Notes – Termination of Resuscitative Efforts

Termination of Resuscitative Efforts

Patient Safety Considerations

  1. All patients found in ventricular fibrillation or whose rhythm changes to ventricular fibrillation should in general have full resuscitation continued on scene.

Notes/Educational Pearls

Key Considerations and Pertinent Assessment Findings

  1. Recent evidence has shown that, in order to capture over 99% of potential survivors from 
medical cardiac arrest (especially VF and pulseless VT arrests), resuscitation should be continued for approximately 40 minutes. This does not imply, however, that all resuscitations should continue this long (e.g. asystolic rhythms)
  2. In remote or wilderness situations, EMS providers should make every effort to contact direct medical oversight, but resuscitation may be terminated in the field without direct medical oversight when the following have occurred:
    1. There has been no return of pulse despite greater than 30 minutes of CPR (this does not apply in the case of hypothermia)
    2. Transport to an emergency department will take greater than 30 minutes (this does not apply in the case of hypothermia)
    3. EMS providers are exhausted and it is physically impossible to continue the resuscitation
  3. Logistical factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public
  4. Survival and functional neurologic outcomes are unlikely if ROSC is not obtained by EMS. It is dangerous to crew, pedestrians, and other motorists to attempt to resuscitate a patient during ambulance transport
  5. Quantitative end-tidal carbon dioxide measurements of less than 10 mmHg or falling greater than 25% despite resuscitation indicates a poor prognosis and provide additional support for termination

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914201 – Cardiac Arrest-Determination of Death/Withholding Resuscitative Efforts
  • 9914169 – Cardiac Arrest-Do Not Resuscitate
  • 9914171 – Cardiac Arrest-Special Resuscitation Orders
  • 9914055 – General-Cardiac Arrest
  • 9914087 – Injury-Cardiac Arrest

Key Documentation Elements

  • All items (a-f in Non-traumatic or Traumatic arrest) listed under patient management must be clearly documented in the EMS patient care report in addition to the assessment findings supporting this medical decision making
  • If resuscitation is continued for special circumstance or despite satisfying the criteria in this guideline, the rationale for such decision making must be documented

Performance Measures

  • Time to CPR
  • Time to AED application if applicable
  • Review of CPR quality
  • Duration of resuscitative efforts
  • Review of biometric data/CPR quality if available
  • Appropriateness of termination
  • Review of every patient transport from scene with patient in arrest

References

  1. American College of Emergency Physicians. Discontinuing resuscitation in the out-of-hospital setting. Ann Emerg Med. 2008;52(5):592.
  2. Fallat ME, American College of Surgeons Committee on Trauma, American College of Emergency Physicians, National Association of EMS Physicians, American Academy of Pediatrics. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics, 2014 Apr; 133(4):e1104-16.
  3. Cha WC, Lee EJ, Hwang SS. The duration of cardiopulmonary resuscitation in emergency departments after out-of-hospital cardiac arrest is associated with the outcome: A nationwide observational study. Resuscitation. 2015;96:323-7.
  4. Eckstein M, Hatch L, Malleck J, McClung C, Henderson SO. End-tidal CO2 as a predictor of survival in out-of-hospital cardiac arrest. Prehosp Disaster Med. 2011;26(3):148-50.
  5. Goldberger ZD, Chan PS, Berg RA, et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet. 2012;380(9852):1473-81.
  6. Goto Y, Funada A, Goto Y. Duration of prehospital cardiopulmonary resuscitation and favorable neurological outcomes for pediatric out-of-hospital cardiac arrests: a nationwide, population-based cohort study. Circulation. 2016;(1):1-10.
  7. Hung SC, Mou CY, Hung HC, Lin IH, Lai SW, Huang JY. Chest compression fraction in ambulance while transporting patients with out-of-hospital cardiac arrest to the hospital in rural Taiwan. Emerg Med J. 2016;0:1-4.
  8. Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest. JAMA. 2014;311(1):45-52.
  9. Matsuyama T, Kitamura T, Kiyohara K, et al. Impact of cardiopulmonary resuscitation duration on neurologically favourable outcome after out-of-hospital cardiac arrest: a
    population-based study in japan. Resuscitation. 2017;113:1-7.
  10. Millin MG, Khandker SR, Malki A. Termination of resuscitation of nontraumatic cardiopulmonary arrest: resource document for the National Association of EMS Physicians position statement. Prehosp Emerg Care. 2011;15(4):547-54.
  11. Morrison LJ, Verbeek PR, Zhan C, Kiss A, Allan KS. Validation of a universal prehospital termination of resuscitation clinical prediction rule for advanced and basic life support providers. Resuscitation. 2009;80(3):324-8.
  12. Ponce A, Swor R, Quest TE, Macy M, Meurer W, Sasson C. Death notification training for prehospital providers: a pilot study. Prehosp Emerg Care. 2010;14(4):537-42.
  13. Reynolds JC, Grunau BE, Rittenberger JC, Sawyer KN, Kurz MC, Callaway CW. The association between duration of resuscitation and favorable outcome after out-of-hospital cardiac arrest: implications for prolonging or terminating resuscitation. Circulation. 2016;134(25):2084-94.