ORIGINAL RESEARCH
Early Identication of Patients With Out-of-Hospital Cardiac Arrest With
No Chance of Survival and Consideration for Organ Donation
Patricia Jabre, MD, PhD; Wulfran Bougouin, MD, MPH; Florence Dumas, MD, PhD; Pierre Carli, MD, PhD; Corinne Antoine, MD;
Laurent Jacob, MD, PhD; Benjamin Dahan, MD; Frankie Beganton, MS; Jean-Philippe Empana, MD, PhD; Eloi Marijon, MD, PhD;
Nicole Karam, MD, MPH; Alexandre Loupy, MD, PhD; Carmen Lefaucheur, MD, PhD; Daniel Jost, MD, PhD; Alain Cariou, MD, PhD;
Frederic Adnet, MD, PhD; Thomas D. Rea, MD, MPH; and Xavier Jouven, MD, PhD
Background: In patients with out-of-hospital cardiac arrest
(OHCA), care requirements can conict with the need to
promptly focus efforts on organ donation in patients who are
pronounced dead.
Objective: To evaluate objective criteria for identifying patients
with OHCA with no chance of survival during the rst minutes of
cardiopulmonary resuscitation to enable prompt orientation to-
ward organ donation.
Design: Retrospective assessment using OHCA data from 2 reg-
istries and 1 trial.
Setting: France (Paris Sudden Death Expertise Center [SDEC]
prospective cohort [2011 to 2014] and PRESENCE multicenter
cluster randomized trial [ClinicalTrials.gov: NCT01009606] [2009
to 2011]) and the United States (King County, Washington, pro-
spective cohort [2006 to 2011]).
Patients: 1771 patients from the Paris SDEC 1-year cohort (2011
to 2012) and 5192 from the validation cohorts.
Measurements: Evaluation of 3 objective criteria (OHCA not
witnessed by emergency medical services personnel, nonshock-
able initial cardiac rhythm, and no return of spontaneous circu-
A cardinal principle of medical ethics is that medical
professionals act rst and foremost for the benet
of the patient. For patients with out-of-hospital cardiac
arrest (OHCA), the prehospital emergency medical ser-
vices (EMS) team must perform standard cardiopulmo-
nary resuscitation (CPR) and consider all available tech-
nologies (such as automated active compression-
decompression CPR devices, extracorporeal life
support, and therapeutic hypothermia) to save the pa-
tient's life. However, despite improvements in resusci-
tation techniques used by prehospital EMS and in-
hospital intensivists, most patients with OHCA do not
survive: Mortality remains as high as 92% to 94% (1 4).
Clinical decision rules known as termination-of-
resuscitation rules help to identify cases where further
resuscitation with the aim of avoiding ambulance trans-
port and its associated costs and risks is futile (57).
Authors of large series on termination-of-resuscitation
rules agree that a survival rate of 1% in patients with
See also:
Editorial comment . . . . . . . . . . . . . . . . . . . . . . . . . 820
Web-Only
Supplement
770 2016 American College of Physicians
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Annals of Internal Medicine
lation before receipt of a third 1-mg dose of epinephrine), sur-
vival rate at hospital discharge among patients meeting these
criteria, performance of the criteria, and number of patients eli-
gible for organ donation.
Results: In the Paris SDEC 1-year cohort, the survival rate among
the 772 patients with OHCA who met the objective criteria was
0% (95% CI, 0.0% to 0.5%), with a specicity of 100% (CI, 97% to
100%) and a positive predictive value of 100% (CI, 99% to 100%).
These results were veried in the validation cohorts. Ninety-ve
(12%) patients in the Paris SDEC 1-year cohort may have been
eligible for organ donation.
Limitation: Several patients had unknown outcomes.
Conclusion: Three objective criteria enable the early identica-
tion of patients with OHCA with essentially no chance of survival
and may help in decision making about the organ donation
process.
Primary Funding Source: French Ministry of Health.
Ann Intern Med. 2016;165:770-778. doi:10.7326/M16-0402 www.annals.org
For author afliations, see end of text.
This article was published at www.annals.org on 13 September 2016.
OHCA reects medical futility and that stopping CPR is
reasonable (8 12). These rules do not, however, take
into consideration the potential utility of transporting
dead patients to the hospital for organ donation.
The major problem facing transplantation world-
wide is the unavailability of organs. Because of this,
transplantation programs using organs from uncon-
trolled donation after cardiac death (UDCD) have been
implemented in many Western countries (1317). The
2015 American Heart Association guidelines for CPR
recommend that patients who do not have return of
spontaneous circulation (ROSC) after resuscitation ef-
forts and who would otherwise have termination of ef-
forts may be considered candidates for organ donation
in settings where such programs exist (class IIb recom-
mendation) (18). Delays in recognizing futile resuscita-
tive efforts result in lost opportunities to direct efforts
toward donation of potentially viable organs. Rapid re-
ferral to an organ donation institution under mechani-
cal ventilation and continuous automated external car-
diac massage must be considered only for patients with
no chance of survival whose organs are reasonably
likely to be suitable for transplantation (17). This UDCD
consideration rule differs from the termination-of-
resuscitation rule in 3 respects. First, it is intended ex-
clusively for patients with absolutely no chance of sur-
vival, because the rst medical concern is patient care
 Out-of-Hospital Cardiac Arrest and Consideration for Organ Donation
and use of a UDCD protocol for potential survivors is
unacceptable. Second, the patient must be eligible to
donate organs according to local legislation. Finally,
the patient must be rapidly transported to an appropri-
ate hospital under continuous resuscitative maneuvers.
This study sought to evaluate objective and practi-
cal criteria for identifying patients with OHCA and no
chance of survival during the rst minutes of advanced
CPR.
METHODS
Setting and Participants
This study evaluated patients from 2 published reg-
istries and 1 published clinical trial managed by 2 EMS
systems in France and the United States, both of which
perform CPR according to international guidelines (19).
Paris Sudden Death Expertise Center Cohort
The Paris Sudden Death Expertise Center (SDEC)
registry is a population-based registry that covers Paris
and its suburbs (about 6.6 million inhabitants). The reg-
istry's methods have been reported previously (Supple-
ment, available at www.annals.org) (20). In this study,
we considered patients included during the rst 3 years
of the registry, from 16 May 2011 to 15 May 2014.
Every case of unexpected OHCA in persons older
than 18 years was prospectively included in the Paris
SDEC registry. Exclusion criteria were a prior terminal
condition, a documented do-not-resuscitate directive,
no attempt at advanced cardiac life support (ACLS) by
EMS personnel, or an obvious noncardiac cause ac-
cording to Utstein templates for resuscitation registries
reporting data on cardiac arrest (21).
The appropriate institutional review boards ap-
proved all aspects of the registry.
PRESENCE Cohort
The PRESENCE study was a prospective, multi-
center, cluster randomized, controlled trial (22). Its prin-
cipal aim was to determine whether offering relatives of
patients the choice of observing CPR would reduce the
likelihood of symptoms of posttraumatic stress disor-
der. The study was approved by the appropriate
institutional review board and was registered at
ClinicalTrials.gov (NCT01009606). It enrolled 570 rela-
tives of adult patients with cardiac arrest at home who
received CPR from 15 French prehospital EMS units
from November 2009 to October 2011. For this study,
we excluded 84 patients with OHCA with obvious ex-
tracardiac causes and analyzed 486 patients.
King County Cohort
The King County EMS in Washington has collected
data on all EMS-treated cardiac arrest cases since 1976
(23). The registry contains information about survival to
hospital discharge and is maintained in the Utstein for-
mat. For this study, all patients aged 18 to 54 years who
had OHCA without an obvious extracardiac cause and
received ACLS from EMS personnel were included. The
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ORIGINAL RESEARCH
date of OHCA was restricted to 2006 to 2011 and pa-
tient age was restricted to 18 to 54 years (the age range
for UDCD [24, 25]) because information on 1 criterion
(epinephrine dosage) was available for this period and
age range. The appropriate institutional ethics board
approved all aspects of the registry.
Study Design
Objective Criteria for Identifying Patients With OHCA
With No Chance of Survival
Among all criteria identied in the literature as be-
ing associated with lack of survival, we selected those
that were the most reliable, robust, objective, easy to
use in different EMS systems, and obtainable during
the rst minutes of resuscitation and assessed patient
outcomes associated with them. The objective criteria
we tested were 1) OHCA not witnessed by EMS person-
nel (reghters [who are rst responders trained in au-
tomated external debrillation] or medical team mem-
bers), 2) nonshockable initial cardiac rhythm (dened
according to whether a shock was given at arrival, ei-
ther by a reghter trained in automated external de-
brillation or a medical team member), and 3) no sus-
tainable ROSC before receipt of a third 1-mg dose of
epinephrine given according to international guide-
lines (1 mg every 3 to 5 minutes). Thus, resuscitation
length was indirectly measured by the epinephrine
dose. These 3 objective criteria are known to be asso-
ciated with lack of survival (1, 12, 20, 26, 27) and can be
accurately assessed at the scene by responders (20, 28,
29). Other independent predictors of mortality at the
population level have been considered, particularly
time from collapse to basic life support (no-ow dura-
tion), time from basic life support to ROSC (low-ow
duration), and performance of CPR by a bystander (30).
However, international guidelines note that, at the indi-
vidual level, the retrospective accuracy of the no-ow
and low-ow durations is often imprecise, and the qual-
ity and duration of CPR are often questionable (21, 23).
We evaluated these objective criteria in 1771 pa-
tients with OHCA from the rst year of the SDEC regis-
try (16 May 2011 to 15 May 2012). We then conducted
an internal prospective validation of these criteria for
the next 2 years of registry data (16 May 2012 to 15
May 2014) and external validation of the PRESENCE
and King County cohorts (5192 patients).
UDCD Eligibility Criteria
We applied the eligibility criteria used in the
French national protocol for kidney retrieval from
UDCD, established by the Agence de la biomedecine
in compliance with the Declaration of Helsinki (24). The
protocol of care has been described in detail (17). The
UDCD eligibility criteria included age 18 to 54 years;
no medical history of hypertension, diabetes, cancer,
sepsis, active viral infection (hepatitis B virus, hepatitis
C virus, HIV, or human T-cell lymphotropic virus), or
renal disease; and cardiac arrest not due to high
kinetic energy polytraumatism. In addition, the time be-
tween collapse and CPR initiation had to be less than
30 minutes, and the time between collapse and intra-
Annals of Internal Medicine Vol. 165 No. 11 6 December 2016 771
 ORIGINAL RESEARCH Out-of-Hospital Cardiac Arrest and Consideration for Organ Donation

Figure 1. Flow chart for the Paris SDEC 1-y cohort.

Paris SDEC 1-y

cohort (n = 1906)

Patients with missing data (n = 135)

Type of missing data:
Only objective criteria*: 126 (all died)
Only outcome: 8 (all with criteria for
continuing ACLS)
Objective criteria and outcome: 1

Patients with complete data

(n = 1771)

Patients meeting 3 objective criteria* All other patients

(n = 772) (n = 999)

Discharged alive Died Discharged alive Died

(n = 0 [0%]) (n = 772 [100%]) (n = 139 [14%]) (n = 860 [86%])

The cohort included patients with out-of-hospital cardiac arrest of presumed cardiac origin from 16 May 2011 to 15 May 2012. ACLS = advanced
cardiac life support; SDEC = Sudden Death Expertise Center.
* Out-of-hospital cardiac arrest not witnessed by emergency medical services personnel, initial nonshockable rhythm, and no return of spontaneous
circulation before receipt of a third 1-mg dose of epinephrine.

aortic double-balloon catheter insertion had to be less
than 150 minutes (warm ischemia). These eligibility cri-
teria were applied to patients identied as having no
chance of survival to evaluate their potential for organ
donation.
End Points
The primary end point was the survival rate at hos-
pital discharge among patients with OHCA who met
the proposed objective criteria. For the PRESENCE co-
hort (22), the survival rate at day 28 instead of at hos-
pital discharge was considered because the latter infor-
mation was unavailable. The secondary end point was
the number of patients eligible for organ donation ac-
cording to the French protocol for kidney retrieval from
UDCD in the SDEC cohorts.
Statistical Analysis
Data are reported as means and SDs or medians
and interquartile ranges (IQRs) for continuous variables
and as percentages for qualitative variables. The sur-
vival rate and 95% CI were determined for patients with
OHCA who fullled the objective criteria. We used
standard 2 2 diagnostic test result tables to report
prehospital or in-hospital mortality among patients
meeting the objective criteria. We estimated the sensi-
tivity (the probability that the criteria identify patients
with no chance of survival [for patients who died]),
specicity (the probability that the criteria recommend
continuing ACLS [for patients discharged alive]), posi-
tive predictive value (PPV) (the probability of death
when the criteria are met), and negative predictive
772 Annals of Internal Medicine Vol. 165 No. 11 6 December 2016
value (NPV) (the probability of survival when 1 crite-
rion is not met) and their respective 95% CIs for the
objective criteria. The specicity and PPV were identi-
ed as the key test characteristics at the study design
stage. We described the amount of missing data for
each variable of interest. Sensitivity analyses based on
multiple imputation were used to account for missing
data on outcomes and the objective criteria in the
SDEC cohorts. The multiple imputation procedure (mi
impute command) in Stata, version 14.1 (StataCorp),
was used. We performed the multiple imputations by
chained equations under a missing-at-random assump-
tion. The imputation models included the following
variables: sex, age, location, whether OHCA was wit-
nessed by a bystander, whether CPR was performed by
a non-EMS bystander, type of witness, presence of ini-
tial shockable rhythm, epinephrine dose, and outcome.
Ten data sets were created, with missing values re-
placed by imputed values. The results of the analyses of
the individual imputed data sets were combined using
Rubin rules. All other statistical tests were done using
SAS, version 9.3 (SAS Institute).
We assumed that for patients with OHCA who
meet the objective criteria, the expected survival to dis-
charge from the hospital is 0.001% (instead of 0% to
allow sample size calculation). Therefore, 732 patients
were required in order to detect a difference from a
survival rate of 0.4%, with 90% power and a 1-sided
type I error rate of 0.05 in a 1-sample test of
proportions.
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 Out-of-Hospital Cardiac Arrest and Consideration for Organ Donation ORIGINAL RESEARCH
Role of the Funding Source Table 1. Baseline Characteristics and Patient Outcomes in
The PRESENCE trial was supported by the Pro- the Paris SDEC Cohorts*
gramme Hospitalier de Recherche Clinique 2008 of the
French Ministry of Health. The Research Delegation of Variable Paris SDEC Paris SDEC
1-y Cohort Validation
the Assistance PubliqueHopitaux de Paris provided (n 1771) Cohort
technical support and monitored the ongoing results of (n 3656)
the trial but had no role in the decision to submit the Baseline characteristics
manuscript for publication. Male, n (%) 1239 (70) 2522 (69)
Mean age (SD), y 65 (16) 65 (16)
OHCA at home, n (%) 1252 (71) 2608 (72)
RESULTS OHCA witnessed by bystander, n (%) 1458 (100) 2893 (100)
EMS 239 (16) 557 (19)
Patients With OHCA With No Chance of Survival Non-EMS 1203 (83) 2259 (78)
Paris SDEC 1-Year Cohort Unknown 16 (1) 77 (3)
Over a 12-month period, 1906 patients had OHCA OHCA not witnessed by bystander, n 313 763
CPR by non-EMS bystander, n (%) 506 (42) 1142 (50)
of presumed cardiac origin with ACLS attempted by Initial shockable rhythm, n (%) 393 (22) 1002 (28)
EMS personnel. The Paris SDEC 1-year cohort included Median epinephrine dose (IQR), mg 5 (19) 6 (210)
135 patients with missing data (1 of whom had missing
Outcomes, n (%)
data for both the objective criteria and the outcome). Admitted alive 618 (35) 1326 (36)
Details about the types of missing data are listed in Discharged alive 139 (8) 337 (9)
Figure 1. CPR = cardiopulmonary resuscitation; EMS = emergency medical ser-
Table 1 summarizes the principal demographic vices; IQR = interquartile range; OHCA = out-of-hospital cardiac ar-
and clinical characteristics of the 1771 (93%) patients rest; SDEC = Sudden Death Expertise Center.
* The 1-y cohort included patients with OHCA of presumed cardiac
with complete data (Figure 1). Of these patients, 618 origin from 16 May 2011 to 15 May 2012; the validation cohort in-
(35%) were admitted alive, and 139 of these 618 pa- cluded such patients from 16 May 2012 to 15 May 2014.
tients (22%) were discharged alive after a median
length of stay of 17 days (IQR, 13 to 29 days). During
hospitalization, 479 patients died after a median length and the probability of death when the 3 criteria were
of stay of 2 days (IQR, 0 to 6 days). met (PPV) was 100% (CI, 99% to 100%) (Table 3).
We rst tested the performance of 2 of the objec-
tive criteria (OHCA not witnessed by EMS personnel
and nonshockable initial cardiac rhythm), which re- Internal Validation Cohort: France
sulted in insufcient specicity. The performance of Over the following 2-year period, 3898 Paris SDEC
each of the 3 criteria individually and in pairs is pre- patients had OHCA of presumed cardiac origin for
sented in Table 2. The addition of the third criterion which EMS personnel attempted ACLS. The validation
was needed to reach 0% survival with a PPV and spec- cohort included 242 patients with missing data. Details
icity of 100%. The survival rate of patients with OHCA about the types of missing data are listed in Appendix
who met the 3 objective criteria was 0% (95% CI, 0.0% Figure 1 (available at www.annals.org). Four patients
to 0.5%). The probability that the 3 criteria recom- who met the 3 objective criteria had missing data for
mended that ACLS be continued for patients dis- the outcome, and 5 patients had missing data for both
charged alive (specicity) was 100% (CI, 97% to 100%), the criteria and the outcome.

Table 2. Performance of Each Objective Criterion for Predicting Death in Patients With OHCA, Individually and in Pairs, in the
Paris SDEC 1-y Cohort (n = 1771)

Criteria OHCA Not Witnessed by EMS Nonshockable Initial Cardiac No Sustainable ROSC Before Receipt
Personnel (n 1532), Rhythm (n 1364), n/N (%) of Third 1-mg Epinephrine Dose
n/N (%) (n 1097), n/N (%)
Survival rate when the 113/1532 (7) 23/1364 (2) 20/1097 (2)
criteria were met
Specicity 26/139 (19) 115/138 (83) 119/139 (86)
PPV 1419/1532 (93) 1341/1364 (98) 1077/1097 (98)

OHCA Not Witnessed by EMS OHCA Not Witnessed by EMS Nonshockable Initial Cardiac Rhythm
Personnel Plus Nonshockable Personnel Plus No Plus No Sustainable ROSC Before
Initial Cardiac Rhythm Sustainable ROSC Before Receipt of Third 1-mg Epinephrine
(n 1174), n/N (%) Receipt of Third 1-mg Dose (n 898), n/N (%)
Epinephrine Dose (n 950),
n/N (%)
Survival rate when the 15/1174 (1) 17/950 (2) 2/898 (0.2)
criteria were met
Specicity 123/138 (89) 122/139 (88) 137/139 (99.0)
PPV 1159/1174 (99) 933/950 (98) 896/898 (99.8)
EMS = emergency medical services; OHCA = out-of-hospital cardiac arrest; PPV = positive predictive value; ROSC = return of spontaneous
circulation; SDEC = Sudden Death Expertise Center.

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 ORIGINAL RESEARCH Out-of-Hospital Cardiac Arrest and Consideration for Organ Donation

Table 3. Sensitivity, Specicity, and Positive and Negative Predictive Values of the Objective Criteria for Predicting Death in
Patients With OHCA*

Cohort Patients Who Met Patients Who Did Sensitivity Specicity Positive Negative Survival Rate
the Objective Not Meet >1 Objective (95% CI), (95% CI), Predictive Predictive When the
Criteria, n Criterion, n % % Value Value Objective
(95% CI), % (95% CI), Criteria Were
Died Survived Died Survived % Met (95% CI), %
(True- (False- (False- (True-
Positive) Positive) Negative) Negative)
Paris SDEC 1-y 772 0 860 139 47 (4550) 100 (97100) 100 (99100) 14 (1216) 0/772=0 (00.2)
cohort (n = 1771)
Paris SDEC validation 1569 1 1750 336 47 (4549) 99.7 (99.0100.0) 99.9 (99.7100.0) 16 (1418) 1/1570=0.1 (00.2)
cohort (n = 3656)
PRESENCE 285 0 185 16 61 (5665) 100 (79100) 100 (99100) 8 (513) 0/285=0 (00.8)
cohort (n = 486)
King County 173 0 640 237 21 (1923) 100 (98100) 100 (98100) 27 (2430) 0/173=0 (00.4)
cohort (n = 1050)
OHCA = out-of-hospital cardiac arrest; SDEC = Sudden Death Expertise Center.
* Criteria included OHCA not witnessed by emergency medical services personnel, nonshockable initial cardiac rhythm, and no return of sponta-
neous circulation before receipt of a third 1-mg epinephrine dose.
Probability that the criteria identify patients with no chance of survival (for patients who died).
Probability that the objective criteria recommend continuing advanced cardiac life support (for patients discharged alive).
Probability of death when the objective criteria are met.
Probability of survival when 1 objective criterion is not met.

Table 1 summarizes the characteristics of the 3656
(94%) patients with complete data. When the objective
criteria were met, 1 patient survived to hospital dis-
charge in a persistent vegetative state (Cerebral Perfor-
mance Category score of 4) (Appendix Figure 1). Table
3 shows the diagnostic test characteristics of the appli-
cation of the objective criteria to this internal validation
cohort.
External Validation Cohorts: France and the
United States
In the PRESENCE cohort, we analyzed 486 patients
with OHCA of presumed cardiac origin who received
ACLS from EMS personnel. The mean age was 68
years, and 64% were male. Bystanders were present in
75% of cases, and CPR was performed by non-EMS by-
standers for 102 (28%) patients. Initial shockable
rhythm was present in 12% of cases, and the median
epinephrine dose administered was 8 mg (IQR, 5 to 10
mg). Eighty-six patients (18%) survived to hospital ad-
mission, and 16 (3%) were still alive at day 28. No pa-
tient who met the objective criteria survived to day 28
(Appendix Figure 2, available at www.annals.org).
The King County cohort included 2669 patients
with OHCA of presumed cardiac origin with ACLS at-
tempted by EMS personnel; 1050 patients were
younger than 55 years and were included in this analy-
sis. The mean age was 45 years, and 65% were men.
Cardiac arrest occurred at home in 692 cases (66%). Of
the 1050 cases of OHCA, 114 (11%) were witnessed by
EMS personnel and 936 (89%) were witnessed by by-
standers before EMS arrival. Non-EMS bystanders per-
formed CPR for 609 (58%) patients. Initial shockable
rhythm was present in 364 (35%) cases. Overall, 468
(45%) patients survived to hospital admission, and 239
(23%) were discharged alive after a median length of
stay of 7 days (IQR, 5 to 12 days). During hospitaliza-
tion, 229 patients died after a median length of stay of
774 Annals of Internal Medicine Vol. 165 No. 11 6 December 2016
3 days (IQR, 1 to 5 days). Of the 173 patients aged 18
to 54 years who met the objective criteria, the median
epinephrine dose administered was 5 mg (IQR, 4 to 6
mg). No patient who met the objective criteria survived
to hospital discharge (Appendix Figure 3, available at
www.annals.org).
The sensitivity, specicity, PPV, and NPV of the ob-
jective criteria for predicting death in patients with
OHCA in these external validation cohorts are shown in
Table 3.
Sensitivity Analysis
For the Paris SDEC 1-year cohort, the survival rate
among patients meeting the 3 objective criteria, includ-
ing the 135 patients with missing data, was 0% (CI,
0.0% to 0.2%). For the Paris SDEC validation cohort, the
survival rate among patients meeting the criteria, in-
cluding the 242 patients with missing data, was 0.06%
(CI, 0.0% to 0.2%), which is consistent with the results of
the main analysis.
UDCD Candidates
Paris SDEC 1-Year Cohort
Among the 772 patients with no chance of survival
who were screened for organ donation eligibility ac-
cording to the French clinical criteria, 95 (12%) might
have had organs that were likely to be suitable for
transplantation (Table 4 and Figure 2). These patients
could have been referred quickly to organ donation
institutions under mechanical ventilation and continu-
ous automated external cardiac massage.
Internal Validation Cohort: France
Among the 1570 patients in the Paris SDEC valida-
tion cohort with no chance of survival, 122 (8%) might
have had organs that were likely to be suitable for
transplantation (Table 4).
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 Out-of-Hospital Cardiac Arrest and Consideration for Organ Donation ORIGINAL RESEARCH

DISCUSSION Table 4. Baseline Characteristics and Outcome of Patients

The ndings of this study can help out-of-hospital Who Were Suitable for Uncontrolled Donation After
EMS teams employing physicians or paramedics in the Cardiac Death* and Who Met the 3 Proposed Criteria in
process of deciding between early transport to the hos- the Paris SDEC Cohorts
pital or termination of resuscitation when OHCA is not
witnessed by EMS personnel, there is a nonshockable Variable Paris SDEC Paris SDEC
1-y Cohort Validation
initial cardiac rhythm, and ROSC does not occur before (n 95) Cohort
receipt of a third 1-mg dose of epinephrine. Both the (n 122)
specicity and the PPV (for death before hospital dis- Baseline characteristics
charge) of these objective criteria were 100% in 3 co- Male, n (%) 78 (82) 97 (80)
horts. On the basis of the Paris SDEC 1-year cohort, one Mean age (SD), y 42 (9) 44 (8)
can be 95% certain that the specicity would be no OHCA at home, n (%) 60 (63) 76 (62)
CPR by non-EMS bystander, n (%) 31 (34) 52 (44)
lower than 97%. In some cases, refocusing efforts to- Initial shockable rhythm, n (%) 0 (0) 0 (0)
ward the maintenance of potentially viable organs for Median epinephrine dose (IQR), mg 10 (813) 10 (712)
donation might make it possible to save other lives. A
rapid medical decision to transport patients for organ Outcome
Discharged alive, n (%) 0 (0) 0 (0)
donation with ongoing resuscitation efforts based on
these reliable and objective criteria could result in CPR = cardiopulmonary resuscitation; EMS = emergency medical ser-
vices; IQR = interquartile range; SDEC = Sudden Death Expertise Cen-
reaching the hospital earlier. ter; OHCA = out-of-hospital cardiac arrest; SDEC = Sudden Death
Resuscitation must always focus rst on the pa- Expertise Center.
tient's survival: UDCD can be considered only after * See reference 24.
The 1-y cohort included patients with OHCA of presumed cardiac
achievement of this primary goal is no longer feasible. origin from 16 May 2011 to 15 May 2012; the validation cohort in-
Our results will enable futile prolonged resuscitation on cluded such patients from 16 May 2012 to 15 May 2014.
site to be limited when patients with OHCA could be
directed to an organ donation center. Continuation of

Figure 2. Candidates for UDCD in the Paris SDEC 1-y cohort.

Paris SDEC 1-y cohort

(n = 1906)

Patients with missing data (n = 135)

Type of missing data:
Only objective criteria*: 126 (all died)
Only outcome: only 8 (all with criteria
for continuing ACLS)
Objective criteria and outcome: 1

Patients with complete data

(n = 1771)

Patients meeting 3 objective criteria* All other patients

(n = 772) (n = 999)

Meets UDCD eligibility criteria

Yes No Pursue ACLS for 2030 min

Transport to hospital under Termination of

CPR maneuvers for evaluation resuscitation may be
of possible organ donation considered
(n = 95) (n = 677)

ACLS = advanced cardiac life support; CPR = cardiopulmonary resuscitation; SDEC = Sudden Death Expertise Center; UDCD = uncontrolled
donation after cardiac death.
* Out-of-hospital cardiac arrest not witnessed by emergency medical services personnel, initial nonshockable rhythm, and no return of spontaneous
circulation before receipt of a third 1-mg dose of epinephrine.
Proposed by the French national protocol for kidney retrieval from UDCD (24).

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 ORIGINAL RESEARCH
futile resuscitative efforts among patients with no
chance of survival could lead to physical and psycho-
logical pain for patients and their relatives and could
divert care and resources from patients who are more
likely to survive (12). Unfortunately, the current require-
ment of 30 minutes of CPR before on-site patient extri-
cation (imposed by the French national protocol for
kidney retrieval from UDCD) may partially explain the
need to discard potential grafts, which has been re-
ported in the literature (17).
In Europe, UDCD data show that organ transplan-
tation programs are benecial in terms of successful
transplantation, although the transport time targets set
by UDCD protocols can be difcult to achieve (3134).
In 2006, the Institute of Medicine projected that nation-
wide implementation of UDCD protocols could gener-
ate an additional 22 000 donation opportunities annu-
ally in the United States, thus substantially reducing
wait times for transplantation (35). Our results and
those of Roberts and colleagues in the United Kingdom
(36) support this idea by specifying the potential num-
ber of patients with OHCA who are eligible for organ
donation. However, our results may be overestimates
because some UDCD eligibility criteria may be difcult
to verify on the scene. In real-world practice in France,
after cannulation, potential donors are actively
screened for infections and pertinent medical history
that might preclude donation, and approximately 30%
of them are refuted for medical reasons (37). In addi-
tion, although our ndings allow improvement of early
assessment for UDCD protocols, several ethical, legal,
and organizational issues raised by UDCD transplanta-
tion must be carefully considered before local imple-
mentation of these protocols (6, 38, 39). Most impor-
tant, UDCD should be considered only when available
therapeutic options are unsuccessful or are not clini-
cally indicated to avoid denying optimum treatment to
patients who might recover (40). In addition, this emer-
gency procedure with specic time constraints requires
highly coordinated multidisciplinary teamwork to pre-
serve organ function.
All communities should optimize retrieval of tissue
and organ donations in patients pronounced dead in
out-of-hospital settings (6). Emergency medical ser-
vices agencies should develop protocols and imple-
mentation plans with their regional organ and tissue
donation program to optimize donation after OHCA
(6). We believe that EMS personnel should implement
our 3 objective criteria in their updated protocols for
cardiac arrest. All patients who meet these criteria,
whose organs are reasonably likely to be suitable for
transplantation, and who would otherwise have termi-
nation of efforts should be considered candidates for
organ donation. Rapid referral to an organ donation
institution under mechanical ventilation and continuous
automated external cardiac massage should be consid-
ered for patients with no chance of survival. In the
United States, however, initiation of organ preservation
without prior patient consent is not allowed; eligibility
for UDCD is restricted to previously registered organ
donors (41).
776 Annals of Internal Medicine Vol. 165 No. 11 6 December 2016
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Out-of-Hospital Cardiac Arrest and Consideration for Organ Donation
Our study has limitations. One patient in the Paris
SDEC 1-year cohort and 9 in the Paris SDEC validation
cohort had missing outcome data. However, the results
of the sensitivity analyses that included these patients
were consistent with the results of the main analyses.
Second, the King County cohort was restricted to pa-
tients aged 18 to 54 years (the age range for UDCD),
with no survivors to hospital discharge among those
meeting the objective criteria. It is unlikely that older
patients with OHCA who were not included in our study
would have better outcomes (42 44).
Our study also has several important strengths. The
data were collected prospectively in the SDEC and
PRESENCE cohorts and were based on Utstein deni-
tions (21). Our study design reects the experience of 3
cohorts of patients with OHCA managed in 2 EMS sys-
tems, which optimized the clinical relevance of our
data. The internal validity of these data is robust with
narrow CIs, and external validation supports their gen-
eralizability. Inclusion of additional traditional criteria,
although associated with poor outcomes, would not
contribute more but may be taken into consideration.
Finally, the implementation of these objective criteria
for patients with OHCA is an important topic in revi-
sions of the international CPR guidelines.
In conclusion, these data from 3 cohorts of patients
with OHCA receiving advanced life support from para-
medics or physicians suggest that there is essentially no
chance of survival in patients whose OHCA is not wit-
nessed by EMS personnel, who have a nonshockable
initial cardiac rhythm, and in whom ROSC does not oc-
cur before receipt of a third 1-mg dose of epinephrine.
Our results may help in decision making about UDCD.
From Paris Cardiovascular Research Center, Hopital Necker-
Enfants Malades, Hopital Cochin, Universite Paris Descartes-
Sorbonne Paris Cite, Hopital Saint-Louis, Universite Paris
Diderot Paris VII, Hopital Europeen Georges Pompidou, and
Paris Fire Brigade, Paris, France; Hopital Avicenne, Universite
Paris 13, Bobigny, France; and Public HealthSeattle & King
County and University of Washington, Seattle, Washington.
Acknowledgment: The authors thank the physicians, para-
medics, nurses, and ambulance attendants at each center for
their valuable cooperation in the study. A list of the Paris
SDEC Investigators is provided in the Appendix (available at
www.annals.org).
Financial Support: The PRESENCE trial was supported by the
Programme Hospitalier de Recherche Clinique 2008 of the
French Ministry of Health and by the Research Delegation of
the Assistance PubliqueHopitaux de Paris.
Disclosures: Dr. Jabre reports a grant from the French Minis-
try of Health during the conduct of the study. Pr. Jacob re-
ports personal fees from AbbVie, Alere, BioPorto, and Frese-
nius outside the submitted work. Pr. Adnet reports a grant
from the French Ministry of Health during the conduct of the
study. Authors not named here have disclosed no conicts of
interest. Disclosures can also be viewed at www.acponline
.org/authors/icmje/ConictOfInterestForms.do?msNum=M16
-0402.
www.annals.org
 Out-of-Hospital Cardiac Arrest and Consideration for Organ Donation
Reproducible Research Statement: Study protocol and data
set: Not available. Statistical code: Available from Pr. Jouven
(e-mail, xavier.jouven@inserm.fr).
Requests for Single Reprints: Xavier Jouven, MD, PhD, Cardi-
ology Department, Hopital Europeen Georges Pompidou, 20
rue Leblanc, 75015 Paris, France; e-mail, xavier.jouven@egp
.aphp.fr.
Current author addresses and author contributions are avail-
able at www.annals.org.
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-199

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 Current Author Addresses: Dr. Jabre: SAMU de Paris, Hopital
Necker-Enfants Malades, 149 Rue de Sevres, 75015 Paris,
France.
Dr. Bougouin and Pr. Jouven: Cardiology Department, Hopi-
tal Europeen Georges Pompidou, 20 rue Leblanc, 75015
Paris, France.
Drs. Dumas, Dahan, Empana, Karam, Loupy, and Lefaucheur
and Mr. Beganton: Paris Cardiovascular Research Center,
INSERM Unit 970, 56 rue Leblanc, 75015 Paris, France.
Pr. Carli: SAMU 75, Necker University Hospital, 149 rue de
Se`vres, 75015 Paris, France.
Dr. Antoine: Agence de la Biomedecine, 1 Avenue du Stade
de France, 93212 Saint Denis, France.
Pr. Jacob: Service danesthesie reanimation, Hopital Saint-
Louis, 1 Avenue Claude Vellefeaux, 75010 Paris, France.
Dr. Marijon: Cardiology Department, Hopital Europeen
Georges Pompidou, 20-40 Rue Leblanc, 75908 Paris, France.
Dr. Jost: Paris Fire Brigade, Medical Emergency Department,
1 place Jules Renard, 75009 Paris, France.
Pr. Cariou: Medical Intensive Care Unit, Cochin University
Hospital, 27 rue du Faubourg Saint Jacques, 75014 Paris,
France.
Pr. Adnet: AP-HP, SAMU 93, Urgences, Hopital Avicenne, 125
rue de Stalingrad, 93000 Bobigny, France.
Pr. Rea: University of Washington, 401 5th Avenue, Suite
1200, Seattle, WA 98104.
Author Contributions: Conception and design: P. Jabre, X.
Jouven.
Analysis and interpretation of the data: P. Jabre, W. Bougouin,
F. Dumas, A. Cariou, F. Adnet, T.D. Rea, X. Jouven.
Drafting of the article: P. Jabre, W. Bougouin, F. Dumas, A.
Cariou, X. Jouven.
Critical revision of the article for important intellectual con-
tent: P. Jabre, L. Jacob, B. Dahan, J.P. Empana, E. Marijon, N.
Karam, C. Lefaucheur, A. Cariou, F. Adnet, T.D. Rea, X.
Jouven.
Final approval of the article: P. Jabre, W. Bougouin, F. Dumas,
P. Carli, C. Antoine, L. Jacob, B. Dahan, F. Beganton, J.P. Em-
pana, E. Marijon, N. Karam, A. Loupy, C. Lefaucheur, D. Jost,
A. Cariou, F. Adnet, T.D. Rea, X. Jouven.
Provision of study materials or patients: P. Jabre, W. Boug-
ouin, P. Carli, L. Jacob, D. Jost, T.D. Rea, X. Jouven.
Statistical expertise: P. Jabre, W. Bougouin, J.P. Empana, X.
Jouven.
Obtaining of funding: P. Jabre, E. Marijon.
Administrative, technical, or logistic support: P. Jabre, W.
Bougouin, F. Dumas, P. Carli, L. Jacob, X. Jouven.
Collection and assembly of data: P. Jabre, W. Bougouin, F.
Dumas, F. Beganton, D. Jost, F. Adnet, X. Jouven.
APPENDIX: PARIS SUDDEN DEATH EXPERTISE
CENTER INVESTIGATORS
Frederic Adnet, AP-HP, Urgences - Samu 93, hopi-
tal Avicenne, Universite Paris 13, Bobigny, France.
Jean-Marc Agostinucci, AP-HP, Urgences - Samu
93, hopital Avicenne, Universite Paris 13, Bobigny,
France.
Nadia Aissaoui-Balanant, Medical Intensive Care
Unit, Georges Pompidou European Hospital, AP-HP,
Paris, France.
www.annals.org
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Francois Alla, French National Health Insurance
(CNAMTS), Paris, France.
Walid Amara, Department of Cardiology, Groupe
Hospitalier Le Raincy-Montfermeil, Montfermeil,
France.
Djillali Annane, General intensive care unit, Ray-
mond Poincare Hospital (AP-HP), Laboratory of Inam-
mation and Infection, U1173, INSERM and University of
Versailles SQY, Garches, France.
Corinne Antoine, Agence de la biomedecine, di-
rection generale medicale et scientique, direction pre-
le`vement greffe organes-tissus, pole strategie prele`ve-
ment greffe, Saint-Denis-la-Plaine, France.
Elie Azoulay, Medical ICU of the Saint-Louis Hospi-
tal, Paris Diderot Sorbonne University, Paris, France.
Frankie Beganton, Paris Sudden Death Expertise
Center, INSERM U970 (PARCC), Paris, France.
Dan Benhamou, Department of Anaesthesia and
Intensive Care Medicine, hopitaux universitaires Paris-
Sud, Le Kremlin-Bicetre cedex, France.
Wulfran Bougouin, Paris Sudden Death Expertise
Center, INSERM U970 (PARCC), Paris, France.
Cedric Bruel, Medical-Surgical ICU, Saint Joseph
Hospital, Paris, France.
Christian Brun Buisson, AP-HP, Hopital Henri Mon-
dor, DHU A-TVB, Service de Reanimation Medicale,
CARMAS Research Group, Creteil, France.
Alain Cariou, Medical ICU, Cochin Hospital, AP-HP,
Paris, France.
Pierre Carli, SAMU de Paris, Hopital Necker-Enfants
Malades, University Paris-Descartes Paris, France.
Charles Cerf, Service de Reanimation Polyvalente,
Foch Hospital, Suresnes, France.
Aures Chaib, Cardiology department, Andre Gre-
goire Hospital, Montreuil, France.
Jean Chastre, Service de Reanimation, Institut de
Cardiologie, ICAN, Groupe Hospitalier Pitie-
Salpetrie`re, APHP, Paris, France.
Albin Chauvet, AP-HP, EMS92 (SAMU92), Garches,
France.
Yves Cohen, Medical-surgical Intensive Care Unit,
Avicenne teaching Hospital, Bobigny, France.
Alain Combes, Service de Reanimation, Institut de
Cardiologie, ICAN, Groupe Hospitalier Pitie-
Salpetrie`re, APHP, Paris, France.
Carole Cornaglia, Service Mobile dUrgences et Re-
animation, AP-HP Hopital Beaujon, Universite Paris 7,
Clichy, France.
Jean-Michel Coulaud, Service de reanimation
medicale et chirurgicale, CHI Montfermeil, France.
Vincent Das, Medical-Surgical Intensive Care Unit,
Andre Gregoire District Hospital Center, Montreuil,
France.
Nicolas Deye, Intensive Care Unit, Lariboisie`re Uni-
versity Hospital, AP-HP, Paris, France.
Annals of Internal Medicine Vol. 15 No. 11 6 December 2016
 Gilles Dhonneur, Universite Paris Est, Faculte de
Medecine, Creteil, France; Service dAnesthesie et des
Reanimations Chirurgicales, APHP, Henri Mondor Hos-
pital, Creteil, France.
Jean-Luc Diehl, Medical Intensive Care Unit,
Georges Pompidou European Hospital, AP-HP, Paris,
France.
Sylvie Dinanian, Cardiology Department, Hopital
Antoine-Becle`re, Assistance Publique-Hopitaux de
Paris, Clamart, France.
Laurent Domanski, Brigade de Sapeurs-Pompiers
de Paris (BSPP), Paris, France.
Didier Dreyfuss, AP-HP, Service de Reanimation
Medico-Chirurgicale, Hopital Louis Mourier, Colombes,
France.
Denis Duboc, Department of Cardiology, Cochin
Hospital, APHP, Paris, France.
Jean Luc Dubois-Rande, Department of Cardiol-
ogy, AP-HP, Henri-Mondor Teaching Hospital, Creteil,
France.
Olivier Dubourg, Department of Cardiology, Assis-
tance Publique-Hopitaux de Paris (AP-HP), Hopital Am-
broise Pare, Centre de reference des maladies cardi-
aques hereditaires, Universite de Versailles-Saint
Quentin (UVSQ), INSERM U-1018, CESP, Team 5, Bou-
logne, France.
FX Duchateau, Service Mobile dUrgences et Reani-
mation, AP-HP Hopital Beaujon, Universite Paris 7,
Clichy, France.
Alexandre Duguet Medical Intensive Care Unit and
Respiratory Division, Pitie-Salpetrie`re University Hospi-
tal, Paris, 75013, France.
Florence Dumas, Emergency Department, Cochin-
Hotel-Dieu Hospital, APHP, Paris, France.
Jean-Philippe Empana, Paris Sudden Death Exper-
tise Center, INSERM U970 (PARCC), Paris, France.
Jean-Yves Fagon, Medical Intensive Care Unit,
Georges Pompidou European Hospital, AP-HP, Paris,
France.
Muriel Fartoukh, AP-HP, Hopital Tenon, Service de
Reanimation Medico-Chirurgicale, Paris, France Sor-
bonne Universites, UPMC Univ Paris 06, Paris, France.
Celine Fenioux, AP-HP, EMS92 (SAMU92), Garches,
France.
Francois Fraisse, ICU, Delafontaine hospital, Saint
Denis, France.
Mehdi Gabbas, French National Health Insurance
(CNAMTS), Paris, France.
Bertrand Guidet, AP-HP, CHU Saint-Antoine, Ser-
vice de Reanimation Medicale, Paris, France; Universite
Pierre et Marie Curie (UPMC), Univ Paris 06, Sorbonne
Universites, Paris, France.
Patrick Henry, Cardiology Department, Universite
Paris Diderot, Sorbonne Paris Cite, APHP, Lariboisie`re
Hospital, Paris, France.
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Francoise Hidden Lucet, service de cardiologie, In-
stitut de Cardiologie, ICAN, Groupe Hospitalier Pitie-
Salpetrie`re, APHP, Paris, France.
Patricia Jabre, Paris Sudden Death Expertise Cen-
ter, INSERM U970 (PARCC), Paris, France.
Laurent Jacob, Departement danesthesie-
reanimation, Hopital Saint-Louis, Paris, France.
Line Jacob, AP-HP, Hopital Henri Mondor, SAMU
94, Creteil, France.
Liliane Joseph, Kremlin-Bicetre University Hospital,
Paris, France.
Daniel Jost, Brigade de Sapeurs-Pompiers de Paris
(BSPP), Paris, France.
Didier Journois, Surgical Intensive Care Unit, De-
partment of Anesthesia and Intensive care, Georges
Pompidou European Hospital, APHP, Paris Descartes
University, Paris, France.
Xavier Jouven, Cardiology Department, Georges
Pompidou European Hospital, AP-HP, Paris, France.
Nicole Karam, Cardiology Department, Georges
Pompidou European Hospital, AP-HP, Paris, France.
Lionel Lamhaut, SAMU de Paris, Hopital Necker-
Enfants Malades, University Paris-Descartes Paris,
France.
Antony Lanceleur, Service de Reanimation Polyva-
lente, Hopital Foch, Suresnes, France.
Olivier Langeron, Unite de surveillance post-
interventionnelle et daccueil des polytraumatises, de-
partement danesthesie reanimation, Pitie-Salpetrie`re,
APHP, Paris, France.
Vincent Lanoe, Brigade de Sapeurs-Pompiers de
Paris (BSPP), Paris, France.
Eric Lecarpentier, AP-HP, Hopital Henri Mondor,
SAMU 94, Creteil, France.
Antoine Leenhardt, Cardiology department, Bichat
Hospital, APHP, Paris, France.
Nicolas Lellouche, Department of Cardiology, AP-
HP, Henri-Mondor Teaching Hospital, Creteil, France.
Virginie Lemiale, Medical ICU of the Saint-Louis
Hospital, Paris Diderot Sorbonne University, Paris,
France.
Frederic Linval, AP-HP, Urgences - Samu 93, hopi-
tal Avicenne, Universite Paris 13, Bobigny, France.
Thomas Loeb, AP-HP, EMS92 (SAMU92), University
Hospital of West Suburb of Paris, Garches, France.
Bertrand Ludes, Institute of Legal Medicine, Paris
Descartes University, Paris, France.
Nadia Mansouri, AP-HP, Hopital Henri Mondor,
SAMU 94, Creteil, France.
Jean Mantz, Surgical Intensive Care Unit, Depart-
ment of Anesthesia and Intensive care, Georges Pom-
pidou European Hospital, APHP, Paris Descartes Uni-
versity, Paris, France.
Eloi Marijon, Cardiology Department, Georges
Pompidou European Hospital, AP-HP, Paris, France.
www.annals.org
 Jean Marty, AP-HP, Hopital Henri Mondor, SAMU
94, Creteil, France.
Eric Maury, AP-HP, CHU Saint-Antoine, Service de
Reanimation Medicale, Paris, France; Universite Pierre
et Marie Curie (UPMC), Univ Paris 06, Sorbonne Univer-
sites, Paris, France.
Virginie Maxime, General intensive care unit, Ray-
mond Poincare Hospital (AP-HP), Garches, France.
Armand Mekontso-Dessaps, AP-HP, Hopital Henri
Mondor, DHU A-TVB, Service de Reanimation Medi-
cale, CARMAS Research Group, Creteil, France.
Jean-Paul Mira, Medical ICU, Cochin Hospital, AP-
HP, Paris, France.
Benot Misset, Medical-Surgical ICU, Saint Joseph
Hospital, Paris, France.
Xavier Monnet, Medical Intensive Care Unit,
Kremlin-Bicetre University Hospital, Paris, France.
Gilles Montalescot, service de cardiologie, Institut
de Cardiologie, ICAN, Groupe Hospitalier Pitie-
Salpetrie`re, APHP, Paris, France.
Armelle Nicolas-Robin, Department of Anesthesiol-
ogy and Critical Care, groupe hospitalier Pitie-
Salpetrie`re, AP-HP, Paris, France.
Marie-Cecile Perier, Paris Sudden Death Expertise
Center, INSERM U970 (PARCC), Paris, France.
Olivier Piot, Centre cardiologique du Nord, Saint-
Denis, France.
Isabelle Plu, Laboratoire de neuropathologie Es-
courolle, pole des maladies du syste`me nerveux, CHU
Pitie Salpetrie`re, Paris, France.
Francois Revaux, AP-HP, Hopital Henri Mondor,
SAMU 94, Creteil, France.
Jean-Damien Ricard, AP-HP, Hopital Louis Mourier,
Service de Reanimation Medico-Chirurgicale, Co-
lombes, France.
Christian Richard, Medical Intensive Care Unit,
Kremlin-Bicetre University Hospital, Paris, France.
Bruno Riou, Sorbonne Universite UPMC Univ Paris
06; and Department of Emergency Medicine and Sur-
gery, Groupe hospitalier Pitie-Salpetrie`re, APHP, Paris,
France.
Jean-Jacques Rouby, Department of Anesthesiol-
ogy and Critical Care Medicine, Pitie-Salpetrie`re Hospi-
tal, University Pierre and Marie Curie of Paris 6, Paris,
France.
France Roussin, Departement danesthesie-
reanimation, Hopital Saint-Louis, Paris, France.
www.annals.org
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Denis Safran, Surgical Intensive Care Unit, Depart-
ment of Anesthesia and Intensive care, Georges Pom-
pidou European Hospital, APHP, Paris Descartes Uni-
versity, Paris, France.
Francesco Santoli, Service de reanimation, hopital
Robert-Ballanger, Aulnay-sous-Bois, France.
Frederique Schortgen, AP-HP, Hopital Henri Mon-
dor, Service de Reanimation Medicale, Creteil, France.
Tarek Sharshar, General Intensive Care Medicine,
APHP, Raymond Poincare Hospital, University of Ver-
sailles Saint-Quentin en Yvelines, Garches, France.
Thomas Similowski, Medical Intensive Care Unit
and Respiratory Division, Pitie-Salpetrie`re University
Hospital, Paris, 75013, France.
Alain Simon, CMPCV, Georges Pompidou Euro-
pean Hospital, AP-HP, Paris, France.
Christian Spaulding, Cardiology Department,
Georges Pompidou European Hospital, AP-HP, Paris,
France.
Philippe Gabriel Steg, Cardiology department, Bi-
chat Hospital, APHP, Paris, France.
Jean-Louis Teboul, Medical Intensive Care Unit,
Kremlin-Bicetre University Hospital, Paris, France.
Jean-Francois Timsit, Medical Intensive Care Unit,
Bichat - Claude-Bernard University Hospital, Paris,
France.
Jean-Pierre Tourtier, Brigade de Sapeurs-Pompiers
de Paris (BSPP), Paris, France.
Philippe Tuppin, French National Health Insurance
(CNAMTS), Paris, France.
Cecile Ursat, AP-HP, EMS92 (SAMU92), Garches,
France.
Alec Vahanian Poghossi, Cardiology department,
Bichat Hospital, APHP, Paris, France.
Olivier Varenne, Department of Cardiology, Cochin
Hospital, APHP, Paris, France.
Antoine Vieillard-Baron, Intensive Care Unit, Sec-
tion Thorax-Vascular Disease-Abdomen-Metabolism,
APHP, University Hospital Ambroise Pare, Boulogne-
Billancourt, France.
Xavier Waintraub, service de cardiologie, Institut
de Cardiologie, ICAN, Groupe Hospitalier Pitie-
Salpetrie`re, APHP, Paris, France.
Simon Weber, Department of Cardiology, Cochin
Hospital, APHP, Paris, France.
Michel Wolff, Medical Intensive Care Unit, Bichat -
Claude-Bernard University Hospital, Paris, France.
Annals of Internal Medicine Vol. 15 No. 11 6 December 2016
 Appendix Figure 1. Flow chart of the Paris SDEC validation cohort.

Paris SDEC validation cohort

(n = 3898)

Patients with missing data (n = 242)

Type of missing data:
Only objective criteria*: 165 (all died)
Only outcome: only 72
Criteria for continuing ACLS: 68
Objective criteria: 4
Objective criteria and outcome: 5

Patients with complete data

(n = 3656)

Patients meeting 3 objective criteria* All other patients

(n = 1570) (n = 2086)

Discharged alive Died Discharged alive Died

(n = 1 [0.1%]) (n = 1569 [99.9%]) (n = 336 [16%]) (n = 1750 [84%])

The cohort included patients with out-of-hospital cardiac arrest of presumed cardiac origin from 16 May 2012 through 15 May 2014. ACLS =
advanced cardiac life support; SDEC = Sudden Death Expertise Center.
* Out-of-hospital cardiac arrest not witnessed by emergency medical services personnel, initial nonshockable rhythm, and no return of spontaneous
circulation before receipt of a third 1-mg dose of epinephrine.
One patient survived to hospital discharge in a persistent vegetative state (Cerebral Performance Category score of 4).

Appendix Figure 2. Flow chart of the PRESENCE cohort.

PRESENCE cohort
(n = 570)

Patients excluded (OHCA with

obvious extracardiac cause) (n = 84)

OHCA of presumed cardiac origin

(n = 486)

Patients meeting 3 objective criteria* All other patients

(n = 285) (n = 201)

Alive at day 28 Died Alive at day 28 Died

(n = 0 [0%]) (n = 285 [100%]) (n = 16 [8%]) (n = 185 [92%])

OHCA = out-of-hospital cardiac arrest.

* OHCA not witnessed by emergency medical services personnel, initial nonshockable rhythm, and no return of spontaneous circulation before
receipt of a third 1-mg dose of epinephrine.

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 Appendix Figure 3. Flow chart of the King County cohort.

King County cohort

(n = 2669)

Patients excluded (aged 55 y)

(n = 1619)

OHCA of presumed cardiac origin

(n = 1050)

Patients meeting 3 objective criteria* All other patients

(n = 173) (n = 877)

Discharged alive Died Discharged alive Died

(n = 0 [0%]) (n = 173 [100%]) (n = 237 [27%]) (n = 640 [73%])

OHCA = out-of-hospital cardiac arrest.

* OHCA not witnessed by emergency medical services personnel, initial nonshockable rhythm, and no return of spontaneous circulation before
receipt of a third 1-mg dose of epinephrine.

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