Resuscitation 85 (2014) 332335

Contents lists available at ScienceDirect

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Clinical Paper

Predicting the lack of ROSC during pre-hospital CPR: Should an

end-tidal CO2 of 1.3 kPa be used as a cut-off value?,
Leif Rogns a,b,c,d, , Troels Martin Hansen c,d , Hans Kirkegaard e , Else Tnnesen f
a

Department of Research and Development, Norwegian Air Ambulance Foundation, P.O. Box 94, 1441 Drbak, Norway
Pre-hospital Critical Care Team, Department of Anaesthesiology, Viborg Regional Hospital, Heibergs All 4, 8800 Viborg, Denmark
Pre-hospital Critical Care Team, Aarhus University Hospital, Oluf Palmes All 32, 8200 Aarhus N, Denmark
d
Department of Pre-hospital Medical Services, Central Denmark Region, Oluf Palmes All 34, 8200 Aarhus N, Denmark
e
Centre for Emergency Medicine Research, Aarhus University Hospital, Trjborgvej 72-74, Building 30, 8200 Aarhus N, Denmark
f
Department of Anaesthesiology, Aarhus University Hospital, Nrrebrogade 44, 8000 Aarhus, Denmark
b
c

a r t i c l e

i n f o

Article history:
Received 19 September 2013
Received in revised form
24 November 2013
Accepted 7 December 2013
Keywords:
Cardiac arrest
End-tidal CO2
Pre-hospital critical care
Emergency medical system
Helicopter emergency medical system
Critical decision making

a b s t r a c t
Aim: The aim of this study was to investigate if an initial ETCO2 value at or below 1.3 kPa can be used
as a cut-off value for whether return of spontaneous circulation during pre-hospital cardio-pulmonary
resuscitation is achievable or not.
Materials and methods: We prospectively registered data according to the Utstein-style template for
reporting data from pre-hospital advanced airway management from February 1st 2011 to October 31st
2012. Included were consecutive patients at all ages with pre-hospital cardiac arrest treated by eight
anaesthesiologist-staffed pre-hospital critical care teams in the Central Denmark Region.
Results: We registered data from 595 cardiac arrest patients; in 60.2% (n = 358) of these cases the prehospital critical care teams performed pre-hospital advanced airway management beyond bag-mask
ventilation. An initial end-tidal CO2 measurement following pre-hospital advanced airway management
were available in 75.7% (n = 271) of these 358 cases. We identied 22 patients, who had an initial end-tidal
CO2 at or below 1.3 kPa. Four of these patients achieved return of spontaneous circulation.
Conclusion: Our results indicates that an initial end-tidal CO2 at or below 1.3 kPa during pre-hospital CPR
should not be used as a cut-off value for the achievability of return of spontaneous circulation.
2013 The Authors. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction
The European Resuscitation Council Guidelines for Resuscitations recommends the use of waveform capnography for
conrmation of tracheal tube placement whenever endotracheal
intubation (ETI) is performed during cardio-pulmonary resuscitation (CPR).1
Several authors,28 most recently Heradstveit et al.9 and
Qvigstad et al.,10 have suggested that measuring end-tidal carbon dioxide (ETCO2 ) may also be useful for optimising CPR quality

A Spanish translated version of the abstract of this article appears as Appendix

in the nal online version at http://dx.doi.org/10.1016/j.resuscitation.2013.12.009.
This is an open-access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided
the original author and source are credited.
Corresponding author at: Pre-hospital Critical Care Team, Aarhus University
Hospital, Oluf Palmes All 32, 8200 Aarhus N, Denmark.
E-mail addresses: leifrogn@rm.dk (L. Rogns), troehans@rm.dk (T.M. Hansen),
hanskirk@rm.dk (H. Kirkegaard), else.toennesen@aarhus.rm.dk (E. Tnnesen).

and as an aid for prognostication during CPR. Kolar et al. from the
emergency medical system (EMS) in Maribor, Slovenia found that
among 1086 non-traumatic adult cardiac arrest patients (collected
during a period of eight years) none of the patients in their study
with an initial ETCO2 below 1.33 kPa achieved ROSC.11 The authors
suggest using an ETCO2 of 1.33 kPa as a cut-off value for whether
return of spontaneous circulation (ROSC) following pre-hospital
cardiac arrest (CA) is achievable. We are not aware of any successful
validation of these ndings and the knowledge of the prognostic
signicance of ETCO2 measurements during pre-hospital CPR
remains limited.
1.1. Objectives
The objective of the study was to investigate if an initial ETCO2
value at or below 1.3 kPa can be used as a cut-off value for whether
ROSC during pre-hospital CPR is achievable or not.
We hypothesised that in patients with pre-hospital CA,
treated according to European Resuscitation Council Guidelines for
Resuscitation,1 an initial ETCO2 at or below 1.3 kPa is a predictor
for lack of ROSC and pre-hospital death.

0300-9572/$ see front matter 2013 The Authors. Published by Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.resuscitation.2013.12.009

L. Rogns et al. / Resuscitation 85 (2014) 332335

2. Methods
2.1. Study design
The data analysed in the present study is part of an observational study12,13 where we prospectively collected data related to
pre-hospital advanced airway management (PHAAM) in accordance with the consensus-based template made by Sollid et al.14
2.2. Setting
We investigated the anaesthesiologist-staffed pre-hospital critical care teams in the Central Denmark Region. This region covers
a mixed urban and rural area of approximately 13,000 km2 with a
population of 1,270,000, and an overall population density is 97.7
inhabitants per km2 .
The standard EU emergency telephone number (1-1-2) covers
all Denmark and there is an Emergency Medical Dispatch Centre
in each of the ve Danish regions. Emergency Medical Dispatch is
criteria based and telephone guided CPR is provided.15
The Emergency Medical Service (EMS) in the region is a twotiered system based on 64 road ambulances staffed by emergency
medical technicians (EMTs) supported by ten pre-hospital critical care teams staffed with an anaesthesiologist (with at least
4 years experience in anaesthesia) and a specially trained EMT.
Rapid response vehicles deploy nine of the pre-hospital critical
care teams; the tenth team staffs a Helicopter Emergency Medical
Service (HEMS) helicopter.
The pre-hospital critical care teams covered by this study
employ approximately 90 anaesthesiologists as part time prehospital physicians. All pre-hospital critical care anaesthesiologists
in the region primarily work in one of the ve regional emergency
hospitals or at the university hospital and they all have in-hospital
emergency anaesthesia and advanced airway management both
in- and outside the operating theatre as part of their daily work.
Intensive care is part of the Danish anaesthesiological curriculum.
EMTs and the pre-hospital critical care teams are expected
to follow the European Resuscitation Council Guidelines for
Resuscitation.1 The LUCAS automated chest compression device
is available on all the anaesthesiologist-staffed rapid response vehicles as well as on the HEMS. We have described the EMS system in
our region in more detail elsewhere.12,13,16
We collected data between February 1st 2011 and November
1st 2012.
2.3. Participants
2.3.1. Inclusion criteria
Consecutive pre-hospital cardiac arrest patients of all ages
where the pre-hospital critical care anaesthesiologist performed
PHAAM beyond bag-mask ventilation (BMV).
2.4. Endpoints and variables
Primary endpoints were: (1) initial ETCO2 after PHAAM during
CPR and (2) return of spontaneous circulation.
Secondary endpoints were: (1) Pre-hospital mortality.
We dened initial ETCO2 as the rst ETCO2 obtained after
PHAAM and return of spontaneous circulation as any period (no
time limit) of spontaneous circulation following PHAAM.
We collected all core data proposed in the consensus-based
template by Sollid et al. and we dened the variables as in this
template.14
The indications for performing PHAAM are categorised by Sollid
et al.14 We included patients where the pre-hospital critical care
physician had marked cardiac arrest as the reason for performing
PHAAM.

333

The pre-hospital critical care teams or the EMTs on the road

ambulances measured oxygen saturation, heart rate and blood
pressure by using a LifePak 12 monitor (Physio-Control, Redmond,
USA). The pre-hospital critical care teams monitored ETCO2 either
via the LifePak 12 or via a Nellcor NPB-75 capnograph (Tyco Healthcare Group LP, Pleasanton, USA). None of these devices can display
the ETCO2 as 1.33 kPa; it is either 1.3 or 1.4. Therefore, we chose at
or below 1.3 kPa as the cut-off value in this study.
The physicians registered the initial ETCO2 as a free-text variable. During data analysis, we labelled the initial ETCO2 as being
either under 1.3 kPa, at 1.3 kPa or above 1.3 kPa.
2.5. Data sources and data collection
We collected data from eight of the ten pre-hospital critical
care teams, including the HEMS. Due to substantial differences in
stafng, caseload, case mix and routines during the study period,
only eight of the ten pre-hospital critical care teams provided data
for the study.
The anaesthesiologists lled in a registration form (provided as
a Supplemental File) containing all the core data recommended by
Solid et al.14 If the patient died on-scene, we reviewed the written pre-hospital charts as well as the entry made in the electronic
patient journal for any evidence of temporary ROSC. For patients
transported during ongoing CPR, we evaluated the same sources
for evidence of temporary ROSC. If there were any doubt, whether
the patient achieved ROSC or not we included the patient in the no
ROSC group during data analysis.
2.6. Bias
To reduce the risk of recall bias and selection bias, the primary
investigator reviewed the registration forms on a day-to-day
basis. We crosschecked the registration forms with the standard
pre-hospital records from the pre-hospital critical care teams to
ensure the highest possible data coverage. In cases of missing data
or inconsistencies, we asked the attending pre-hospital critical
care physician to provide additional details for clarication.
2.7. Study size and statistical methods
In-depth discussions with an expert statistician at Aarhus University resulted in the following:
In theory, it would only take one single patient with a true initial
ETCO2 at or below 1.3 kPa and subsequent ROSC for us to have to
reject the hypothesis. However, this one case could be due to for
instance equipment malfunction and we therefore decided that we
would reject the hypothesis if two or more patients with an initial
ETCO2 at or below 1.3 kPa achieved ROSC.
Sample size calculations made by the statistician in the statistical software Stata 12 (StataCorpLP) showed that to be able to
conrm the hypothesis with a power of at least 80% and a level
of signicance of 95% we would need to include 100 patients with
an ETCO2 of less than 1.3 and no ROSC. In cases of unobtainable
missing data, we performed complete case analyses.
2.8. Ethics
No patients had their treatment altered because of the study.
All physicians participated in the study on a voluntary basis
there were no refusals.
The study did not involve any alterations from normal practice
and according to Danish law, it did not need the approval of the
Regional Ethics Committee, nor did we need the patients consent
to register and publish the data. The Danish Data Protection Agency
approved the study (Journal number 2013-41-1462).

334

L. Rogns et al. / Resuscitation 85 (2014) 332335

Table 1
Demographic data.

Total patients included (N)

Age (years) mean
Age < 16 years
Age < 2 years
Males
ASA-PSa -score mean
Pre-existing cardiac disease
Pre-existing hypertension
Pre-existing COPDb
Pre-existing diabetes
Pre-existing neurological disease
Other pre-existing disease
Traumatic cardiac arrest
Non-traumatic cardiac arrest
a
b

Numbers

358
63.1
11
6
232
2.32
96
29
40
18
23
99
32
326

097 (range)
3.1
1.7
64.8
14 (range)
26.8
8.1
11.2
5.0
6.4
27.7
8.9
91.1

American Society of Anesthesiologists Physical Performance.

Chronic obstructive pulmonary disease.

In a study of 575 Norwegian pre-hospital cardiac arrest patients

treated by physician-staffed HEMS, Heradstveit et al., 9 found many
confounding factors complicating the interpretation of ETCO2
monitoring during CPR. The authors could not identify a clear generalised cut-off value determining whether ROSC would be achieved
or not. Our results seem to support this view.
In our opinion, ETCO2 monitoring during CPR provides important information but the results of the current study does not allow
us to support the use of an initial ETCO2 at or below 1.3 as a cutoff value for the achievement of ROSC in pre-hospital CA patients.
Basing the decision of whether or not to terminate CPR on this cutoff value may diminish patients safety and impair patient outcome
following pre-hospital CA.
We advocate the use of ETCO2 measurements as one parameter
among others (such as the result of focused ultrasound assessment)
to guide the critical decision-making during pre-hospital CPR.
4.2. Limitations

3. Results
3.1. Participants
During the 21 months, the participating pre-hospital critical
care teams treated 24 693 patients. The teams registered data from
1081 PHAAM cases corresponding to 93.3% of PHAAM patients.
Patients in CA accounted for 55.0% (n = 595) of these cases. The prehospital critical care physicians performed PHAAM beyond BMV on
60.2% (n = 358) of the 595 patients in CA; the rest were treated with
bag-mask ventilation and in these cases ETCO2 were not routinely
measured. In 97.8% (n = 350) of the 358 cases the anaesthesiologists performed PHETI, in 2.0% (n = 7) they inserted an SAD and in
one case a surgical airway (SAW) were needed. These 358 PHAAM
patients were included in the current study.
3.2. Descriptive data
Table 1 displays demographic data of the 358 CA patients treated
with PHETI/SAD/SAW.
3.3. Main results
An initial ETCO2 was available in 271 of the CA cases.
Among these 271 cases, we identied 22 patients, who had an
initial ETCO2 after PHAAM below 1.3 kPa; additional seven patients
had an initial ETCO2 = 1.3 kPa.
Three patients with an initial ETCO2 below 1.3 kPa and one
patient with an initial ETCO2 of 1.3 kPa achieved ROSC. We describe
these four patients in detail in Table 2.
4. Discussion
4.1. Main results
Based on an retrospective analysis of over 700 pre-hospital cardiac arrest patients Kolar et al. suggests an initial ETCO2 of less than
1.33 kPa as a cut-off value to identify patients who will not achieve
ROSC.11 Our results cannot conrm their ndings. We identied
four CA patients with an initial ETCO2 at or below 1.3 kPa who all
achieved ROSC, and our hypothesis that an initial ETCO2 at or below
1.3 kPa during pre-hospital CPR can be used as a predictor of prehospital death, must therefore be rejected. It is unlikely that all four
cardiac arrest cases who achieved ROSC following an initial ETCO2
of 1.3 kPa or less should have experienced a falsely low ETCO2 value.
The results published by Callaham et al. support our ndings.17
They investigated 55 patients in CA and found that four of those
with an initial ETCO2 below 1.3 kPa achieved ROSC.

The study was designed according to the Utstein-style template

for reporting data from pre-hospital advanced airway management
by Sollid et al.,14 and not according to the template for reporting data from pre-hospital cardiac arrest.18 Consequently, readers
should interpret the non-airway management related results in the
current study with caution.
We measured the ETCO2 values on one of the two portable
capnographs and we did not routinely check the readings by measurement of ETCO2 on both capnographs or by measuring the
partial pressure of CO2 in arterial blood. Never the less, our way
of measuring ETCO2 depicts daily clinical practice.
The 23% lacking measurements of ETCO2 is a potential source
of bias. We do not know the reason for these missing data. It
could be because of equipment malfunction or unavailable equipment due to maintenance. It could also be because the attending
anaesthesiologist chose not to use capnography, which is not in
adherence with current guidelines.1 However, the missing data
does not change the fact that four patients with an initial ETCO2 at
or below 1.3 kPa achieved ROSC and it does therefore not inuence
our conclusion. In a more general perspective, our ndings indicate
a need for an increased use of ETCO2 - measurements during CPR in
our service.
We did not design this study to investigate the different factors
inuencing ETCO2 during CPR and our results are merely an attempt
to investigate the use of an initial ETCO2 at or below 1.3 kPa as a cutoff value in the critical decision making process during pre-hospital
CPR in a non-selected population of pre-hospital CA patients.
Survival beyond survival to admission was outside the scope of
this study. This is in coherence with the paper by Kolar et al.11
The attending anaesthesiologists registered all the data. They
are therefore potentially subject to registration bias (systematic
errors in the registration of data) or recall bias. The high capture
rate reduces the risk of selection bias. Based on the day-to-day
crosscheck of the registration forms against both the written
pre-hospital journals and the compulsory entries made by the
anaesthesiologists in the patients hospital records, the extent of
selection bias is probably limited.
4.3. Generalisability
This was a study from one homogenous Danish system of
anaesthesiologist-staffed pre-hospital critical care teams. This limits the ability to generalise the ndings to other systems with
different stafng, caseload or case mix. Never the less, treatment
were according to current guidelines and we believe that our results
can be of use to other physician-staffed as well as paramedic-staffed
pre-hospital services performing pre-hospital advanced airway

L. Rogns et al. / Resuscitation 85 (2014) 332335

335

Table 2
Patients with return of spontaneous circulation after an initial ETCO2 1.3 during CPR.a
Sex

Age (years)

ASA-PSb score

Pre-existing disease

Type of cardiac arrest

First ECG

First ETCO2 (kPa)

ETCO2 (kPa) in the EDc

Spontaneous circulation
in the ED

Fd
F
Mg
M

74
84
79
72

2
2
3
2

None
Other
Cardiac + other
Cardiac

Medical
Medical
Medical
Medical

Sinus rhythme
PEAf
Unknown
VF

1.1
0.8
1.3
1.2

1.3
3.3
8.0
2.5

Yes
Yes
Yes
Noh

a
b
c
d
e
f
g
h

Cardio-pulmonary resuscitation.
American Society of Anesthesiologists Physical Performance.
Emergency department.
Female.
Ventricular brillation occurred after arrival of the Emergency Medical Services.
Pulseless electrical activity/non-shock able rhythm.
Male.
Short pre-hospital period of ROSC, transported during ongoing CPR with LUCAS automated chest compression device.

management with ETCO2 monitoring during pre-hospital cardiac

arrest.
4.4. Perspectives
Further research is needed to conrm or reject the existence of a
universal cut-of value of ETCO2 for the achievement of ROSC during
pre-hospital CPR. Based on our results, we nd it doubtful whether
such a value does exist.
5. Conclusion
In this study of 271 pre-hospital cardiac arrest patients treated
with pre-hospital advanced airway management other than bagmask ventilation by pre-hospital critical care anaesthesiologists,
we identied four patients with an initial ETCO2 at or below 1.3 kPa
who achieved return of spontaneous circulation. Our results cannot conrm the hypothesis that an initial ETCO2 at or below 1.3 kPa
found during pre-hospital CPR is a predictor for the lack of return
of spontaneous circulation. We advise against using our results to
discard the use of ETCO2 measurements as one important parameter among several in the critical decision making process during
pre-hospital CPR.
Conict of interest statement
The authors declare that they have no conict of interests.
Acknowledgements
The Norwegian Air Ambulance Foundation, The Laerdal Foundation for Acute Medicine and The Central Denmark Region, founded
the study by sponsoring the salary of LR.
TMH, HK and ET were funded by their departments.
The sponsors have had no inuence on study design, data collection, data analysis and interpretation, the writing of the manuscript
or the decision to submit the paper for publication.
The authors wish to thank all the pre-hospital critical care physicians who collected the data and all the EMTs who reminded them
to do so.
A special thanks to EMT Tinna Hjmose stergaard for her
invaluable assistance in all the practicalities of the data collection.
Appendix A. Supplementary data
Supplementary data associated with this article can be found,
in the online version, at http://dx.doi.org/10.1016/j.resuscitation.
2013.12.009.

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