Literature Review: Terminating Resuscitation

     Identifying patients in the out-of-hospital setting who have no realistic hope of surviving an out-of-hospital cardiac arrest could enhance utilization of scarce healthcare resources. Objective—To validate two out-of-hospital termination-of-resuscitation rules developed by the Ontario Prehospital Advanced Life Support (OPALS) study group, one for use by responders providing BLS and the other for those providing ALS. Design, setting and patients—Retrospective cohort study using data prospectively submitted by EMS systems and hospitals in eight U.S. cities to the Cardiac Arrest Registry to Enhance Survival (CARES) between Oct. 1, 2005, and April 30, 2008. Case patients were 7,235 adults with out-of-hospital cardiac arrest; of these, 5,505 met inclusion criteria. Main outcome measures—Specificity and positive predictive value of each termination-of-resuscitation rule for identifying patients who likely will not survive to hospital discharge.

     Results—The overall rate of survival to hospital discharge was 7.1% (n=392). Of 2,592 patients (47.1%) who met BLS criteria for termination of resuscitation efforts, only five (0.2%) patients survived to hospital discharge. Of 1,192 patients (21.7%) who met ALS criteria, none survived to hospital discharge. The BLS rule had a specificity of 0.987 and a positive predictive value of 0.998 for predicting lack of survival. The ALS rule had a specificity of 1.000 and positive predictive value of 1.000 for predicting lack of survival. Conclusion—In this validation study, the BLS and ALS termination-of-resuscitation rules performed well in identifying patients with out-of-hospital cardiac arrest who have little or no chance of survival.

     We've all seen it many times: the unwitnessed cardiac arrest patients who do not respond to BLS (or ALS) treatment and whom we rush to the hospital, where, of course, they die. And we've all asked the question many times over: Is this the best we can offer our patients (who are dead), their families (cost and inappropriate hope), the hospitals (cost and delayed care for others), EMS systems (less availability and prolonged response times), nearby drivers and pedestrians, and ourselves (vehicle crashes)?

     The bedridden 96-year-old with diabetes and COPD who is found unresponsive (and a little cool) and asystolic in the morning—we can all pick him out as someone we are not going to help. But how about the 75-year-old someone saw collapse? What if there was a pulse at one point? A rhythm?

     This study used specific rules to identify likely non-survivors. The BLS rules were: 1) arrest not witnessed by EMS, 2) no defibrillation performed and 3) no return of spontaneous circulation. The ALS rules used the three BLS rules and added two more: 1) arrest not witnessed by anyone and 2) no bystander CPR.

     Previous reports have concluded it is extremely unlikely these patients will survive. The National Association of EMS Physicians and American Heart Association have published guidelines to identify patients with little to no chance for survival, but most of our EMS systems still do not follow them. This study further confirms that it is safe and reasonable to determine that certain patients will not survive and their resuscitation can be terminated. EMS systems should look at incorporating these rules into their protocols. Any change of this importance requires discussion, broad consensus and training in grief support.

     Angelo Salvucci, Jr., MD, FACEP, is an emergency physician and medical director for the Santa Barbara County and Ventura County (CA) EMS Agencies.

     A new CPR/ACLS protocol tested in Los Angeles led to a 70% improvement in return of spontaneous circulation, a study presented at the American College of Emergency Physicians' annual Scientific Assembly found.

     "When EMS in Los Angeles treated cardiac arrest patients with the new protocol, which emphasizes 20 minutes of advanced life support efforts on the scene prior to transport, they restored a heartbeat 29% of the time, versus 17% of the time under the old protocol," reported lead author Marc Eckstein, MD, medical director for the Los Angeles Fire Department. "We obviously want to improve upon these numbers, but this is a big step forward."

     Under the protocol, out-of-hospital cardiac arrest patients receive two minutes of CPR, with an emphasis on continuous, uninterrupted chest compressions, prior to use of an AED, and at least 20 minutes of advanced life support efforts at the scene prior to transport. Hyperventilation is avoided, and transports of patients who do not achieve ROSC are minimized. For more, see www.acep.org.