autopsy cause of death in - resuscitation council (uk) · autopsy are not standardised between...
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Autopsy Cause of death in
‘Presumed Cardiac’ aetiology
Out-of-Hospital Cardiac
Arrests in Young Adults
Presenter; Dr Conor Deasy, FACEM, FCEM
PhD Student
Deasy C, Bray J, Smith K, Harriss L,
Bernard S, Cameron P on behalf of the
VACAR Steering Committee
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Background
• OHCA is presumed of cardiac aetiology unless as best
determined by rescuers it is known or likely to have
been caused by;
- Trauma
- Submersion
- Drug overdose
- Asphyxia
- Exsanguination
- Other noncardiac cause
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Background
• The aetiology in the young adult age group is likely to be
different to that of older adults where ischemic heart
disease is more common. Zipes et al. Sudden cardiac death. Circulation.
1998;98(21)
• Realising the aetiology of the cardiac arrest may
influence treatment decisions.
• Much attention towards structural heart abnormalities &
cardiac electrical disorders
- Genetic screening Doolan A et al. Causes of sudden cardiac death in
young Australians. Med J Aust. 2004;180(3)
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Aims
We aim to describe the autopsy findings of young adults
in Melbourne where the OHCA precipitant was
‘presumed cardiac.’
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Melbourne, Australia
• Population; 4 million
• 35.6% aged 16-39 years
• Area; 10,000 km2
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Ambulance Victoria
Paramedics all educated to ALS
Base qualification for a paramedic
is a Bachelor's degree
Post graduate diploma conversion
course
MICA – university level
postgraduate diploma
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Data
Electronic patient record (VACIS)
Victorian Ambulance Cardiac
Arrest Registry (VACAR)
- Clinical and Utstein data
elements
- Hospital data including
outcome
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Methods
• VACAR was searched for all OHCAs occurring in
patients aged 16-39 years occurring 2000-2009.
• Cross checked cause of death with coroner’s office
• Excluded Patients
EMS witnessed OHCA
Drug overdoses on autopsy
• Compared autopsy confirmed ‘cardiac’ and confirmed
‘non cardiac’ OHCA
Ethics approval
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Results
OHCA
• OHCAs n=842
• Discharged Alive n=86
• Survival 10.2%
Post Mortems
• PMs not done or unavailable n=278
• 551 PMs available (73%)
• Cause of death not ascertainable on PM n=98 (18%)
• Confirmed ‘Cardiac’ n=233 (42%)
• Confirmed ‘Non Cardiac’ n=220 (40%)
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Results
• Years 2000-2009
• Age Median(IQR) 33(27-37) years
• 71% male
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‘Cardiac’ Cause of Death (n=233)
%
53
12 10
5 4 3 3 2 1 2
0
10
20
30
40
50
60
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‘Non Cardiac’ Cause of Death (n=220)
26
13 11
10 8
7 6
5 4
3 2 2
3
0
5
10
15
20
25
30
%
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Unascertainable n=98
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Results
‘Non Cardiac’ n=220 ‘Cardiac’ n=233
Age 32(26-37) 34(30-38)*
Male 64% 78%*
Bystander CPR 21% 34%*
Witnessed Arrest 24.6% 42%*
EMS Response Time 7(5.9-10.3) 7.95(6-9.7)
Shockable Rhythm 21.5% 78.5%*
Resuscitated 45.8% 61.2%*
ROSC 47.6% 52.4%
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Discussion
• Cause of cardiac arrest in the 16-39 year old sub group
patients is challenging to predict.
• Where autopsy provided cause of death in ‘presumed
cardiac’ OHCA 49% were ‘non cardiac’
• ‘Presumed cardiac’ group was significantly different
Older, Male, Shockable, Witnessed, Received Bystander CPR.
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Discussion
• Better knowledge of the causes of OHCA is important in
supporting the development of diagnostic and treatment
pathways in OHCA
Prehospital ultrasound, echo, thrombolysis
• Aetiological heterogeneity may undermine the impact of
improved EMS standards of care
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Limitations
• The data does not report drug overdose
• Aetiology of OHCA in those that survived to hospital
discharge is not reported
• Decisions to perform/withhold performing a complete
autopsy are not standardised between coroner’s, states,
countries.
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Conclusion
Linkage of Cardiac Arrest Registries with Coroner’s data
and hospital diagnostics may provide the key to
improved diagnostic and treatment algorhythms in
OHCA and be more sensitive to the outcome benefits of
such interventions.