is still a challenge. End-tidal carbon dioxide (ETCO2) has been shown to be a reliable parameter to reflect the quality of cardiopulmonary resuscitation and the chance of return of spontaneous circulation (ROSC).

OBJECTIVES This study assessed the validity of early capnography as a predictive factor for ROSC and survival in out-of-hospital cardiac arrest victims with an underlying nonshockable rhythm.

DESIGN Retrospective observational study.

SETTING/PATIENTS During a 2-year observational period, data from 2223 out-of-hospital cardiac arrest victims within the city of Vienna were analysed. The focus was on the following patients: age more than 18 years, an underlying nonshockable rhythm, and advanced airway management within the first 15 min of advanced life support with subsequent capnography.

INTERVENTION No specific intervention was set in this observational study.

MAIN OUTCOME MEASURES The first measured ETCO2, assessed immediately after placement of an advanced airway, was used for further analysis. The primary outcome was defined as sustained ROSC, and the secondary outcome was 30-day survival.

RESULTS A total of 526 patients met the inclusion criteria. These were stratified into three groups according to initial ETCO2 values (<20, 20 to 45, >45 mmHg). Baseline data and resuscitation factors were similar among all groups. The odds of sustained ROSC and survival were significantly higher for patients presenting with higher values of initial ETCO2 (>45 mmHg): 3.59 [95% CI, 2.19 to 5.85] P = 0.001 and 5.02 [95% CI, 2.25 to 11.23] P = 0.001, respectively. On the contrary ETCO2 levels less than 20 mmHg were associated with significantly poorer outcomes.

CONCLUSION Patients with a nonshockable out-of-hospital cardiac arrest who presented with higher values of initial ETCO2 had an increased chance of sustained ROSC and survival. This finding could help decision making as regards continuation of resuscitation efforts.

From the Emergency Medicine, Medical University of Vienna (MP, PS, CC, CS, AN, IM, A-MW, PH, EL, AS, CT) and Municipal Ambulance Service of Vienna, Vienna, Austria (AZ)

Correspondence to Michael Poppe, Universitätsklinik für Notfallmedizin, Medizinische Universität Wien, Währinger Gürtel 18–20/6D, 1090 Wien, Austria Tel: +43 14040019640; fax: +43 14040019650; e-mail:

Published online 5 April 2019

© 2019 European Society of Anaesthesiology