Confirmation of COVID-19 in Out-of-Hospital Cardiac Arrest Patients and Postmortem Management in the Emergency Department during the COVID-19 Outbreak

Abstract

Background: There is currently a lack of evidence-based postresuscitation or postmortem guidelines for patients with out-of-hospital cardiac arrest (OHCA) in the setting of an emerging infectious disease. This study aimed to develop and validate a multimodal screening tool that aids in predicting the disease confirmation in emergency situations and patients with OHCA during a coronavirus disease 2019 (COVID-19) outbreak.

Materials and methods: We conducted a retrospective, multicenter observational study of adult patients with OHCA in Daegu, Korea. To identify the potential predictors that could be used in screening tools in the emergency department, we applied logistic regression to data collected from March 1 to March 14. The prediction performance of the screening variables was then assessed and validated on the data of patients with OHCA who were treated between February 19 and March 31, 2020. General patient characteristics and hematological findings of the COVID-19-negative and COVID-19-positive groups were compared. We also evaluated confirmation test criteria as predictors for COVID-19 positivity in patients with OHCA.

Results: Advanced age, body temperature, and abnormal chest X-ray (CXR) revealed significant predictive ability in the derivation cohort. Of the 184 adult patients with OHCA identified in the validation cohort, 80 patients were included in the analysis. Notably, 9 patients were positive and 71 were negative on the COVID-19 reverse transcription polymerase chain reaction test. Five patients (55.6%) in the COVID-19-positive group had a fever before OHCA, and 12 (16.9%) of the COVID-19-negative group had a fever before OHCA (P = 0.018). Eight patients (88.9%) in the COVID-19-positive group had a CXR indicating pneumonic infiltration. Of the criteria for predicting COVID-19, fever or an abnormal CXR had a sensitivity of 100% (95% confidence interval [CI]: 65.4 - 100) and a specificity of 22.5% (95% CI: 13.5 - 34.0).

Conclusion: The screening tools that combined fever or abnormal CXR had a good discriminatory ability for COVID-19 infection in adult patients with OHCA. Therefore, during the COVID-19 outbreak period, it is recommended to suspect COVID-19 infection and perform COVID-19 test if patients present with a history of fever or show abnormal findings in postmortem CXR.

Keywords: COVID-19; Chest X-ray; Fever; Heart arrest; Screening.

Figure 1. Sum test cases of COVID-19 RT-PCR for OHCA during the COVID-19 outbreak in Daegu.

COVID-19, coronavirus disease 2019; RT-PCR, reverse transcription polymerase chain reaction; OHCA, out of hospital cardiac arrest.

Figure 2. OHCA patient enrollment during the COVID-19 outbreak in Daegu and patient characteristics.

OHCA, out of hospital cardiac arrest; COVID-19, coronavirus disease 2019; DOA, death on arrival; EMS, emergency medical service; RT-PCR, reverse transcription-polymerase chain reaction.

Figure 3. Forest plot for predicting potential factors for confirmation of COVID-19 in the derivation cohort.

COVID-19, coronavirus disease 2019; RR, respiratory rate.

Figure 4. Guidelines for management in OHCA patients and the confirmation test during the COVID-19 outbreak.

OHCA, out of hospital cardiac arrest; COVID-19, coronavirus disease 19; CPR, cardiopulmonary resuscitation; PPE, personal protective equipment; ER, emergency room; PAPR, powered air purifying respirator; DNR, do not resuscitate; CXR, chest X-ray; RT-PCR, reverse transcription-polymerase chain reaction.