Resuscitation in OHCA:When to START

andWhen to STOP

Review by : Kanok Ongskul , MD2nd yr emergency medicine resident

Rajavithi hospital

Goals of Resuscitation

Preserve life

Restore health

Relieve suffering

Limit disability

Respect the individual’s decisions, rights, and privacy

Ethical Issues

HCP should consider the ethical, legal, and cultural factors assoc. w/ resuscitation.

Guided by science, the preferences of the individual or surrogates, and local policy and legal requirements

Healthcare Advance Directive

A legal binding document

Tells the thoughts, wishes, or preferences for healthcare decisions during periods of incapacity

Verbal or Written (more trustworthy)

May be based on conversations, written directives, living wills, or durable power of attorney for health care

Do Not Attempt Resuscitation (DNAR) order

Described more recently as a DNACPR decision, or “Allow Natural Death” (AND)

Given by a licensed physician or alternative authority

Must be signed and dated to be valid

Most preceded by a documented discussion with the patient, family, or surrogate decision maker

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Withholding & Withdrawing CPRin OHCA

Reduce unnecessary transport

Reduce associated road hazards

Reduces inadvertent paramedic exposure to potential biohazards

Reduce cost of ED pronouncement

Criteria for Not Starting CPR (OHCA)

Begin CPR without seeking consent except… (where withholding CPR might be appropriate)

1. Situations would place the rescuer at risk of serious injury or mortal peril

2. Obvious signs of irreversible death (eg, rigor mortis, dependent lividity, decapitation, transection, or decomposition)

3. A valid, signed, and dated DNAR order or an advance directive indicating that resuscitation is not desired

DNAR Orders in OHCA

Can take many forms (eg, written bedside orders, identification cards/bracelets)

In some EMS systems this includes verbal DNAR requests from family members (pts w/ a terminal illness, who were under the care of a physician)

Advance Directives in OHCA

Do not have to include a DNAR order

DNAR order is valid w/o an advance directive.

Initiate CPR if doubt …the validity of a DNAR orderthe victim may have had a change of mindwhether the pt intended the advance directive to be applied under that condition

Termination of Resuscitation (TOR)in OHCA

Neonatal / Pediatric: NO validated clinical decision rules

AdultBLSALSCombined BLS and ALS

When to STOP BLSROSC

Care is transferred to ALS

The rescuer is unable to continue because ofExhaustionDangerous environmental hazardsIt places others in jeopardy

Reliable and valid criteriaIrreversible death / Obvious death“BLS termination of resuscitation rule” (prospectively validated)

BLS Termination of Resuscitation Rule for Adult OHCA

1. Arrest not witnessed by EMS provider or first responder

2. No ROSC after 3 full rounds of CPR and AED analyses

3. No AED shocks delivered

If ALL criteria are met >>> consider TOR

Morrison LJ, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2006;355: 478-487.

BLS termination-of-resuscitation rule for adult OHCA

Use the rule to develop protocols in areas where ALS is not available or may be significantly delayed (Class I, LOE A).

When to STOP ALS

NAEMSP: Resuscitation could be terminated in pts not respond to at least 20 min of ALS.

“ALS termination of resuscitation rule”

(retrospectively externally validated)

ALS Termination of Resuscitation Rule for Adult OHCA

Arrest not witnessed (by anyone)

No bystander CPR provided

No ROSC after complete ALS care in the field

No shocks delivered

If ALL criteria are met >> consider TOR

Morrison LJ, et al. Derivation and evaluation of a termination of resuscitation clinical prediction rule for advanced life support

providers. Resuscitation. 2007;74: 266.275.

It is reasonable to employ this rule in all ALS services (Class IIa, LOE B).

ALS termination-of-resuscitation rule for adult OHCA

TOR in a Combined BLS and ALSOut-of-Hospital System

Use of a universal rule can avoid confusion

The BLS rule is reasonable to use in these services (Class IIa, LOE B).

Implementation of the Rules

Applied BEFORE ambulance transport

Contact online medical control when the criteria are met

EMS providers should receive training in sensitive communication with the family

Support for the rules should be sought from collaborating agencies such as hospital EDs, the medical coroner’s office, online medical directors, and the police.

When to Start/Stop CPR ?

Consider the therapeutic efficacy of CPR, potential risks, and pt’s preferences

All rules should be validated prospectively before implementation

Grey areas where subjective opinions are required in pts with HF & severe respiratory compromise, asphyxia, major trauma, head injury and neurological disease.

General Rule

In generalResuscitation should be continued as long as VF persistsOngoing asystole > 20 min in the absence of a reversible cause, and with ongoing ALS TOR

Reports of exceptional cases that do not support the general rule

The quality of CPR is compromised during transport, and survival is linked to optimizing scene care rather than rushing to hospital.

In OHCA of cardiac origin, if recovery is going to occur, ROSC usually takes place on site.

Organ Procurement

Continuing futile resuscitation attempts with the sole purpose of harvesting organs is debatable

If considering prolonging CPR and other resuscitative measures to enable organ donation to take place mechanical chest compressions may be valuable.

Traumatic Cardiopulmonary Arrest

(TCPA)

J Am Coll Surg 2003;196:475—81.

Blunt Trauma

Resuscitation efforts may be withheld if

1. Apneic2. Pulseless3. No organized ECG activity

Penetrating Trauma

Resuscitation efforts may be withheld If1. Apneic2. Pulseless3. No other signs of life, such as

Pupillary reflexesSpontaneous movementOrganized ECG activity

If any of these signs are present>> resuscitation and

transport

Penetrating or Blunt Trauma

Resuscitation should be withheld if

1. Injuries obviously incompatible with life, such as decapitation or hemicorporectomy

2. Evidence of a significance time lapse since pulselessness, including dependent lividity, rigor mortis, and decomposition

Nontraumatic Cause of Arrest ?

Mechanism of injury not correlate with clinical condition

>> Standard Resuscitation

Termination of Resuscitation (TOR)

should be considered if

1. EMS-witnessed arrest + 15 min of unsuccessful CPR

2. Transport time > 15 min after the arrest

Special Consideration

Drowning

Lightning Strike

Significant Hypothermia

These recommendations specifically DO NOT address

1. Pediatric pts

2. Pts in whom a medical cause (i.e. MI) is the likely inciting event

3. Pts w/ complicating factors, such as severe hypothermia

Guidelines and protocols must be individualized for each EMS system.

Consider the factors such asaverage transport timethe scope of practice of the various EMS providersdefinitive care capabilities

Airway management and IV line placement during transport when possible

EMS providers should be thoroughly familiar with the guidelines and protocols.

All termination protocols should be developed and implemented under the guidance of the medical director.

On-line medical control may be necessary.

Policies and protocols for TOR must include notification of the law enforcement agencies and medical examiner or coroner.

Families of the deceased should have access to resources, including clergy, social workers, and other counseling personnel, as needed.

EMS providers should have access to resources for debriefing and counseling as needed.

…Still Controversy

Retrospective cohort study in Seattle

184 TCPA pts transported to a Level I trauma center by EMS between January 1, 1994 and April 1, 2001

If the NAEMSP/ACSCOT guidelines applied, 13 of the 14 survivors would not have been resuscitated

J Trauma. 2005;5:951-958.

Retrospective review of a statewide major trauma registry between 2001 to 2004 in Australia

89 pts received CPR in the field and transport

4 survivors: 2 penetrating inj. with 1 demonstrating signs of life2 blunt inj. probably experiencing cardiac arrest secondary to electrocution and hypoxia (In 1 casea a total prehospital time of 54 min)

Injury, Int. J. Care Injured (2006) 37, 448—454

Retrospective review of trauma pts receiving out-of-hospital CPR between 1994-2004 in UK

Helicopter EMS include an experienced physician

909 pts 68 (7.5%) survive to hospital discharge

13 (19%) of 68 would not have been resuscitated if NAEMS/ACS-COT guidelines adherence

Ann Emerg Med. 2006;48:240-244.

The NAEMS/ACS-COT guidelines require careful consideration when applied in the field.

THANK YOU