Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest

The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of “do not resuscitate” or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling. PREHOSPITAL EMERGENCY CARE 2000;4:190-195     

CPR Induced Consciousness During Out-of-Hospital Cardiac Arrest: A Case Report on an Emerging Phenomenon

Background: High quality cardiopulmonary resuscitation (CPR) has produced a relatively new phenomenon of consciousness in patients with vital signs absent. Further research is necessary to produce a viable treatment strategy during and post resuscitation. Objective: To provide a case study done by paramedics in the field illustrating the need for sedation in a patient whose presentation was consistent with CPR induced consciousness. Resuscitative challenges are provided as well as potential future treatment options to minimize harm to both patients and prehospital providers. Case Report: A 52-year-old male presented as a witnessed out-of-hospital cardiac arrest (OHCA). During CPR the patient began to exhibit signs of life including severe agitation and thrashing of his limbs while CPR was ongoing for ventricular fibrillation prior to defibrillation. Resuscitation became considerably more complicated due to the violent and counterintuitive motions done by the patient during their own resuscitation. Despite the atypical presentation of cardiac arrest the patient was successfully resuscitated employing high quality CPR, standard advanced life support (ALS) care as well as two double sequential external defibrillation shocks. The patient underwent emergency percutaneous coronary intervention (PCI) for a 100% occlusion of his left anterior descending artery (LAD). The patient returned home 3 days later fully recovered with a Cerebral Performance Score of 1. Conclusion: CPR induced consciousness is emerging as a new phenomenon challenging providers of high quality CPR during cardiac arrest resuscitation. Our case report describes the manifestations of CPR induced consciousness as well as the resuscitative challenges which occur during resuscitation. Further research is required to determine the true frequency of this condition as well as treatment algorithms that would allow for appropriate and safe management for both the patient and EMS providers.     

Termination of Nontraumatic Cardiac Arrest Resuscitative Efforts in the Field: A National Survey

Objectives : 1) To describe elements of adult nontraumatic cardiac arrest protocols in those U.S. cities in which resuscitative efforts are being terminated in the out-of-hospital setting. 2) To determine the prevalence and methods of on-scene family grief counseling delivered in this setting.
Methods : Emergency medical services (EMS) systems in each of the 200 largest cities in the United States were surveyed by telephone regarding the content of their adult cardiac arrest protocols. Type of arrest (medical vs trauma), final dysrhythmia, termination policies, and presence or absence of a grief counseling protocol were recorded.
Results : All of the target population responded to the telephone survey. Most (135; 68%) EMS systems currently have written protocols that allow in-field termination of resuscitative efforts for adult nontraumatic cardiac arrest patients who remain asystolic. Only 47 (24%) EMS systems allow cessation of efforts for patients without return of spontaneous circulation regardless of the dysrhythmia. Base station contact is required for authorization to end resuscitative efforts in 120/135 (89%) EMS systems. Only 26/135 (19%) EMS systems that cease efforts in the field have written policies concerning on-scene family grief counseling. This counseling is most likely to be conducted by the out-of-hospital providers themselves.
Conclusion : Many U.S. urban EMS systems are terminating efforts for selected adult nontraumatic cardiac arrest patients, although few have written policies to address grief intervention for family members at the scene.     

Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation

Records on 1,297 people with witnessed out-of-hospital cardiac arrest, caused by heart disease and treated by both emergency medical technicians (EMTs) and paramedics, were examined to determine whether or not early cardiopulmonary resuscitation (CPR) initiated by bystanders independently improved survival. Bystanders initiated CPR for 579 patients (bystander CPR); for the remaining 718 patients, CPR was delayed until the arrival of EMTs (delayed CPR). Survival was significantly better (P less than 0.05) in the bystander-CPR group (32%) than in the delayed-CPR group (22%). Multivariate analysis revealed that the superior survival in the bystander-CPR group was due almost entirely to the much earlier initiation of CPR (1.9 minutes for the Bystander-CPR group and 5.7 minutes for the delayed-CPR group; P less than 0.001). There were significantly more people with ventricular fibrillation (VF) in the bystander-CPR group (80%) than in the delayed-CPR group (68%); and, for people in VF, the survival rate was significantly better if they had received bystander-CPR (37% versus 29%). The authors conclude that early initiation of CPR by bystanders significantly improves survival from out-of-hospital cardiac arrest, and they suggest that it may do so by prolonging the duration of VF after collapse and by increasing cardiac susceptibility to defibrillation. The benefit of this early CPR, however, appears to exist within a rather narrow window of effectiveness. It must be started within 4-6 minutes from the time of collapse and must be followed within 10-12 minutes of the collapse by advanced life support in order to be effective.     

Termination of Resuscitative Efforts for Out-of-hospital Cardiac Arrests

OBJECTIVE: To determine the rate of termination of resuscitative efforts for out-of-hospital cardiac arrest patients and whether variability exists among different base hospitals providing online medical control (OLMC). METHODS: This was an observational one-year study that included all adult patients in the city of Los Angeles with nontraumatic, out-of-hospital cardiac arrests with attempted resuscitative efforts by paramedics. OLMC was provided by 13 base hospitals. The main outcome measure was the incidence of termination of resuscitative efforts on scene as directed by OLMC. RESULTS: Of 1,700 patients, 151 (9%) had resuscitative efforts terminated on scene via direction by OLMC. Patients pronounced on scene were statistically more likely to be older, be found in an extended care facility, have an unwitnessed arrest, and present in asystole. Two base hospitals were more likely to terminate resuscitative efforts via OLMC than all others. Incidence at base hospital A was 37% (odds ratio, 18.6; 95% confidence interval = 11.7 to 30.0; p < 0.0001); incidence at base hospital B was 14% (odds ratio, 3.3; 95% confidence interval = 1.9 to 5.5; p < 0.0001), and incidence at all other base hospitals was 5%. Cardiac arrest patients handled by base hospital A were more likely to be found in ventricular fibrillation; those patients handled by base hospital B had shorter emergency medical services response times and were more likely to be found in an extended care facility. All other characteristics of cardiac arrest patients were not significantly different among the base hospitals. CONCLUSIONS: There is significant variability in Los Angeles, depending on the particular base hospital that provides OLMC, in pronouncement of death and termination of resuscitative efforts for medical cardiac arrest in the field. Given potential ethical, logistical, and economic concerns, efforts to assure consistency in the practice of discontinuing resuscitative efforts in the field is warranted.     

Improved Survival from Cardiac Arrest in the Community

We now know that the elements required to achieve the highest survival rates from out-of-hospital cardiac arrest include: witnessed arrest, rapid telephone notification of the emergency medical service, early initiation of cardiopulmonary resuscitation, rapid arrival within minutes of emergency personnel equipped with a defibrillator, and early advanced airway management and intravenous pharmacology. In the United States, and in several other countries innovative approaches have been tried to bring all these elements together in one system. These approaches include community-wide CPR training programs, telephone-assisted CPR instruction delivered at the time of a cardiac arrest, early defibrillation performed by family members of high risk patients, early defibrillation performed by minimally trained community responders, and early defibrillation performed by minimally trained ambulance personnel. Controlled, prospective studies have demonstrated the effectiveness and practicality of all of these approaches. New studies are in progress with the prehospital use of early transcutaneous cardiac pacing and these show promise. This article reviews the evidence that supports these multi-layered and innovative approaches to the treatment of out-of-hospital cardiac arrest.     

Spontaneous defibrillation after cessation of resuscitation in out-of-hospital cardiac arrest: a case of Lazarus phenomenon

This report describes a case of out-of-hospital cardiac arrest with spontaneous defibrillation and subsequent return of circulation after cessation of resuscitative efforts. A 47-year-old man was found in cardiac arrest and resuscitation was initiated. As no response was achieved, the efforts were withdrawn and final registered cardiac rhythm was ventricular fibrillation. Fifteen minutes later the patient was found to be normotensive and breathing spontaneously. The patient made a poor neurological recovery and died 3 months after the arrest. The authors are unable to give an explanation to the event, but suspect the effect of adrenaline combined with mild hypothermia to have contributed to the self-defibrillation of the myocardium.     

Management of cardiac arrest following poisoning

Toxic cardiac arrest is an uncommon manifestation of poisoning. Patients might benefit from resuscitative measures that are over and above those recommended in standard ACLS resuscitation guidelines. Extraordinary resuscitative measures might include the use of toxin‐specific antidotes, prolonged CPR and/or other measures to bypass the poisoned myocardium (such as extra‐corporeal membrane oxygenation). Treating medical staff should seek expert advice from a toxicologist or from their Poisons Information Centre network (Australia 13 11 26; New Zealand 0800 764 766) at the earliest opportunity when managing patients with cardiac arrest or intractable shock from known or suspected poisoning. Ideally, toxicological expertise should be sought before the withdrawal of active treatment in cardiac arrest or shock from known or suspected poisoning.     

Prompt Advanced Life Support Improves Survival from Ventricular Fibrillation

Objective. To determine whether the interval between the arrival of basic life support (BLS) providers and the arrival of advanced life support (ALS) providers is associated with patient outcome after cardiac arrest. Methods. We conducted a retrospective cohort study of all witnessed, out-of-hospital ventricular fibrillation (VF) cardiac arrests between January 1, 1991, and December 31, 2007. Eligible patients (n = 1,781) received full resuscitation efforts from both BLS and ALS providers. Results. The BLS-to-ALS arrival interval was a significant predictor of survival to hospital discharge (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93–0.99); the likelihood of survival decreased by 4% for every minute that ALS arrival was delayed following BLS arrival. Other significant predictors of survival were whether the arrest occurred in public (OR 1.48, 95% CI 1.19–1.85), whether a bystander administered cardiopulmonary resuscitation (CPR) (OR 1.34, 95% CI 1.07–1.68), and the interval between the 9-1-1 call and BLS arrival (OR 0.78, 95% CI 0.73–0.83). Conclusions. We found that a shorter BLS-to-ALS arrival interval increased the likelihood of survival to hospital discharge after a witnessed, out-of-hospital VF cardiac arrest. We conclude that ALS interventions may provide additional benefits over BLS interventions alone when utilized in a well-established, two-tiered emergency medical services (EMS) system already optimized for rapid defibrillation. The highest priorities in any EMS system should still be early CPR and early defibrillation, but timely ALS services can supplement these crucial interventions.     

A MIODARONE AND R URAL E MERGENCY M EDICAL S ERVICES C ARDIAC A RREST P ATIENTS : A C OST A NALYSIS

Objective: Recent American Heart Association guidelines suggest amiodarone as an antiarrhythmic in refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). The authors sought to assess the impact of amiodarone use on outcomes and cost associated with this practice in a rural emergency medical services (EMS) state. Methods: Statewide EMS records were reviewed for the calendar year 1999. Data reviewed included prehospital diagnosis, medications given by prehospital providers to patients with cardiac arrest, and procedures performed, including cardiopulmonary resuscitation (CPR) and defibrillation. Cost-benefit analysis assumed the cost of amiodarone treatment to be $137.65 per patient encounter. Absolute risk reduction (ARR) and number needed to treat (NNT) analysis utilized resuscitation rates published in the ARREST and ALIVE trials. Results: During the study period, EMS providers diagnosed 2,189 patients as having cardiac arrest. Five hundred thirty-five (24.4%) cardiac arrest patients were defibrillated. One hundred sixty patients (7.3%), including 15 who did not receive defibrillation, were given lidocaine during resuscitation efforts. The annual cost increase from current practice for a statewide amiodarone VF/VT protocol was $21,822.40 (10,572.87%). The initial cost to stock EMS vehicles for this protocol would be $50,115.52. The cost-benefit analysis yielded a potential for one additional patient survival to hospital discharge in Maine per 3.125 years of system-wide practice at a cost of $68,840.00. Conclusion: Based on current data, instituting amiodarone treatment for refractory VF and pulseless VT in a rural EMS setting requires the investment of substantial resources, relative to current treatment strategies, for any potential survival benefit.     

Lactic acidosis as a predictor of downtime during cardiopulmonary arrest in dogs

Studies have shown that over 50% of cardiovascular deaths occur before hospitalization. A major factor associated with survival in cases of out-of-hospital cardiac arrest is the time from cardiovascular collapse to the initiation of cardiopulmonary resuscitation (CPR) or "downtime." The purpose of this study was to determine whether blood lactate levels could be used to predict downtime in the canine cardiac arrest model. Femoral arterial and Swan-Ganz catheters were placed in 22 mongrel dogs, and ventricular fibrillation was electrically induced. The dogs remained in ventricular fibrillation without ventilation for 5, 10, 15, 30, or 60 minutes. After the predetermined fibrillation time, a left anterolateral thoracotomy was performed, and open-chest cardiac massage was begun. Arterial and mixed venous lactate levels were determined for every 5 minutes during 30 minutes of cardiopulmonary resuscitation. The correlation coefficient between the mixed venous and arterial lactate levels was 0.96 or greater during all stages of resuscitation. Peak serum lactate level increased linearly in relation to downtime. The increase in lactate level was not evident until after CPR was begun, and it remained at peak levels or decreased insignificantly, despite optimal open-chest CPR. Linear regression analysis revealed that 84% of the variability in serum lactate levels could be explained by downtime differences. In this model, blood lactate level is a reliable and objective measure of downtime and may be a useful indicator of the adequacy of CPR if levels decrease or remain stable. The clinical implications of this study lie with the use of blood lactate levels in the emergency department to guide the aggressiveness of resuscitative efforts.     

A 35-Year-Old Pregnant Woman Presenting with Sudden Cardiac Arrest Secondary to Peripartum Cardiomyopathy

Abstract

We present a case of successful resuscitation from cardiac arrest after 25 minutes of ventricular fibrillation (VF) secondary to peripartum cardiomyopathy. This case highlights a rare disease, but also, more importantly, the successful use of the five links of survival: early access to 9-1-1, early cardiopulmonary resuscitation (CPR), early defibrillation, early advanced life support, and postresuscitative care. We also demonstrate the importance of high-quality resuscitation practices in order to achieve a successful outcome. Manual compressions can be performed at a guidelines-compliant rate. With training, users are able to achieve high compression fractions. Pre/post shock delays can be minimized to further increase compression fraction. Nationally, CPR interruptions are often long. We recommend closer attention to uninterrupted 2-minute cycles of CPR, minimizing delays in CPR through training, and a focus on a closely choreographed approach. User review of transthoracic impedance feedback data should play a vital role in a cardiac arrest quality-improvement program.     

Successful extracorporeal life support in cardiac arrest with recurrent ventricular fibrillation unresponsive to standard cardiopulmonary resuscitation

Extracorporeal life support has been used as an extension of conventional cardiopulmonary resuscitation (CPR). However, the appropriate indications for extracorporeal CPR (ECPR) including the duration of CPR are unknown. We present a case of a male, 37-year-old out-of-hospital cardiac arrest patient who received prolonged CPR followed by ECPR. Despite advanced cardiac life support, he did not regain a sustained spontaneous circulation and had recurrent ventricular fibrillation (VF) during the prolonged CPR. VF was unresponsive to CPR, defibrillation, adrenaline (epinephrine), and antiarrhythmics. The CPR time before ECPR was approximately 2h. During extracorporeal life support, the VF did not recur and percutaneous coronary angioplasty was achieved. Ultimately, the patient was discharged without neurological complications. Although cardiac arrest occurred out-of-hospital and CPR was performed for a long time, a patient might be a candidate for ECPR if perfusing rhythms are restored transiently but not successfully maintained due to recurrent VF. ECPR may be used for VF unresponsive to standard CPR techniques.     

Surrogate Consent by Family Members for Out-of-hospital Cardiac Arrest Research

OBJECTIVES: To evaluate the availability of family members of potential subjects to provide consent for participation in out-of-hospital cardiac arrest (OOHCA) research and to estimate the time required to contact a family member. METHODS: This study was a prospective observational study of adult patients (>18 years old) with nontraumatic OOHCA treated by an urban emergency medical service. Emergency medicine resident physicians responded to each scene and noted the presence of family members. A subsequent convenience sample of family members answered standardized questions about their ability to provide consent for research participation on behalf of the patient. RESULTS: Physicians were present at 100 of the 112 adult medical cardiac arrests during the study period. A family member was present at 57% of the scenes (95% CI = 47% to 67%). Patients with family present were older and were less likely to have bystander cardiopulmonary resuscitation (CPR) or live in a nursing home. The mean time (+/-SE) from emergency dispatch to family contact was 24.40 (+/-2.60) minutes and from physician arrival to family contact was 2.45 (+/-0.87) minutes (n = 20). Eight of 13 family members were willing to enroll the patient into a resuscitation study, but five family members were unable to understand the explanation of informed consent. CONCLUSIONS: Family members were present for an unrepresentative subset of OOHCA cases, and were contacted after the therapeutic window for many interventions. The emotional nature of the emergency situation also limited the reliability of surrogate consent for OOHCA research.     

Double Sequential External Defibrillation and Survival from Out-of-Hospital Cardiac Arrest: A Case Report

Background: Patients who present in ventricular fibrillation are typically treated with cardiopulmonary resuscitation (CPR), epinephrine, antiarrhythmic medications, and defibrillation. Although these therapies have shown to be effective, some patients remain in a shockable rhythm. Double sequential external defibrillation has been described as a viable option for patients in refractory ventricular fibrillation. Objective: To describe the innovative use of two defibrillators used to deliver double sequential external defibrillation by paramedics in a case of refractory ventricular fibrillation resulting in prehospital return of spontaneous circulation and survival to hospital discharge with good neurologic function. Case: A 28-year-old female sustained a witnessed out-of-hospital cardiac arrest (OHCA). Bystander CPR was performed by her husband followed by paramedics providing high-quality CPR, antiarrhythmic medication, and 6 biphasic defibrillations using standard energy levels. Double sequential external defibrillation was applied and a return of spontaneous circulation was attained on scene and maintained through to arrival to the emergency department. Following admission to hospital the patient was diagnosed with long QT syndrome. An implantable cardioverter defibrillator was placed and the patient was discharged with a Cerebral Performance Category of 2 as well as a modified Rankin Scale of 2 after an 18-day hospital stay. The patient's functional status continued to improve post discharge. Conclusion: The addition of double sequential external defibrillation as part of a well-organized resuscitation effort may be a valid treatment option for OHCA patients who present in refractory ventricular fibrillation.     

Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: a prospective observational study

Introduction

Prognosis in patients suffering out-of-hospital cardiac arrest is poor. Higher survival rates have been observed only in patients with ventricular fibrillation who were fortunate enough to have basic and advanced life support initiated soon after cardiac arrest. An ability to predict cardiac arrest outcomes would be useful for resuscitation. Changes in expired end-tidal carbon dioxide levels during cardiopulmonary resuscitation (CPR) may be a useful, noninvasive predictor of successful resuscitation and survival from cardiac arrest, and could help in determining when to cease CPR efforts.

Methods

This is a prospective, observational study of 737 cases of out-of-hospital cardiac arrest. The patients were intubated and measurements of end-tidal carbon dioxide taken. Data according to the Utstein criteria, demographic information, medical data, and partial pressure of end-tidal carbon dioxide (Pet CO ₂) values were collected for each patient in cardiac arrest by the emergency physician. We hypothesized that an end-tidal carbon dioxide level of 1.9 kPa (14.3 mmHg) or more after 20 minutes of standard advanced cardiac life support would predict restoration of spontaneous circulation (ROSC).

Results

Pet CO ₂ after 20 minutes of advanced life support averaged 0.92 ± 0.29 kPa (6.9 ± 2.2 mmHg) in patients who did not have ROSC and 4.36 ± 1.11 kPa (32.8 ± 9.1 mmHg) in those who did (P < 0.001). End-tidal carbon dioxide values of 1.9 kPa (14.3 mmHg) or less discriminated between the 402 patients with ROSC and 335 patients without. When a 20-minute end-tidal carbon dioxide value of 1.9 kPa (14.3 mmHg) or less was used as a screening test to predict ROSC, the sensitivity, specificity, positive predictive value, and negative predictive value were all 100%.

Conclusions

End-tidal carbon dioxide levels of more than 1.9 kPa (14.3 mmHg) after 20 minutes may be used to predict ROSC with accuracy. End-tidal carbon dioxide levels should be monitored during CPR and considered a useful prognostic value for determining the outcome of resuscitative efforts and when to cease CPR in the field.