Duration Of Resuscitation Efforts Research Articles

In-hospital cardiac arrest in middle-income settings: A comprehensive analysis of clinical profiles and outcomes of both adults and pediatrics

BackgroundIn hospital cardiac arrest is associated with poor survival despite basic and advanced life support measures. This study aimed to identify the clinical characteristics and outcomes of cardiac arrests occurring during in-hospital admission to the tertiary care center in Pakistan. MethodA retrospective, cross-sectional study at Aga Khan University Hospital from 2021 to 2023 analyzed 230 cardiac arrest cases. Data included demographics, arrest type, timing, initial rhythm, resuscitation duration, and arrest location. American Heart Association guidelines were adhered to for life support. The main outcomes focused on the return of spontaneous circulation survival to hospital discharge. ResultsDuring the study, 230 cardiac arrests were observed: 152 in adults (mean age 57.8, 142 shockable cases, ROSC 52.6 %, alive at discharge 28.3 %) and 78 in pediatric patients (mean age 4.99, non-shockable rhythm 85.9 %, ROSC 51.3 %, alive at discharge 17.9 %). Adult Charles comorbidity index: 2.88 (SD±2.08), pediatric index: 0.610 (SD±0.88). Survival rates were lower with a high comorbidity index and code duration > 20 min. ConclusionThe study provides valuable observational data that challenges global survival rates for in-hospital cardiac arrest. It highlights how factors like being in monitored units and the presence of rapid response teams can lead to higher survival rates. The research underscores the influence of comorbidities, initial rhythms, and the duration of resuscitation efforts on patient outcomes, emphasizing the need for more research, especially in settings with limited resources.

Association of Frailty and Cardiopulmonary Resuscitation Outcomes in Older U.S. Veterans.

Objectives: Determine the association between frailty and immediate survival of cardiopulmonary resuscitation (CPR) in older Veterans. Secondary outcomes: compare in-hospital mortality, duration of resuscitation efforts, hospital and intensive care unit (ICU) length of stay, neurologic outcomes, and discharge disposition between frail and non-frail Veterans. Methods: Retrospective cohort study including Veterans 50years and older, who were "Full Code" and had in-hospital cardiac arrest between 7/1/2017 and 6/30/2020, at the Miami VAMC. Frailty Index for the VA (VA-FI) was used to determine frailty status. Immediate Survival was determined by return of spontaneous circulation (ROSC) and in-hospital mortality was determined by all-cause mortality. We compared outcomes between frail and non-frail Veterans using chi-square test. After adjusting for age, gender, race, and previous hospitalizations, we used multivariate binomial logistic regression with 95% confidence intervals to analyze the relationship between immediate survival and frailty, and in-hospital mortality and frailty. Results: 91% Veterans were non-Hispanic, 49% Caucasian, 96% male, mean age 70.7 ± 8.5years, 73% frail and 27% non-frail. Seventy-six (65.5%) Veterans had ROSC, without difference by frailty status (P = .891). There was no difference based on frailty status of in-hospital mortality, discharge disposition, or neurologic outcomes. Frail and non-frail Veterans had resuscitation efforts lasting the same amount of time. Conclusions and Implications: CPR outcomes were not different depending on frailty status in our Veteran population. With these results, we cannot use frailty - as measured by the VA-FI - as a prognosticator of CPR outcomes in Veterans.

Abstract 13412: Gender Based Differences in Duration of Cardiopulmonary Resuscitation in the Inpatient Setting

Introduction: The decision to terminate cardiopulmonary resuscitation (CPR) prior to return of spontaneous circulation (ROSC) may be impacted by resuscitation parameters or by patient demographics. Studies show that longer resuscitation efforts have a higher likelihood of ROSC and survival to discharge. It is unclear if gender of the code leader and the patient may be associated with duration of unsuccessful CPR attempt. Methods: Retrospective chart review of inpatient CA that occurred at the UC San Diego Health System between 2011-2019. All adult inpatients with an index cardiac arrest who expired within three days of admission were included. Exclusion criteria included patients who achieved ROSC, CA that occurred outside of the wards or ICU, those with active pre-arrest DNR status, and patients with CA > 3 days after admission (done to minimize provider bias based on prior knowledge of the patient). Data were identified from an internal cardiac arrest quality improvement database. Patient gender was self-reported and code leader gender was identified. Primary outcome was duration of resuscitation efforts. To determine differences in duration of CPR between code leader and patient gender a one-sided ANOVA test was used. A p value < 0.05 was considered statistically significant. Results: We identified 91 patients between 2011 and 2019 that met inclusion criteria. Thirty-eight patients (41.8%) identified as female, fifty-three identified as male (58.2%), the average age was 62.7 years old, and seventeen (18.7%) had initial shockable rhythm. Thirty (33%) of the code leaders identified as female and sixty-one (67%) identified as male. Average duration of CPR was 31.6 minutes (2 - 135 minutes) for male patients with male code leader, 32.2 minutes (9 - 71 minutes) for male patients with female code leader, 27.0 minutes (7 - 60 minutes) for female patients with female code leader, and 33.7 minutes (10 - 73 minutes) for female patients with male code leader. No significant difference in duration of unsuccessful CPR attempt associated with gender of code leader and gender of patient in ANOVA analysis was found (p = 0.512). Conclusions: We did not identify a significant association between code leader and patient gender on duration of CPR in the inpatient setting.

Duration of resuscitation efforts and long-term prognosis following in-hospital cardiac arrest (IHCA)

Abstract Background The decision to terminate resuscitation efforts can be challenging. Notably, the association between duration of resuscitation and long-term survival and functional outcomes after in-hospital cardiac arrest (IHCA) is unknown. Purpose To examine 30-day and 1-year survival stratified by duration of resuscitation efforts. Further, to report long term outcome (1-year survival) without anoxic brain damage or nursing home admission among 30-day IHCA survivors. Methods We included all patients with IHCA from 13 Danish hospitals between January 1st, 2013 to December 31st, 2015. Patients were only included if there was clinical indication for a resuscitation attempt. Data on IHCA was obtained from the DANARREST database, which was linked to national registries to retrieve information on patient characteristics, survival, anoxic brain damage and nursing home admission. Patients were stratified into four groups (A-D) according to quartiles of duration of resuscitation efforts: Group A (<5 minutes), group B (5–11 minutes), group C (12–20 minutes) and group D (≥21 minutes). Using multivariable regression analysis, outcomes were standardized for patient age, sex, Charlson Comorbidity Index, witnessed arrest, monitored arrest, cardiopulmonary resuscitation (CPR) prior to arrival of the in-hospital cardiac arrest team and defibrillation. Results The study population comprised of 1868 patients, median age was 74 (1st-3rd quartile [Q1-Q3] 65–81 years) and 65.0% were men. In total, 52.1% (n=973) of the patients achieved return of spontaneous circulation (ROSC). The overall median duration of resuscitation was 12 min (Q1-Q3 5–21 min). The standardized absolute chance of 30-day survival was 63.6% (95% CI 58.0%-69.0%) for group A, 34.0% (95% CI 29.7%-38.2%) for group B, 14.1% (95% CI 10.7%-17.5%) for group C and 9.0% (95% CI 6.8%-11.8%) for group D. Similarly, the chance of 1-year survival was highest for group A (51.5%; 95% CI 46.3%-56.7%) gradually decreasing to 7.0% (95% CI 4.5%-9.5%) in group D (Fig. 1). Among 30-day survivors of an IHCA, the standardized absolute chance of survival without anoxic brain damage or nursing home admission within one-year post-arrest was highest for patients resuscitated in group A (83.2%; 95% CI 78.4%-88.1%), decreasing to 72.3% (95% CI 64.5%-80.0%) in group B, 68.3% (95% CI 55.3%-81.2%) in group C and 71.1% (95% CI 54.2%-88.0%) in group D (Fig. 2). Conclusion Short time to ROSC after in-hospital cardiac arrest is associated with better long-term prognosis. However, the majority of 30-day survivors are alive 1-year post-arrest without anoxic brain damage and without need for nursing home admission despite prolonged resuscitation. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

201 Effect of Gender, Race, and Ethnicity on Duration of Resuscitative Efforts Following Out-of-Hospital Cardiac Arrest

The duration of unsuccessful resuscitation attempts in the emergency department (ED) following out-of- hospital cardiac arrest (OHCA) may be influenced by many factors. Factors known to be associated with a decreased likelihood of survival may influence providers to consider resuscitative efforts futile sooner, and may include: whether the arrest was witnessed, if bystander CPR was performed, duration of CPR in the pre-hospital setting, and the presence of a shockable rhythm. More subtle, and potentially sub-conscious factors may also influence the duration of unsuccessful resuscitation efforts, as well.

The impact of downtime on neurologic intact survival in patients with targeted temperature management after out-of-hospital cardiac arrest: National multicenter cohort study

Aim of studyThe association between long duration of resuscitation efforts in out-of-hospital cardiac arrest (OHCA) and neurologic outcome is unclear and understudied with advancements in post-cardiac arrest care and high-quality cardiopulmonary resuscitation. We investigated how downtime, defined as the interval from collapse-to-return of spontaneous circulation (ROSC), impacts on neurologic outcome in OHCA patients treated with targeted temperature management (TTM). MethodsA multicenter, registry-based, retrospective cohort study was conducted using cases from 24 hospitals across South Korea. Of the 930 adults (≥18 years) non-traumatic OHCA patients treated with TTM between January 2007 and December 2012 at these hospitals, we included 858 patients who had sufficient data for calculating downtime. Good neurologic outcome was defined as a cerebral performance category score of 1 or 2. ResultsMedian downtime was 30.0 (22.0–41.0min) and 242 patients (28.2%) had good neurologic outcome. When downtime was divided by 10-min intervals (≤10min, 11–20min, 21–30min, 31–40min, 41–50min, 51–60min, and >60min), their neurologically intact survival rate were 48.2%, 51.6%, 29.2%, 22.1%, 16.1%, 14.8%, and 7.1%, respectively (p=0.01). Although downtime was associated with poor neurologic outcome [odds ratio 1.06 (1.05–1.08), p<0.01], the area under the receiver operating characteristic curve of downtime for outcome was only 0.67, 95% CI (0.63–0.71). Furthermore, even with downtime >20min, 22.2% (150/526) patients still had a good neurologic outcome, and this percentage increased to 50.3% (93/185) in patients with an initial shockable rhythm, and 31.1% (134/431) with age <65 years. ConclusionsWe found that neurologically intact survival can occur at prolonged downtimes and were unable to identify a downtime for which survivability was clearly futile. These data suggest that downtime should not be considered as a factor in determining whether to provide aggressive post-arrest care, especially in patients with young patients or those with an initially shockable rhythm.

Abstract 322: Duration of Resuscitation Efforts for In-Hospital Cardiac Arrest by Predicted Survival Outcomes: Insights from Get With The Guidelines - Resuscitation

Background. The duration of cardiopulmonary resuscitation has implications for patient survival of in-hospital cardiac arrest (IHCA). However, the duration of resuscitation efforts should be balanced against the probability of patient survival. It is unknown whether the duration of attempted resuscitation for IHCA is associated with the predicted probability of patient survival. Methods. We identified 40,563 non-survivors of resuscitation efforts for IHCA within the Get With The Guidelines [[Unable to Display Character: &amp;#8211;]] Resuscitation Registry between 2000 and 2012. In these patients, we determined the pre-arrest predicted probability of survival to discharge with good neurologic status using the previously validated GO-FAR score. Using this tool, predicted survival was categorized into very low (&lt;1%), low (1-3%), average (&gt;3% to 15%), and above average (&gt;15%). Duration of resuscitation efforts were measured in minutes from the onset of cardiac arrest to termination of resuscitation efforts. We then compared the duration of resuscitation efforts by predicted survival categories. Results. Among 40,563 non-survivors of IHCA, the predicted survival to discharge was very low in 4801 (11.8%) patients, low in 8889 (21.9%), average in 19910 (49.1%) patients, and above average in 6963 (17.2%) patients. The median duration of attempted resuscitation was 19 minutes and the duration of attempted resuscitation was longer in non-survivors with a higher predicted probability of survival (median duration in minutes from very low to above average categories of predicted survival, 16 vs 17 vs 20 vs 23, P&lt;.001). However, the duration of attempted resuscitation was often discordant with predicted survival (Figure), including shorter than median duration of attempted resuscitation in 31.9% of patients with above average predicted survival. Conclusions. In a national cohort of non-survivors of IHCA, the duration of attempted resuscitation correlated overall with predicted arrest survival. However, nearly a third of patients with above average predicted survival received shorter than average attempted resuscitation efforts. Emphasis on an adequate duration of attempted resuscitation, particularly among patients with better than average predicted outcomes, may have implications for improving in-hospital cardiac arrest outcomes.

Survival by the Fittest: Hospital‐Level Variation in Quality of Resuscitation Care

Despite several advances in resuscitation care over the last decade, in-hospital cardiac arrest (IHCA) remains common and is linked to poor survival. Approximately 200 000 hospitalized patients suffer IHCA and undergo cardiopulmonary resuscitation in the United States annually, with fewer than 20%

Board 375 - Research Abstract Should the Manikin Die During Mock Codes? (Submission #1444)

Introduction/Background Most postgraduate pediatric training programmes include neonatal mock codes. Little is known about the anxiety they create. Although it is clinically realistic, the educational value of an unsuccessful resuscitation is debated. The aims of the study were: 1) Assess the impact of neonatal simulation, in particular the situation of the dying manikiin, on trainees stress level and performance; 2) Evaluate trainees’ application of the 10-minute resuscitation recommendation of the asystolic baby from the Neonatal Resuscitation Program (NRP). Methods Pediatric residents and Neonatalogy fellows were randomized to two neonatal simulation scenarios: 1) Term baby who remained pulseless (RP) despite all interventions; 2) Term baby who was born pulseless but responded to appropriate resuscitation (RR). Performance was assessed using the NRP megacode score sheet by two independent reviewers. Salivary cortisol was collected from participants on three occasions: baseline (lecture), pre-simulation (T1) and post-simulation (T2) (after the first simulation scenario). A questionnaire was filled after the simulation session. Results Forty two of forty seven trainees consented to the study. Eighty eight percent of participants were female. Salivary cortisol levels significantly increased from baseline to T1 (p<0.05) . T2 salivary cortisol levels were also significantly higher (p<0.001) than T1. This increase was not scenario dependent (p = 0.06) and was not associated with performance scores on the 1st (p=0.94) or 2nd scenario (p=0.73). Performance scores were similar for RP: 81% (65-98%) and RR: 81% (66-95%) (p=0.66), did not differ according to if RP scenario was done 1st or 2nd and were not different for junior or senior residents. On the post-simulation questionnaire, there is a significant positive association between trainees perceived and actual performance (p=0.003). There is, however no correlation between perceived stress level and actual increase in salivary cortisol (p=0.09) or with performance scores (p=0.41). In RP scenario, 29/42 (69%) of trainees cease resuscitation efforts at an average time of 14 minutes while 13/42 (31%) had not ceased resuscitation efforts by 20 minutes, at which time we interrupted them. Junior residents stop significantly less often than senior residents (p=0.05). Conclusion Neonatal simulation causes anticipatory stress and increases trainees anxiety level without interfering with performance. Trainees are good at evaluating their performance level during simulation. Having a manikin die during simulation does not increase trainees stress or interfere with their performance. A third of trainees do not apply the NRP recommendations on the duration of resuscitation efforts in an asystolic infant. Disclosures None.

Duration of Resuscitation Efforts and Functional Outcome After Out-of-Hospital Cardiac Arrest

Background— Functionally favorable survival remains low after out-of-hospital cardiac arrest. When initial interventions fail to achieve the return of spontaneous circulation, they are repeated with little incremental benefit. Patients without rapid return of spontaneous circulation do not typically survive with good functional outcome. Novel approaches to out-of-hospital cardiac arrest have yielded functionally favorable survival in patients for whom traditional measures had failed, but the optimal transition point from traditional measures to novel therapies is ill defined. Our objective was to estimate the dynamic probability of survival and functional recovery as a function of resuscitation effort duration to identify this transition point. Methods and Results— Retrospective cohort study of a cardiac arrest database at a single site. We included 1014 adult (≥18 years) patients experiencing nontraumatic out-of-hospital cardiac arrest between 2005 and 2011, defined as receiving cardiopulmonary resuscitation or defibrillation from a professional provider. We stratified by functional outcome at hospital discharge (modified Rankin scale). Survival to hospital discharge was 11%, but only 6% had a modified Rankin scale of 0 to 3. Within 16.1 minutes of cardiopulmonary resuscitation, 89.7% (95% confidence interval, 80.3%–95.8%) of patients with good functional outcome had achieved return of spontaneous circulation, and the probability of good functional recovery fell to 1%. Adjusting for prehospital and inpatient covariates, cardiopulmonary resuscitation duration (minutes) is independently associated with favorable functional status at hospital discharge (odds ratio, 0.84; 95% confidence interval, 0.72–0.98; P =0.02). Conclusions— The probability of survival to hospital discharge with a modified Rankin scale of 0 to 3 declines rapidly with each minute of cardiopulmonary resuscitation. Novel strategies should be tested early after cardiac arrest rather than after the complete failure of traditional measures.

Abstract XXXXX: Duration of resuscitation eff orts and survival after in-hospital cardiac arrest: an observational study

Zachary D. Goldberger, 2013 Finalist and Presenting Author

Abstract 319: Duration of Resuscitation Efforts and Functional Outcome After Out-of-Hospital Cardiac Arrest: When Should We Change to Novel Therapies?

Objectives: Strategies such as extracorporeal life support yield favorable outcomes in select OHCA patients who fail traditional CPR. However, it is unclear how long to attempt CPR before switching to more intensive strategies. We hypothesized that most patients with good outcome after traditional CPR achieve return of spontaneous circulation (ROSC) quickly, and determined the maximal CPR duration (DUR) required to restore pulses in the majority (75%, 95% or 99%) of patients with good outcome. Methods: Retrospective cohort study of subjects with atraumatic OHCA and attempted resuscitation from 2005-2011. Good outcome was defined as a modified Rankin scale (mRS) 0-3. We determined DUR until ROSC for subjects with mRS 0-3 (good outcome), mRS 4-5 (poor outcome), or mRS 6 (in-hospital death) with Kaplan-Meier curves, and the association between DUR and good outcome with logistic regression. Results: Of 1,014 patients, 47% had ROSC, 11% survived, and 6% had mRS 0-3. DUR for each outcome are in Table 1. Cumulative proportions of good outcomes versus DUR are in Figure 1. Adjusting for prehospital and inpatient covariates, DUR (min) is associated with mRS 0-3 (OR 0.84; 95%CI 0.72, 0.98;p=0.02). Conclusions: Novel strategies should be considered early, because 75% and 90% of patients with good outcome have ROSC within 10 and 16 minutes of traditional resuscitation, respectively.

Duration of Resuscitation Efforts and Survival After In-Hospital Cardiac Arrest: An Observational Study

Efforts to systematically increase duration of resuscitation for in-hospital patients with cardiac arrest could improve survival in this high-risk population.

Duration of Resuscitation Efforts and Survival after In-hospital Cardiac Arrest: An Observational Study: Goldberger ZD, Chan PS, Berg RA, et al. Lancet 2012;380:1473–81.

In-hospital cardiac arrest occurs in one to five of every 1000 hospital admissions. Despite this relative frequency, little evidence exists to guide the length of the resuscitation of these patients, which has lead to significant differences between hospitals. This observational study examined the variation in the length of resuscitation across 435 U.S. hospitals and whether longer resuscitations correlated with higher rates of survival to hospital discharge.

Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study

During in-hospital cardiac arrests, how long resuscitation attempts should be continued before termination of efforts is unknown. We investigated whether duration of resuscitation attempts varies between hospitals and whether patients at hospitals that attempt resuscitation for longer have higher survival rates than do those at hospitals with shorter durations of resuscitation efforts. Between 2000 and 2008, we identified 64,339 patients with cardiac arrests at 435 US hospitals within the Get With The Guidelines—Resuscitation registry. For each hospital, we calculated the median duration of resuscitation before termination of efforts in non-survivors as a measure of the hospital's overall tendency for longer attempts. We used multilevel regression models to assess the association between the length of resuscitation attempts and risk-adjusted survival. Our primary endpoints were immediate survival with return of spontaneous circulation during cardiac arrest and survival to hospital discharge. 31,198 of 64,339 (48·5%) patients achieved return of spontaneous circulation and 9912 (15·4%) survived to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 min (IQR 6-21) compared with 20 min (14-30) for non-survivors. Compared with patients at hospitals in the quartile with the shortest median resuscitation attempts in non-survivors (16 min [IQR 15-17]), those at hospitals in the quartile with the longest attempts (25 min [25-28]) had a higher likelihood of return of spontaneous circulation (adjusted risk ratio 1·12, 95% CI 1·06-1·18; p<0·0001) and survival to discharge (1·12, 1·02-1·23; 0·021). Duration of resuscitation attempts varies between hospitals. Although we cannot define an optimum duration for resuscitation attempts on the basis of these observational data, our findings suggest that efforts to systematically increase the duration of resuscitation could improve survival in this high-risk population. American Heart Association, Robert Wood Johnson Foundation Clinical Scholars Program, and the National Institutes of Health.

Commentary on "duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study".

Decisions about the appropriate termination of resuscitation attempts are among the most important that teams must face, yet there have been very few studies looking into the issue. Many national guidelines refer only to advance decisions to prevent the initiation of resuscitation, such as DNAR orders,1–3 and yet the decision to continue or abort on-going treatment is a clinical one, which should be evidence based like any other. This observational study4 is one of the largest to examine the relationship between length of resuscitation efforts in hospital and outcome, and provides novel, powerful, and highly relevant results.The authors tested the hypothesis that hospitals with longer attempted duration of resuscitation in patients who don’t survive would correlate with higher hospital survival outcomes, both immediate and to discharge. They assessed whether higher survival rates were associated with poor neurological status; additionally they directly estimated risk ratios for various at-risk groups, including breakdowns by cardiac rhythm. Hospital data was collected from ‘Get With The Guidelines – Resuscitation’; the largest world-wide in-hospital resuscitation registry, managed by the American Heart Association.5 Between 2000–2008, 64,339 cardiac arrests were considered that lasted at least 2 minutes (to exclude ‘partial arrests’) in 435 hospitals in the USA, each with a minimum experience of at least 10 arrests over 8 years. Exclusions were made for Emergency Departments, operating theatres, postoperative areas, procedure areas, rehabilitation areas, and arrests with area unknown, to avoid the ‘distinct circumstances’ of arrests in those settings. The median value for each hospital was calculated, and hospitals were divided into quartiles based on median length of resuscitation in non-survivors, with corresponding lengths of 16, 19, 22, and 25 minutes. Median resuscitation times overall were 17 minutes (IQR 10-26), with a breakdown of 12 minutes (IQR 6-21) for immediate survivors and 20 minutes (IQR 14–30) for non-survivors.4

Outcome of Out-of-Hospital Cardiorespiratory Arrest in Children

To analyze the characteristics and outcome of out-of-hospital cardiorespiratory arrest in children in Spain. Secondary analysis of data from a prospective, multicenter study analyzing cardiorespiratory arrest in children. Ninety-five children between 7 days and 16 years with cardiorespiratory arrest. Data were recorded according to the Utstein style. The outcome variables were the sustained return of spontaneous circulation (initial survival), and survival at 1 year (final survival). Neurologic and general performance outcome was assessed by the Pediatric Cerebral Performance Category (PCPC) scale and the Pediatric Overall Performance Category (POPC) scale. Initial survival was 47.3% and 1-year survival was 26.4%. Mortality was higher in children younger than 1 year. Survival of patients with respiratory arrest (82.1%) was significantly higher than survival of cardiac arrest victims (14.4%). Patients who were initially resuscitated by laypersons or paramedics had higher survival (53.6%) than those who were initially resuscitated by doctors and/or nurses (15.2%) (P < 0.01). Mortality was higher in the patients who presented slow rhythms (asystole, severe bradycardia) or pulseless electrical activity than in those presenting ventricular fibrillation (P = 0.001). Multivariate logistic regression revealed that the best indicator of mortality was duration of cardiopulmonary resuscitation longer than 20 minutes. After 1 year, most survivors had normal or mild disability. Mortality of out-of-hospital cardiorespiratory arrest in children is high. When resuscitation is started soon by layperson or paramedics, survival is increased. Duration of resuscitation efforts is the best indicator of mortality. Most of survivors had good long-term neurologic outcome.

R ESUSCITATION IN THE O UT-OF-HOSPITAL S ETTING : M EDICAL F UTILITY C RITERIA FOR O N-SCENE P RONOUNCEMENT OF D EATH

The complete and irreversible cessation of life is often difficult to determine with complete confidence in the dynamic environment of out-of-hospital emergency care. As a result, resuscitation efforts often are initiated and maintained by emergency medical services (EMS) providers in many hopeless situations. Medical guidelines are reviewed here to aid EMS organizations with respect to decisions about: 1) initiating or waiving resuscitation efforts; 2) the appropriate duration of resuscitation efforts; and 3) recommended procedures for on-scene or prehospital pronouncement of death (termination of resuscitation). In cases of nontraumatic cardiac arrest, few unassailable criteria, other than certain physical signs of irreversible tissue deterioration, exist for determining medical futility at the initial encounter with the patient. Thus, the general medical recommendation is to attempt to resuscitate all patients, adult or child, in the absence of rigor mortis or dependent lividity. Conversely, well-founded guidelines now are available for decisions regarding termination of resuscitation in such patients once they have received a trial of advanced cardiac life support. In practice, however, the final decision to proceed with on-scene pronouncement of death for these patients may be determined more by family and provider comfort levels and the specific on-scene environment. For patients with posttraumatic circulatory arrest, the type of injury (blunt or penetrating), the presence of vital signs, and the electrocardiographic findings are used to determine the futility of initiating or continuing resuscitation efforts. In general, patients who are asystolic on-scene are candidates for on-scene pronouncement, regardless of mechanism. With a few exceptions, blunt trauma patients with a clearly associated mechanism of lethal injury are generally candidates for immediate cessation of efforts once they lose their pulses and respirations. Regardless of the medical futility criteria, specialized training of EMS providers and targeted related testing of operational issues need to precede field implementation of on-scene pronouncement policies. Such policies also must be modified and adapted for local issues and resources. In addition, although the current determinations of medical futility, as delineated here, are important to establish for societal needs, the individual patient's right to live must be kept in mind always as new medical advances are developed.

Personal Awareness and Effective Patient Care-Reply

In Reply —We derived our statement about Indian and Pakistani residents' training from a qualitative study of international medical graduates, coauthored by a member of our working group. 1 The study illustrated how cultural differences may act as barriers to patient care and reflected the opinions of Indian and Pakistani residents in a single program. We apologize for what may have been an overgeneralization. We certainly meant no offense to our Indian and Pakistani colleagues. We made no claims to scientific proof that particular physician personal qualities caused certain behaviors. We cited studies to substantiate our assertion that physician personal factors affect patient care. Nightingale and Grant 2 reported strong associations between physicians' attitudes toward risk and their use of certain health care resources, preferences for intubation, and the duration of resuscitation efforts. Physician gender affects clinical decisions. The presence of a cautionary statement in 1 of our 12 citations on gender

In-Hospital Cardiopulmonary Resuscitation

To the Editor. — Taffet et al 1 present interesting and controversial data regarding the outcome of in-hospital cardiopulmonary resuscitation (CPR). The study itself was well done, and the data were, for the most part, analyzed adequately for possible confounding factors, such as the duration of resuscitation efforts and preexisting health condition. The authors' call to expend greater effort identifying those patients likely to benefit from CPR at the time of admission is laudable. However, they make two critical mistakes with interpretation of the data and give us a faulty recommendation. The authors remark on the disparity in best mental status between the younger and older cohorts after CPR and infer that this difference is due to the amount of neurological function recovered. However, since data regarding mental status before the cardiopulmonary arrest are not presented, no such inference can be made. Recovery cannot be judged in the absence of