Guidelines for discontinuing prehospital CPR in the emergency department — A review

doi:10.1016/S0196-0644(85)80928-8

Annals of Emergency Medicine

Volume 14, Issue 11, November 1985, Pages 1093-1098

https://doi.org/10.1016/S0196-0644(85)80928-8 Get rights and content

Summary

We provide information that we believe should allow the establishment of rational guidelines for discontinuing, with physician supervision, unsuccessful prehospital CPR. Goldberg³⁵ has advocated that CPR be terminated only after evidence of brain or cardiac death has persisted for more than one hour of adequately applied advanced CPR. This recommendation was made for inhospital resuscitation and does not reflect the limited capabilities of basic and advanced CPR techniques to sustain life outside the hospital. In addition, White and associates³⁶ have demonstrated that after resuscitation from prolonged cardiac arrest, cerebral cortical blood flow is reduced severely. This state of hypoperfusion may last up to 18 hours. Because this condition can result in extensive neurologic damage, it may explain the poor survival rates after prolonged resuscitation.

We propose that CPR be terminated in the ED when, despite adequate rescue attempts (intubation, defibrillation, IV medications, CCCM en route) by those responding at the scene of cardiac arrest, intrinsic cardiac activity has not been achieved in patients brought to the hospital with asystole or bradyarrhythmia. Additionally patients who have had advanced prehospital CPR for more than 45 minutes without generation of any intrinsic cardiac activity are not resuscitatable by current standard techniques, and CPR may be discontinued. These criteria must not be used for victims of hypothermia before a core temperature of 35 C to 36.1 C is achieved by active core rewarming during CPR. The available data suggest that if these criteria are implemented, many unproductive hospital-based resuscitative efforts can be eliminated without jeopardizing potential survivors.

In patients brought to the hospital with VF or VT vigorous resuscitation is indicated, particularly if the patient has received only prehospital CCCM without the benefit of defibrillation. Patients with witnessed cardiac arrest who have had immediate CPR but not definitive prehospital care may benefit from ED CPR even if they have a bradyarrhythmia. Continued efforts at resuscitation are potentially lifesaving in these patients.

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Cited by (42)

Transfer of care is associated with longer unsuccessful resuscitations
2008, American Journal of Emergency Medicine
Citation Excerpt :
Similarly, for both blunt and penetrating posttraumatic circulatory arrests, the National Association of Emergency Medical Services Physicians and the American College of Surgeons Committee on Trauma guidelines recommend, in most cases, to stop after 15minutes of unsuccessful resuscitation in the field [4]. Both medical [5-7] and trauma [8-13] guidelines are based on a large body of evidence suggesting that after these periods of unsuccessful resuscitation, the chances for meaningful recovery are small and the risks of continued resuscitation rapidly begin to outweigh the benefits. Emergency departments (EDs) are unique in that they perform such resuscitations not only on patients who arrest in front of the provider but also on patients who arrive in the midst of a prehospital resuscitation.
Accepted guidelines define when to terminate unsuccessful resuscitations. We examined whether such resuscitations last longer for transported arrests in the field compared with those occurring in the emergency department (ED).
This was a retrospective study of patients who died in an urban, academic ED over 32 months starting from January 2001. Total length of resuscitation and the interval occurring in-ED were compared for arrests in the ED and transported arrests from the field.
A total of 132 patients met the criteria, of whom 71 (53.8%) arrested in the field. Mean overall resuscitation times were longer for arrests occurring in the field (44 minutes; 95% confidence interval [CI], 39-48) compared with those in the ED (19 minutes; 95% CI, 16-22; P < .001). Mean resuscitation intervals occurring in the ED were no different for arrests occurring in the field (16 minutes; 95% CI, 13-19) than in the ED (19 minutes; 95% CI, 16-22; P > .05).
Unsuccessful resuscitations were longer and beyond guideline recommendations when arrests occurred in the field and were transported. The interval of resuscitation that occurred in the ED was the same whether or not prehospital resuscitation occurred.
Inter-rater reliability and comfort in the application of a basic life support termination of resuscitation clinical prediction rule for out of hospital cardiac arrest
2007, Resuscitation
Citation Excerpt :
The most recent American Heart Association Guidelines for cardiopulmonary resuscitation acknowledged the need for such protocols in situations where ACLS care is not rapidly available.12 Much of the current research supporting termination of resuscitation clinical prediction rules has been limited to patients who received full prehospital ACLS care.13–21 We recently derived and validated a BLS TOR clinical decision rule.1,22
This study evaluates inter-rater reliability and comfort of BLS providers with the application of an out-of-hospital Basic Life Support Termination of Resuscitation (BLS TOR) clinical prediction rule. This rule suggests that continued BLS cardiac resuscitation is futile and can be terminated in the field if the following three conditions are met: (1) no return of spontaneous circulation; (2) no shock given prior to transport; (3) cardiac arrest not witnessed by EMS personnel.
Providers hypothetically applied the rule and rated their comfort level on a five-point Likert-type scale, from “very comfortable” to “very uncomfortable” during the prospective validation of a BLS TOR clinical prediction rule in out-of-hospital cardiac arrest conducted in 12 rural and urban communities [Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. New Engl J Med 2006;355(5):478–87]. A Kappa score measured agreement between providers and compared to the correct interpretation of the rule.
We compared mean comfort levels of providers who interpreted the rule correctly versus incorrectly. Of 1240 enrolled cases, 1184 (95.5%) had paramedic attendant forms and 1211 (97.7%) had driver forms and 1175 (94.7%) had both. Kappa for interpretation agreement between driver and attendant was 0.90 (95% CI, 0.87–0.92); between attendant and correct interpretation of the BLS TOR clinical prediction rule, 0.88 (95% CI, 0.85–0.91); between driver and correct interpretation of the BLS TOR clinical prediction rule, 0.88 (95% CI, 0.85–0.91). For instances in which both providers applied the rule correctly (607/635 [95.6%]), the providers were significantly more comfortable (χ²(4) = 30.5, p < 0.0001) than those instances in which they did not (28/635 [4.4%].
The vast majority of providers were able to apply the BLS TOR clinical prediction rule correctly and were comfortable doing so. This suggests that both reliability and comfort will remain high during routine application of the rule when paramedics are well trained as users of the rule.
Resuscitation attempts in asystolic patients: The legal tail wagging the dog?
2006, Journal of Emergency Medicine
In today’s litigious society, legal worries can cause Emergency practitioners to alter their delivery of clinical care. One clinical scenario in which this particularly true is in resuscitation of the so called “medically futile” patient. Patients who arrive to the Emergency Department in prolonged asystole have a uniformly dismal prognosis at best. Yet, many Emergency Physicians often continue resuscitative efforts for fear of being sued. These fears are largely unjustified. This article attempts to analyze the factors and elements involved in support of the assertion that the risk of a lawsuit is negligible at best.
Decision making by emergency physicians when assessing cardiac arrest patients on arrival at hospital
2001, Resuscitation
Objective: To investigate the factors which influence decision making by experienced emergency physicians when they decide whether to (a) pronounce ‘life extinct’ in adult patients with non traumatic cardiac arrest while in the ambulance, or (b) bring them into the resuscitation room in the Emergency Department for further assessment/management. Design: Qualitative study involving semi structured interviews and a focus group. Setting: Accident & Emergency (A&E) departments in the Yorkshire region. Participants: Fifteen emergency physicians (two clinical fellows, nine specialist registrars and four consultants) working in the Yorkshire region. Results: Six main themes were identified that impacted upon the decision making process: the doctor's past experience, ambulance service issues, prehospital care, patient characteristics, presence and views of relatives, and organisational issues. Conclusion: The reasoning behind decisions made when a patient arrives at the Emergency Department in cardiac arrest is multifactorial. Strict guidelines would be difficult to construct since individuals vary in the importance they attach to different factors.
Objectivo: Investigar os factores que influenciam a tomada de decisão por médicos da emergência experientes quanto à decisão de a) declarar a morte em adultos vı́timas de paragem cárdio respiratória não traumática, b) iniciar a reanimação no departamento de urgência com a intenção de fazer a avaliação / tratamento ulterior. Desenho: estudo qualitativo envolvendo entrevista semi estruturada e em “focus group”. Contexto: departamento de “Accident & Emergency” (A&D) na região de Yorkshire. Participantes: quinze Médicos de Emergência (dois clı́nicos gerais, nove especialistas e quatro consultores) a trabalhar na região de Yorkshire. Resultados: Identificaram-se seis temas principais com influência no processo de tomada de decisão.
Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest
2000, Prehospital Emergency Care
The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of “do not resuscitate” or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling. PREHOSPITAL EMERGENCY CARE 2000;4:190-195
Determination of 'futility' in emergency medicine
2000, Annals of Emergency Medicine
The practice of emergency medicine routinely requires rapid decisionmaking regarding various interventions and therapies. Such decisions should be based on the expected risks and benefits to the patient, family, and society. At times, certain interventions and therapies may be considered “futile,” or of low expected likelihood of benefit to the patient. Various interpretations of the term “futility” and its practical application to the practice of emergency medicine are explored, as well as background information and potential application of various legal, ethical, and organizational policies regarding the determination of “futility.” Decisions regarding potential benefit of interventions should be based on scientific evidence, societal consensus, and professional standards, not on individual bias regarding quality of life or other subjective matters. Physicians are under no ethical obligation to provide treatments they judge to have no realistic likelihood of benefit to the patient. Decisions to withhold treatment should be made with careful consideration of scientific evidence of likelihood of medical benefit, other benefits (including intangible benefits), potential risks of the proposed intervention, patient preferences, and family wishes. When certain interventions are withheld, special efforts should be made to maintain effective communication, comfort, support, and counseling for the patient, family, and friends. [Marco CA, Larkin GL, Moskop JC, Derse AR. Determination of “futility” in emergency medicine. Ann Emerg Med. June 2000;35:604-612.]

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Collective reviewGuidelines for discontinuing prehospital CPR in the emergency department — A review

Summary

Lancet

Am J Med

JACEP

JACEP

JACEP

Ann Emerg Med

Am J Med

Ann Emerg Med

JACEP

Lancet

JACEP

JACEP

Am J Surg

Lancet

Ann Emerg Med

A community program for emergency cardiac care: A three-year coronary ambulance/ paramedic evaluation

JAMA

Emergency Medical Care System: Lincoln (Neb) Mobile Heart Team

Arch Surg

Emergency care

Circulation

Collective review
Guidelines for discontinuing prehospital CPR in the emergency department — A review