Termination of Resuscitation for Adult Traumatic Cardiopulmonary Arrest

Abstract

The National Association of EMS Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACS-COT) believe that emergency medical services (EMS) systems should have protocols that allow EMS providers to terminate resuscitative efforts for certain adult patients in traumatic cardiopulmonary arrest. This document is the official position of the NAEMSP and ACS-COT.     

Noninvasive Positive Pressure Ventilation: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

The National Association of EMS Physicians (NAEMSP) believes that noninvasive positive pressure ventilation (NIPPV) is an important treatment modality for the prehospital management of acute dyspnea. This document serves as a resource to the NAEMSP position on prehospital NIPPV.     

Who Gets Bystander Cardiopulmonary Resuscitation in a Witnessed Arrest?

Objective: To identify characteristics associated with provision of bystander CPR in witnessed out-of-hospital cardiac arrest cases.
Methods: An observational, prospective, cohort study was performed using cardiac arrest cases as identified by emergency medical services (EMS) agencies in Oakland County, MI, from July 1, 1989, to December 31, 1993. All patients who sustained a witnessed arrest prior to arrival of EMS personnel were reviewed.
Results: Of the 927 patients meeting entry criteria, the 229 patients receiving bystander CPR were younger: 60.9 ± 14.7 vs 67.9 ± 14.7 years (p < 0.01). Most (76.6%) cardiac arrests occurred in the home. In a multivariate logistic model, only the location of arrest outside the home was a significant predictor of receiving bystander CPR [odds ratio (OR) 3.8; 99% CI 2.5, 5.9]. Arrests outside the home were associated with significantly improved outcome, with 18.2% of out-of-home and 8.2% of in-home victims discharged from the hospital alive (OR 2.5; 99% CI 1.4, 4.4).
Conclusion: Patients who have had witnessed cardiac arrests outside the home are nearly 4 times more likely to receive bystander CPR, and are twice as likely to survive. This observation emphasizes the need for CPR training of family members in the authors' locale. This phenomenon may also represent a significant con-founder in studies of out-of-hospital cardiac arrest and resuscitation.     

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.     

Ambulance Diversion and Emergency Department Offload Delay: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

The emergency medical services (EMS) system is a component of a larger health care safety net and a key component of an integrated emergency health care system. EMS systems, and their patients, are significantly impacted by emergency department (ED) crowding. While protocols designed to limit ambulance diversion may be effective at limiting time on divert status, without correcting overall hospital throughput these protocols may have a negative effect on ED crowding and the EMS system. Ambulance offload delay, the time it takes to transfer a patient to an ED stretcher and for the ED staff to assume the responsibility of the care of the patient, may have more impact on ambulance turnaround time than ambulance diversion. EMS administrators and medical directors should work with hospital administrators, ED staff, and ED administrators to improve the overall efficiency of the system, focusing on the time it takes to get ambulances back into service, and therefore must monitor and address both ambulance diversions and ambulance offload delay. This paper is the resource document for the National Association of EMS Physicians position statement on ambulance diversion and ED offload time.     

Withholding of Resuscitation for Adult Traumatic Cardiopulmonary Arrest

ABSTRACT

The National Association of EMS Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACS-COT) believe that it is appropriate to withhold resuscitation for certain trauma patients for whom death is the predictable outcome. This paper is the official statement on the withholding of resuscitation that has jointly been passed by the NAEMSP and ACS-COT.     

Mass Gathering Medical Care: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

Mass gatherings are heterogeneous in terms of size, duration, type of event, crowd behavior, demographics of the participants and spectators, use of recreational substances, weather, and environment. The goals of health and medical services should be the provision of care for participants and spectators consistent with local standards of care, protection of continuing medical service to the populations surrounding the event venue, and preparation for surge to respond to extraordinary events. Pre–event planning among jurisdictional public health and EMS, acute care hospitals, and event EMS is essential, but should also include, at a minimum, event security services, public relations, facility maintenance, communications technicians, and the event planners and organizers. Previous documented experience with similar events has been shown to most accurately predict future needs. Future work in and guidance for mass gathering medical care should include the consistent use and further development of universally accepted consistent metrics, such as Patient Presentation Rate and Transfer to Hospital Rate. Only by standardizing data collection can evaluations be performed that link interventions with outcomes to enhance evidence-based EMS services at mass gatherings. Research is needed to evaluate the skills and interventions required by EMS providers to achieve desired outcomes. The event-dedicated EMS Medical Director is integral to acceptable quality medical care provided at mass gatherings; hence, he/she must be included in all aspects of mass gathering medical care planning, preparations, response, and recovery. Incorporation of jurisdictional EMS and community hospital medical leadership, and emergency practitioners into these processes will ensure that on-site care, transport, and transition to acute care at appropriate receiving facilities is consistent with, and fully integrated into the community's medical care system, while fulfilling the needs of event participants.     

EMS Provider Perceptions on Termination of Resuscitation in a Large,Urban EMS System

Objective: Despite the value of out-of-hospital Termination of Resuscitation (TOR) and the scientific evidence in favor of this practice, TOR has not been uniformly adopted or consistently practiced in EMS systems. Previous focus group studies have identified multiple barriers to implementation of out of hospital TOR but existing literature on EMS provider perceptions is limited. We sought to identify EMS providers' perceived barriers to performing out-of-hospital TOR in a large urban EMS system. Methods: The Chicago EMS System is a regional collaborative of EMS physicians, nurses and provider agencies, including the Chicago Fire Department (CFD), which provides exclusive emergency response for 9-1-1 calls in Chicago. CFD is an urban, fire-based EMS agency with a tiered response, with fire-fighter EMTs and paramedics providing initial care, and single role paramedics providing supplemental care and transport. A 2-page written survey was distributed to understand providers' experiences with managing OHCA and perceived barriers to TOR to inform subsequent improvements in protocol development and education. Results: Of 3500 EMS providers that received the survey, 2309 were completed (66%). Survey respondent demographics were fire-fighter/EMTB (69%), fire-fighter/paramedic (14%), and single role paramedic (17%). The most frequent barrier to field TOR was scene safety (86%). The most common safety issue identified was family reaction to TOR (68%) and many providers felt threatened by family when trying to perform

TOR (38%). Providers with a higher career numbers of OHCA were more likely to have felt threatened by the family (OR 6.70, 95% CI 2.99–15.00) and single role paramedics were more likely than FF/EMTBs to have felt threatened (OR 3.34, 95% CI 2.65–4.22). Barriers to delivering a death notification after TOR, include being uncomfortable or threatened with possible family reaction (52%) and family asking to continue the resuscitation (45%). There was lack of formal prior death notification training, the majority learned from colleagues through on the job training. Conclusions: Our study identifies scene safety, death notification delivery, and lack of formal training in death notification as barriers that EMS providers face while performing TOR in a large urban EMS system. These findings informed educational and operational initiatives to overcome the identified provider level issues and improve compliance with TOR policies.     

126例心跳骤停心肺复苏临床分析

目的：探讨急诊抢救心跳骤停的程序及方法，以便提高心肺复苏成功率。方法：回顾性分析126例在急诊抢救心跳骤停患者的临床资料，分析抢救程序及方法对心肺复苏的影响。结果：126例患者中31例复苏成功，63例复苏有效，32例复苏无效。结论：心肺复苏抢救成功与开始抢救时间、胸外按压方法、抢救药物及仪器的合理应用有密切关系。     

Emergency Incident Rehabilitation: Resource Document to the Position Statement of the National Association of EMS Physicians

Position Statement: Emergency Incident Rehabilitation

The National Association of EMS Physicians® believes that:

• Emergency operations and training conducted while wearing protective clothing and respirators is physiologically and cognitively demanding.

• The heat stress and fatigue created by working in protective clothing and respirators creates additional risk of illness/injury for the public safety provider.

• Emergency incident rehabilitation provides a structured rest period for rehydration and correction of abnormal body core temperature following work in protective clothing and respirators.

• Emergency incident rehab should be conducted at incidents (e.g. fireground, hazardous materials, and heavy rescue emergencies) and trainings involving activities that may lead to exceeding safe levels of physical and mental exertion.

• Emergency incident rehabilitation is incident care, not fitness for duty, and meant to reduce physiologic strain and prepare the responder to return to duty at the current incident and for the remainder of the shift.

• EMS should play a role in emergency incident rehabilitation with providers trained to understand the physiologic response of healthy individuals to environmental, exertional, and cognitive stress and implement appropriate mitigation strategies.

• An appropriately qualified physician should have oversight over the creation and implementation of emergency incident rehabilitation protocols and may be separate from the roles and responsibilities of the occupational medicine physician.

• There are no peer-reviewed data related to cold weather rehabilitation. Future studies should address this limitation to the literature.

     

Impact of the 2005 American Heart Association Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Guidelines on Out-of-Hospital Cardiac Arrest Survival

Objective. To describe changes in out-of-hospital cardiac arrest (OOHCA) survival before and after the release of the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC). Methods. Data were extracted from an OOHCA registry for 1,681 adult cases of cardiac arrest treated by one emergency medical services (EMS) system between April 1, 2004, and December 31, 2007, in a large city (2005 population 730,657). The primary endpoint was survival to hospital discharge. A convenience sample of 69 electronic electrocardiogram (ECG) recordings was reviewed to assess CPR quality parameters using impedance waveform analysis during corresponding time periods. Intervention. Implementation of the 2005 AHA guidelines for CPR and ECC in spring 2006. Results. The annual treated OOHCA incidence rate was 68/100,000; and the treated ventricular fibrillation (VF) incidence rate was 15/100,000. Bystanders performed CPR in 28% of cases. Public automated external defibrillator (AED) use was < 2% over the entire study, and few patients received hypothermia therapy. Unadjusted OOHCA survival rates were significantly higher in the postguidelines period at 9.4% (n = 1,021) than in the preguidelines period at 6.1% (n = 660), despite similarities in all major predictors of outcome (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.1 to 2.4). Bystander-witnessed OOHCA survival for victims in VF on EMS arrival was 19 of 78 (24%) in the preguidelines period versus 34 of 112 (30%) in the postguidelines period (OR 1.4; 95% CI 0.7 to 2.6). CPR quality measures showed significant improvement in the postguidelines period. The mean no-flow fraction in the preguidelines group was 0.46 and dropped to 0.34 in the postguidelines group, a difference of 0.12 (95% CI 0.05 to 0.19). Multivariate regression analysis adjusting for significant predictors of survival showed that OOHCA in the postguidelines period was associated with 1.8 greater odds of survival than in the preguidelines period (95% CI 1.2 to 2.7). Conclusion. In this large city, substantial improvement occurred in overall OOHCA survival rates following the implementation of the 2005 AHA guidelines for CPR and ECC. These changes were associated with improvements in the quality of CPR.     

The Use of Epinephrine for Out-of-Hospital Treatment of Anaphylaxis: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

Anaphylaxis is a potentially life-threatening condition that requires both prompt recognition and treatment with epinephrine. All levels of emergency medical services (EMS) providers, with appropriate physician oversight, should be able to carry and properly administer epinephrine safely when caring for patients with anaphylaxis. EMS systems and EMS medical directors should develop a mechanism to review the charts of patients who received epinephrine and were not in cardiac arrest. This will help to ensure the safe and appropriate use of epinephrine in order to provide continued quality improvement. Despite the safety of epinephrine, EMS systems that carry epinephrine autoinjectors should establish protocols to deal with patients or emergency responders who have an unintentional injection of epinephrine into the hand or digit. Continued research is needed to better define the role that EMS plays in the management of anaphylaxis. This paper serves as a resource document to the National Association of EMS Physician position on the use of epinephrine for the out-of-hospital treatment of anaphylaxis.     

Potential Impact of a Targeted Cardiopulmonary Resuscitation Program for Older Adults on Survival from Private-residence Cardiac Arrest

OBJECTIVE: Traditional cardiopulmonary resuscitation (CPR) training programs do not target older adults who are most likely to witness private-residence cardiac arrests and do not reliably result in a bystander who is likely to perform CPR in the event of an arrest. This study was performed to compare targeted CPR training programs for older adults (older than 50 years) that 1) increase numbers of CPR-trained bystanders of private-residence cardiac arrest or 2) increase the percentage of trained bystanders of private-residence cardiac arrest who perform CPR. A simultaneous outcome was to estimate the minimal significant survival benefit associated with each of the training programs. METHODS: A probabilistic simulation model was developed in Fortran95 that incorporated key out-of-hospital cardiac arrest elements, including witnessed arrests, CPR-trained witness, CPR provision, and impact of CPR on ventricular fibrillation. Input data were derived from published or publicly available data, including a large prospective cohort study of outcomes in Oakland County, MI. Monte Carlo simulation (n = 10,000) and sensitivity analyses (n = 40) were used to assess median and the empiric 95% confidence intervals [CIs] for incremental survival with either intervention. RESULTS: The baseline model, calibrated to the characteristics of the input-data community, established that, for private-residence cardiac arrests, 40.8% of cardiac arrest bystanders were trained in CPR; however, only 25.7% performed CPR. This yielded 4.81% survival (95% CI = 4.72 to 4.89). Modeling the impact on the baseline training level with increased CPR performance among trainees indicated that 75% of private-residence trained bystanders would need to perform CPR in order to reach a minimally significant improvement in survival (5.02%; 95% CI = 4.94 to 5.15). Similarly, targeted CPR training that would result in a significant survival benefit (to 5.01%; 95% CI = 4.93 to 5.09) would require that 70.8% of bystanders be trained. CONCLUSIONS: CPR training programs that focus on yielding 75% of trainees who perform CPR in the event of witnessing an arrest would have equivalent results to mass CPR training programs that result in 70% of bystanders being trained in CPR. However, the minimal survival benefit associated with these programs (around 0.2%) may prove either method costly with minimal effect.     

心跳呼吸骤停与复苏效果

复习1987年以来国内期刊发表的有关复苏的文献,就资料完整的1521例及我院复苏成功的6例进行分析并指出:心肺复苏既要突破4 min急救极限,又要树立骤停时间20 min仍有可能复苏的信念,但骤停时间小于4 min仍是长期存活不留后遗症的主要因素,而有效的心肺复苏则是提高复苏成功率的关键。开胸心脏按压的血流机制明显优于胸外心脏按压。大剂量肾上腺素有利于自主循环的恢复。而复苏后,积极维持有效循环的稳定有利于提高复苏成功率。     

Termination of Resuscitation Rules to Predict Neurological Outcomes in Out-of-Hospital Cardiac Arrest for an Intermediate Life Support Prehospital System

Aim: Futile resuscitation can lead to unnecessary transports for out-of-hospital cardiac arrest (OHCA). The Basic Life Support (BLS) and Advanced Life Support (ALS) termination of resuscitation (TOR) guidelines have been validated with good results in North America. This study aims to evaluate the performance of these two rules in predicting neurological outcomes of OHCA patients in Singapore, which has an intermediate life support Emergency Medical Services (EMS) system. Methods: A retrospective cohort study was carried out on Singapore OHCA data collected from April 2010 to May 2012 for the Pan-Asian Resuscitation Outcomes Study (PAROS). The outcomes of each rule were compared to the actual neurological outcomes of the patients. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and predicted transport rates of each test were evaluated. Results: A total of 2,193 patients had cardiac arrest of presumed cardiac etiology. TOR was recommended for 1,411 patients with the BLS-TOR rule, with a specificity of 100% (91.9, 100.0) for predicting poor neurological outcomes, PPV 100% (99.7, 100.0), sensitivity 65.7% (63.6, 67.7), NPV 5.6% (4.1, 7.5), and transportation rate 35.6%. Using the ALS-TOR rule, TOR was recommended for 587 patients, specificity 100% (91.9, 100.0) for predicting poor neurological outcomes, PPV 100% (99.4, 100.0), sensitivity 27.3% (25.4, 29.3), NPV 2.7% (2.0, 3.7), and transportation rate 73.2%. BLS-TOR predicted survival (any neurological outcome) with specificity 93.4% (95% CI 85.3, 97.8) versus ALS-TOR 98.7% (95% CI 92.9, 99.8). Conclusion: Both the BLS and ALS-TOR rules had high specificities and PPV values in predicting neurological outcomes, the BLS-TOR rule had a lower predicted transport rate while the ALS-TOR rule was more accurate in predicting futility of resuscitation. Further research into unique local cultural issues would be useful to evaluate the feasibility of any system-wide implementation of TOR.     

Ethical Issues of Cardiopulmonary Resuscitation: Current Practice among Emergency Physicians

Objective : To determine current practice and attitudes among emergency physicians (EPs) regarding the initiation and termination of CPR.
Methods : An anonymous survey was mailed to randomly selected EPs. Main outcome measures included respondents' answers to questions regarding outcome of resuscitation, and current practice regarding initiation, continuation, and termination of resuscitation for victims of cardiopulmonary arrest.
Results : The 1,252 respondents were from all 50 states, a variety of practice settings, and varying board certification. Most (78%) respondents honor legal advance directives regarding resuscitation. Few (7%) follow unofficial documents, or verbal reports of advance directives (6%). Many (62%) make decisions regarding resuscitation because of fear of litigation or criticism. A majority (55%) have recently attempted numerous resuscitations despite expectations that such efforts would be futile. Most respondents indicated that ideally, legal concerns should not influence physician practice regarding resuscitation (78%), but that in the current environment, legal concerns do influence practice (94%).
Conclusions : Most EPs attempt to resuscitate patients in cardiopulmonary arrest, regardless of futility, except in cases where a legal advance directive is available. Many EPs' decisions regarding resuscitation are based on concerns of litigation and criticism, rather than their professional judgment of medical benefit or futility. Compliance with patients' wishes regarding resuscitation is low unless a legal advance directive is present. Possible solutions to these problems may include standardized guidelines for the initiation and termination of CPR, tort reform, and additional public education regarding resuscitation and advance directives.     

Expert Witness Qualifications and Ethical Guidelines for Emergency Medical Services Litigation: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

The clinical provision of medical care by emergency medical services (EMS) providers in the out-of-hospital environment and the operation of EMS systems to provide that care are unique in the medical arena. There is a substantive difference in the experience of individuals who provide medical care in the out-of-hospital setting and the experience of those who provide similar care in the hospital or other clinical settings. Furthermore, physicians who provide medical direction for EMS personnel have a clinical and oversight relationship with EMS personnel. This relationship uniquely qualifies EMS medical directors to provide expert opinions related to care provided by nonphysician EMS personnel. Physicians without specific EMS oversight experience are not uniformly qualified to provide expert opinion regarding the provision of EMS. This resource document reviews the current issues in expert witness testimony in cases involving EMS as these issues relate to the unique qualifications of the expert witness, the standard of care, and the ethical expectations.     

Extracorporeal Resuscitation of Cardiac Arrest

OBJECTIVE: Extracorporeal support of heart and lung function (venoarterial perfusion) during cardiac arrest (ECPR) has been advocated as a means of improving survival following cardiac arrest. The authors retrospectively reviewed their institution's seven-year experience with this intervention. METHODS: Emergency department patients and inpatients in cardiac arrest or immediately postarrest were considered candidates. ECPR was instituted using venoarterial bypass and was continued until patients regained sufficient cardiopulmonary function to allow weaning from the device or until their condition was deemed irrecoverable. RESULTS: ECPR was attempted in 25 patients and successfully instituted in 21. Four patients (16%) were converted from ECPR to ventricular assist devices, two of whom survived and await transplantation. Seven additional patients were discharged from the hospital, resulting in an overall survival of 36%. Because none of the children treated survived, there was a trend toward higher age among survivors (survivors 40 +/- 14 yr, nonsurvivors 33 +/- 15 yr, p = 0.29). The duration of conventional CPR was shorter among survivors (survivors 21 +/- 16 min, nonsurvivors 43 +/- 32 min, p = 0.04), as was the duration of extracorporeal support (survivors 44 +/- 21 hr, nonsurvivors 87 +/- 96 hr, p = 0.18). Survival was seen only in patients whose conditions were amenable to a definitive therapeutic intervention, particularly cardiac arrest due to respiratory or pulmonary embolic disease. While four of the five patients treated in the ED were successfully supported, none survived to discharge. CONCLUSION: In select patients with reversible disease, extracorporeal CPR can be used to successfully treat cardiac arrest. Further investigation into its most appropriate application is warranted.