Authors: Rob Hirst, Andy Neill, Dave McCreary Codes: CC4, RP3, SLO7, SLO9 / Published: 02/10/2023

New in EM - Routine head to pelvis CT post arrest

Clinical question

Should we be doing a head to pelvis ct on everyone post arrest?

Title

Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study

Authors

Branch et al 2023, Resuscitation

Background

We see lots of cardiac arrests, it’s core business for EM. And most places are wll set up to identify and manage the common and treatable causes of arrests – namely coronary occlusion needing the cath lab. But those of us with any degree of experience realise that many if not most of the arrests that make it to ED (without bypassing to the cath lab) clearly don’t fit in the PCI box. Something has caused the cardiac arrest and like most illnesses it’s hard to treat what you haven’t diagnosed. Can a routine head to pelvis CT help us know what’s going on?

Methods – prospective study from the states – compared a control cohort of cardiac arrest patients with a cohort who all got a routine head to pelvis CT scan. The data is quite old with enrolment finishing in 2018 but only published now

– CT had to be done within 6 hrs and excluded obvious cardiac causes like those with known coronary disease or those who went immediately for PCI.

– Scan was a non contrast head, a gated thoracic CT to look at aorta and coronaries and a venous abdominal study.

– The coronary CT bit was not given to treating clinicians as they had concerns it wasn’t optimised enough

– 2 people on the research team adjudicated whtha they thought the most likely cause of arrest was based on all the data.

– Primary outcome was diagnostic yield. Which is deeply probelmatic as findiging more stuff is inevitable here but proving it caused arrest or is even treatable is a whole different story.

Results

– They plucked 140 pts from a historic cohort from the year before and then enrolled 110 pts in their CT cohort.

– Interestingly most of the historic cohort got a CT of at least head and chest anyhow (though when they got it is not clear)

– Causes of arrest were a smorgasboard with MI being the commonest at 15% but drug overdose and “unknown” where the two other categories notes – treatable things like PE for example where fairly uncommon at 5% in the CT group

– For their primary outcome they felt they got an accurate diagnosis in 92% in the CT group but in the historic cohot it was only 75%

– The diagnosis seemed to be much quicker too as you might imagine

Thoughts

– I want to admit my biases up front, i love a good CT. If i can get a CT i will. Lack of diagnosis causes me great angst, or rather insufficient effort to make the diagnosis causes me angst. I’m happy to ride it out once i know i’ve had a good luck. If you have the resources then get the scan.

– It’s hard to see the downsides beyond that. Once you’ve died and been resuscitated the risk of radiation seems silly. This is not the population to spare the diagnostic tests in

– It’s not just diagnostic data but prognostic data that you get. If there’s early cerebral oedema or some catastrophic diagnosis then it might avoid 12 hrs of futile and invasive resuscitiation.

– In our place this is fairly routine at this stage for most patients where diagnosis is unclear. Our CT is practically in resus and a CT on the way to ICU is fairly easily done, rather than arriving in ICU and then deciding we have to go back to CT

RCEM ASC Interview Megamix

(00:00) Chelcie Jewitt – Challenging the culture of sexism and sexual misconduct in healthcare

(06:33) Jamie Morrison – Tayside Flow Project

(15:30) Ed Carlton – The RELIEF Trial

(24:37) Heidi Edmondsen – Measuring the clouds: what’s stopping us from improving staff wellness?

(32:57) Mo Al-Haddad – Differential attainment and well-being amongst IMGs

(44:44) James Van Oppen – Person Centred GEM – evidence and application

(54:39) David Lowe and Alex Novak – AI & EM

(01:08:21) Harriet Tucker and Lisa Ramage – The TETRIS Project

(01:17:31) David Lowe – The Trauma App