Prehospital Termination of Resuscitation in Cases of Refractory Out-of-Hospital Cardiac Arrest

Abstract

It is estimated that 166 200 out-of-hospital cardiac events occur each year in the United States, with approximately 60% of these events treated by emergency medical services (EMS). 1 Reported rates of survival following outof-hospital cardiac arrest (OHCA) vary widely, from 0.2% (Detroit [2007]) 2 to 23% (London, England [2005]). 3 Nationwide, the median reported survival rate is 6.4%. 4 The vast majority of patients who survive OHCA are resuscitated at the scene of the cardiac arrest and subsequently transported to the hospital for definitive care. 5,6 Nevertheless, the practice of EMS systems in cases of refractory OHCA vary widely from agency to agency. Although most systems generally follow the basic life support (BLS) and advanced life support(ALS)generalresuscitationguidelines outlined by the American Heart Association, 7 there is widespread variability in their application. In one study, adherence to American Heart Association guidelines for the out-of-hospital care of cardiac arrest was only 40%. 8 During the past 30 years, several research teams have sought to define objective clinical criteria to identify patients who likely will not benefit from rapid transport to the hospital for further resuscitative efforts. 9-18 Despite this research, many EMS systems still urgently transport patients with refractory cardiac arrest to the hospital for continued resuscitative efforts. 19-21 Rapid transport with lights and siren may pose hazards for EMS personnel and the public and should occur only when the risks of high-speed trans-See also pp 1423 and 1462.

Association of Neighborhood Characteristics With Bystander-Initiated CPR

“…Detailed information about this registry, including catchment area, emergency-medical-service (EMS) characteristics, and cardiac-arrest protocols, has been reported previously. [18][19][20][21] During the study period, from October 1, 2005, through December 31, 2009, CARES collected data on all 911-activated events involving cardiac arrest that occurred in 29 U.S. sites (Fig. 1S in the Supplementary Appendix, available with the full text of this article at NEJM.org).…”

Should we resuscitate or not—that is the question!

“…The 2015 American Heart Association (AHA) as well as the European Resuscitation Council (ERC) guidelines for cardiopulmonary resuscitation (CPR) describe basic life support (BLS) and advanced life support (ALS) rules for termination of resuscitation (TOR) (2). Several studies have evaluated the generalizability of the TOR rules in BLS and ALS emergency medical services (EMS) systems ( Table 1) (3)(4)(5)(6)(7)(8)(9)(10)(11)(12). The BLS TOR rule suggests that resuscitative efforts may be aborted in patients whose arrest was not witnessed by EMS, in whom return of spontaneous circulation (ROSC) is not achieved in the field and when no shocks are delivered ( Table 1).…”

The Robert Wood Johnson Foundation Clinical Scholars Program and Emergency Medicine

“…4 Herb Garrison commented on how this research collaboration exemplifies the Clinical Scholar network:…”