Post on 06-May-2015
description
When to Stop Resuscitation?
Dan StevensEmergency Medicine
When to Stop?
When to Stop?
When to Start?
When to Stop CPR
1. When the patient doesn’t want it• Advance directive
2. No chance of meaningful outcome• ???????
3. There is nothing else that can be done• ???????
No Chance of a Meaningful Outcome
• Asystole• Pupils are unreactive– Reactive pupils is a good sign– Unreactive is a bad sign (but can still have good
functional neurological outcome)– Lack of pupillary response at 72 hours is a very bad
sign• Cardiac standstill on Ultrasound• Low CO2– NEJM – An end tidal CO2 < 1.3 kPa after 20 minutes of
resuscitation no one achieved ROSC
Chance of a Meaningful Outcome
• Pre-morbid state• Time to CPR• Quality of CPR• Signs of life– Good colour– Occassional movements– Reactive pupils
• Special circumstances– Drowning / hypothermia
There is Nothing Else That Can be Done
Resuscitation By Specialists• Best resuscitation care
– Minimal / no pause CPR – good quality (LUCUS)– Best Airway management– Capnography– Thrombolysis– Upping energy, changing position of pads
• 4 pads better than 2?– ECHO– Other drugs
• Vasopressin, esmolol, steroids– ECLS (extracorporeal life support) – Cath Lab (PCI) during arrest– The Traumatic arrest
Summary
• Discuss with patients / family about DNAR• The Decision on when to stop resuscitation
should be taken on a case by case basis
When to StopSTOP CPR CONTINUE CPR
Low ETCO2 at 20 minutes of resuscitation Hypothermia
Ventricular standstill on ultrasound Fit and well
Poor Pre-morbid state At scene good quality CPR
Prolonged period without CPR Reversible cause
No reversible cause VF / VT persists
Asystole
Resources• http://intensivecarenetwork.com/reid-when-should-resuscitation-s
top/• http://edecmo.org/• http://intensivecarenetwork.com/scott-weingart-cutting-edge-intra
-arrest-care/• http://intensivecarenetwork.com/reid-cliff-resuscitation-dogmalysi
s/• http://emcrit.org/podcasts/traumatic-arrest/• http://blog.ercast.org/trauma-arrest/• http://emcrit.org/wp-content/hypoarts/rittenberger
%20prognosis.pdf• http://stemlynsblog.org/als-airway-breathing-c02/• http://www.nejm.org/doi/pdf/10.1056/NEJM199707313370503