Cardiac arrest while using the toilet: not uncommon and associated with adverse resuscitation profile

Out-of-hospital cardiac arrest (OHCA) on the toilet has been reported to be common and possibly driven by straining or vagal stimulus. Toilet-associated OHCA may also create a challenging resuscitation environment.

The national Danish sudden death registry and state-wide Australian End Unexplained Cardiac Death (EndUCD) registry were examined. Persons with a fatal OHCA aged 5-50 years with autopsy-confirmed cardiac or unascertained aetiology were included. Resuscitation-related, aetiological and forensic factors were compared between persons experiencing fatal toilet-associated OHCA versus elsewhere. A composite variable of physiological conditions creating pressure-load or pressure-sensitivity was created, comprising hypertrophic cardiomyopathy, aortic stenosis/coarctation, and aortic aneurysm/dissection.

Of 2,463young persons, 75 (3.0 %) experienced toilet-associated fatal OHCA while 2,388 (97.0 %) experienced out-of-toilet OHCA. Australians experienced toilet-associated OHCA 1.7 times more frequently than Danes (4.1 % vs 2.4 %, p = 0.016). Toilet-associated OHCA was less frequently witnessed (13.3 % vs 32.1 %, p = 0.001), with lower rates of bystander cardiopulmonary resuscitation (32.0 % vs 55.7 %, p < 0.0001) and shockable rhythm (5.9 % vs 23.8 %, p = 0.003) compared to non-toilet OHCA. Toxicological results were more frequently positive for illicit substances in toilet-associated OHCA (32.8 % vs 16.3 %, p < 0.0001). No differences were identified in OHCA aetiology, including rates of the composite variable of aetiologies such as hypertrophic cardiomyopathy and aortic dissection.

3.0 % of young fatal OHCA of cardiac aetiology is toilet-associated, with almost double the rates of toilet-associated OHCA in Australia compared to Denmark. No differences in OHCA aetiology were identified in toilet-associated OHCA. Resuscitation-related factors were adverse in toilet-related OHCA, highlighting the need for innovative ways to recognise and respond to toilet-associated OHCA.