Population‐based Time Determinant for Termination of Resuscitation: Reply

Abstract

I am grateful to Drs. Michael G. Millin and Samuel M. Galvagno for their interest in the article titled ‘‘Outcomes from prehospital cardiac arrest in blunt trauma patients’’ [1]. In their letter they raise a worthwhile question regarding the time interval for the decision of termination of resuscitating efforts (TOR) for out-of-hospital cardiopulmonary arrest (CPA) in blunt trauma patients. The outlier patient Drs. Millin and Galvagno refer to was a 74 year-old man who was unconscious and unresponsive after falling down steps in his house. His wife called an ambulance, and 7 min after the emergency call our emergency lifesaving technicians (ELST; paramedics) confirmed his CPA with some bleeding from the head and chest. Seventeen minutes after the call, he was transferred to our critical care and emergency center. He was treated in our emergency department (ED) with tracheal intubation, mechanical ventilation, ED thoracotomy, direct cardiac massage, rapid and massive infusion via a sheath introducer from the subclavian vein and 2 mg of adrenaline, resulting in the return of spontaneous circulation (ROSC) 17 min after arrival. A stable circulatory condition was achieved without catecholamines. We evaluated the cause of his cardiac arrest, determined that it was pneumohemothorax, and proceeded to the operating room where we sutured his injured lung and performed thoracic lavage and drainage. Computed tomography (CT) of the head revealed no fresh hemorrhagic brain lesion, and the patient was transferred to another hospital in a vegetative state. Of course I agree with Drs. Millin and Galvagno’s opinion that 10 min of resuscitation will capture the population of patients with CPA from blunt trauma. However, this patient (case 5) suffered a CPA without witness and without bystander CPR under normal temperature and normal circumstances. He presented no distinct evidence of a fainting attack before the event. He had a CPA without any special condition which could increase a possibility of recovery, and I therefor continued my attempt to resuscitate him because there was still a slight possibility that he would regain consciousness. I feel it is worth attempting to treat patients like this man, and to devise better strategies for performing cerebro-cardiopulmonary resuscitation in the future [2]. Although I agree that, from the viewpoint of medical optimization, there is little benefit in continuing resuscitation beyond 10 min, I think another 7 min resuscitation effort after the 10 min resuscitation does not increase the risk to rescuers such as infection, although there is some increase in the cost and physical effort. As shown in Figure 8 of the original article, most of the clusters of patients who were admitted to the ICU or who underwent surgery achieved ROSC in under 20 min. I think that there is still a slight possibility of saving these patient clusters if we can apply new management strategies for post-cardiac arrest syndrome in the future. Different strategies for resuscitation may be applied in different countries, and emergency medical service systems and customs regarding lifesaving efforts also differ [3]. Both medical optimization and lifesaving measures should be taken into account, even for trauma patients.