When to stop resuscitation?
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Transcript of When to stop resuscitation?
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When to Stop Resuscitation?
Dan StevensEmergency Medicine
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When to Stop?
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When to Stop?
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When to Start?
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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• ???????
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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
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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
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There is Nothing Else That Can be Done
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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
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Summary
• Discuss with patients / family about DNAR• The Decision on when to stop resuscitation
should be taken on a case by case basis
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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
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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