Termination Of Resuscitation Criteria Research Articles

Abstract 158: Exploring the Potential for Kidney Donation in Out-of-Hospital Cardiac Arrest Cases With No Chance of Survival

Introduction: The global kidney shortage can potentially be addressed through the implementation of the uncontrolled donation after circulatory death (uDCD) pathway. However, the current Termination-of-Resuscitation (TOR) rules, although effective in identifying futile resuscitation, do not consider the potential benefits of organ donation. Objective: This study aims to assess the potential pool of uDCD kidney donors among patients with resuscitation attempts by Emergency Medical Services (EMS) who meet TOR criteria. Methods: Retrospective analysis was conducted using data from the Paris Sudden Death Expertise Center (SDEC) registry spanning from 2011 to 2020. TOR criteria evaluation and identification of potential organ donors were performed using established selection criteria from previous protocols on TOR rules and uDCD. Incidence rates (per patient-years) were calculated using data from the National Institute of Statistics and Economic Studies. Results: Out of 19,976 cases of Out-of-Hospital-Cardiac Arrest (OHCA) with resuscitation attempts by EMS, 12,890 (64.5%) did not achieve sustained Return of Spontaneous Circulation (ROSC). Among patients with no successful ROSC, the annual number and incidence of patients with no chance of survival varied across different TOR rules, ranging from 626 to 1081 cases and from 8.14 to 10.04 per 100,000 patient-years. The proportion of OHCA patients meeting both TOR criteria and extended kidney criteria ranged from 67.8% to 73.6% of total cases of OHCA who did not achieve sustained ROSC. Conclusion: Our findings demonstrate that the implementation of a uDCD program, in cases where TOR rules indicate no chance of survival, has the potential to significantly increase the pool of potential organ donors.

Usability of EtCO2 values in the decision to terminate resuscitation by integrating them into the TOR rule (an extended TOR rule): A preliminary analysis

ObjectiveEnd tidal carbon dioxide (EtCO2) is measured to confirm the placement of an endotracheal tube and evaluate the efficacy of cardiopulmonary resuscitation (CPR), and as an assistive tool for terminating CPR. However, there are no highly accurate or definitive recommendations for its use when deciding on the termination of CPR. We aimed to merge EtCO2 values with existing termination of resuscitation (TOR) rules to obtain a more accurate combination for terminating resuscitation. MethodsThis observational, prospective study included non-traumatic adult patients who were admitted to a tertiary university hospital Emergency Medicine Department due to cardiac arrest. EtCO2 cutoff values (at 5, 10, and 20 min) were integrated into currently used TOR parameters (arrest was not witnessed, no bystander CPR was provided, no return of spontaneous circulation (ROSC) after full advanced life support care in the field, and no shock was delivered) and the extended TOR rule was created. These extended TOR rules were compared at three different times (5, 10, and 20 min) for specificity and positive predictive value for ROSC. ResultsWe included a total of 86 cases. The cutoff value of EtCO2 from ROC analysis was 19.5, 23.5, and 20.5 mmHg at 5, 10, and 20 min, respectively. “The extended TOR rule created with the 20-min EtCO2 cutoff (20.5 mmHg) was the most accurate in detecting ROSC (−) patients. The specificity was 100% (95% CI 63.1–100.0) sensitivity was 20.0% (95% CI 9.1–35.7), positive predictive value was 100% and negative predictive value was 20.0% (95% CI 17.6–22.6) for ROSC (−) patients. The parameters of this rule were as follows: arrest was not witnessed, no bystander CPR was provided, no ROSC after full advanced life support care in the field, no shock was delivered, and EtCO2 value at 20 min of resuscitation <20.5 mmHg. ConclusionsIntegration of EtCO2 values into the classically used TOR criteria increases the specificity to 100% without a significant decrease in sensitivity. These results need to be validated in larger groups before this rule is used clinically. EtCO2 seems to be a beneficial tool in establishing new TOR rules.

Retrospective analysis of out-of-hospital cardiac arrest outcome in a tertiary care emergency department in Abu Dhabi

Background: Despite all the development in healthcare access and services, out-of-hospital cardiac arrest (OHCA) remains a challenge and still has a poor prognosis. Thus, this study aimed to retrospectively apply the American Heart Association (AHA),Advanced Life Support (ALS), and Termination of Resuscitation (TOR) 2010 criteria to all OHCA patients who arrived at the emergency department (ED) in Abu Dhabi and determine their survival outcome. Methods: A retrospective chart review was done among OHCA patients received by a tertiary care hospital&amp;apos;s ED in Abu Dhabi over a period of 1 year in 2018. Results: A total of 87 patients were included; 21 (24.1%) patients met the AHA ALS TOR criteria and none of them survived To hospital discharge, with specificity and positive predictive value (PPV) of 100%. Only three patients (3.4%) who survived to be discharged from the hospital did not meet the AHA ALS TOR criteria. Conclusion: AHA ALS TOR criteria were derived and validated; it must be applied by emergency medical services (EMS) on the field however, it could be applied on patient arrival to the ED in systems where EMS are not using it.

Impact of dispatcher-assisted cardiopulmonary resuscitation on performance of termination of resuscitation criteria

BackgroundCurrent Advanced Life Support Termination of Resuscitation (TOR) guidelines suggest when to cease cardiopulmonary resuscitation (CPR). With the significant increase of Dispatch-Assisted CPR (DA-CPR) programs, the impact of DA-CPR on the TOR criteria performance is not clear. MethodsWe conducted a secondary analysis of a prospectively collected registry, the Pan-Asian Resuscitation Outcomes Study. We included patients >15 years old with out-of-hospital cardiac arrest between 2014 and 2017 (after implementation of Singapore’s DA-CPR program). We excluded patients with non-cardiac etiology, known do-not-resuscitate status, and healthcare provider bystanders. All cases were collected in accordance to Utstein standards. We evaluated the addition of DA-CPR to the diagnostic performance of TOR criteria using logistic regression modeling. The primary outcome was performance for predicting non-survival at 30 days. Sensitivity, specificity, and positive and negative predictive values were calculated. ResultsOf the 6009 cases, 319 (5.3%) were still alive at 30 days. Patients had a mean age of 67.9 (standard deviation 15.7) years and were mostly male and Chinese. Almost half of patients had no bystander CPR. The TOR criteria differentiating DA-CPR from unassisted bystander CPR has a specificity of 94% and predictive value of death of 99%, which was not significantly different from undifferentiated CPR criteria. There were differences in adjusted association with survival between unassisted and DA-CPR. ConclusionAdvanced life support TOR criteria retain high specificity and predictive value of death in the context of DA-CPR. Further research should explore the differences between unassisted CPR and DA-CPR to understand differential survival outcomes.

Abstract 13678: Validation of the Termination of Resuscitation Rules in Detroit

Introduction: 326,000 patients suffer from an out of hospital cardiac arrest (OHCA) each year. The Termination of Resuscitation (TOR) criteria, which recommends termination when the arrest is unwitnessed by EMS, no shocks are administered, and no ROSC occurs, guides physicians in determining the futility of continuing CPR and transporting patients to the hospital. We examined compliance with current BLS TOR rules as well as assessed an alternate set of rules, with the goal of retrospectively deriving improved TOR guidelines for OHCAs in Detroit. Methods: This is a retrospective study utilizing non-traumatic OHCA cases in Detroit from January 1, 2017 to December 31, 2019, which includes time before and after BLS TOR guidelines were officially implemented (June 1, 2018). Data is extracted from the Detroit Cardiac Arrest Registry (DCAR). Patients younger than 18 years of age and arrests of traumatic origin or those with no resuscitation attempted were excluded. Results: BLS TOR criteria was applied to the pre-TOR implementation data with resulting specificity of 79% (95% CI: 50.7-80.8) and PPV of 97.3% (95% CI: 95.5-98.6). Survival to hospital discharge when termination was recommended was projected at 2.9% (13/444). Overall transportation rate was 85% (559/656). Post-TOR implementation, specificity was 88.9% (95% CI: 78.6-99.1) and PPV was 99.1% (95% CI: 98.3-99.9). Survival to hospital discharge was 0.88% (4/453) with a 69% (451/650) overall transportation rate. Post-hoc addition of age or EMS time to patient side increased transportation rates to 81% (529/650) and 88% (571/650), respectively, and decreased false positive terminations to 0.84% (2/237) and 0% (0/148), respectively. Conclusion: Overall survival when TOR was recommended as well as futile transportation rates decreased since the implementation of the BLS TOR guidelines in Detroit. Addition of EMS time to patient side or patient age to the current TOR guidelines suggested improved performance. Although the additional criteria resulted in higher transportation rates, these factors may be useful for physicians to consider when deciding to transport patients who meet the current TOR criteria. However, further derivation and validation are needed to create optimal TOR guidelines.

Applying a set of termination of resuscitation criteria to paediatric out-of-hospital cardiac arrest

ObjectivePrehospital Termination of Resuscitation (TOR) protocols for adults can reduce the number of futile transports of patients in cardiac arrest, yet similar protocols are not widely available for paediatric out-of-hospital cardiac arrest (POHCA). The objective of this study was to apply a set of criteria for paediatric TOR (pTOR) from the Maryland Institute for Emergency Medical Services Systems (MIEMSS) to a large national cohort and determine its association with return of spontaneous circulation (ROSC) after POHCA. MethodsWe identified patients ages 0–17 treated by Emergency Medical Services (EMS) with cardiac arrest in 2019 from the ESO dataset and and applied the applicable pTOR certeria for medical or traumatic arrests. We calculated predictive test characteristics for the outcome of prehospital ROSC, stratified by medical and traumatic cause of arrest. ResultsWe analyzed records for 1595 POHCA patients. Eighty-eight percent (n = 1395) were classified as medical. ROSC rates were 23% among medical POHCA and 27% among traumatic POHCA. The medical criteria correctly classified >99% (322/323) of patients who achieved ROSC as ineligible for TOR. The trauma criteria correctly classified 93% (50/54) of patients with ROSC as ineligible for TOR. Of the five misclassified patients, three were involved in drowning incidents. ConclusionsThe Maryland pTOR criteria identified eligible patients who did not achieve prehospital ROSC, while reliably excluding those who did achieve prehospital ROSC. As most misclassified patients were victims of drowning, we recommend considering the exclusion of drowning patients from future pTOR guidelines. Further studies are needed to evaluate the long-term survival and neurologic outcome of patients misclassified by pTOR criteria.

External validation of multimodal termination of resuscitation rules for out-of-hospital cardiac arrest patients in the COVID-19 era

BackgroundFutile resuscitation for out-of-hospital cardiac arrest (OHCA) patients in the coronavirus disease (COVID)-19 era can lead to risk of disease transmission and unnecessary transport. Various existing basic or advanced life support (BLS or ALS, respectively) rules for the termination of resuscitation (TOR) have been derived and validated in North America and Asian countries. This study aimed to evaluate the external validation of these rules in predicting the survival outcomes of OHCA patients in the COVID-19 era.MethodsThis was a multicenter observational study using the WinCOVID-19 Daegu registry data collected during February 18–March 31, 2020. The subjects were patients who showed cardiac arrest of presumed cardiac etiology. The outcomes of each rule were compared to the actual patient survival outcomes. The sensitivity, specificity, false positive value (FPV), and positive predictive value (PPV) of each TOR rule were evaluated.ResultsIn total, 170 of the 184 OHCA patients were eligible and evaluated. TOR was recommended for 122 patients based on the international basic life support termination of resuscitation (BLS-TOR) rule, which showed 85% specificity, 74% sensitivity, 0.8% FPV, and 99% PPV for predicting unfavorable survival outcomes. When the traditional BLS-TOR rules and KoCARC TOR rule II were applied to our registry, one patient met the TOR criteria but survived at hospital discharge. With regard to the FPV (upper limit of 95% confidence interval < 5%), specificity (100%), and PPV (> 99%) criteria, only the KoCARC TOR rule I, which included a combination of three factors including not being witnessed by emergency medical technicians, presenting with an asystole at the scene, and not experiencing prehospital shock delivery or return of spontaneous circulation, was found to be superior to all other TOR rules.ConclusionAmong the previous nine BLS and ALS TOR rules, KoCARC TOR rule I was most suitable for predicting poor survival outcomes and showed improved diagnostic performance. Further research on variations in resources and treatment protocols among facilities, regions, and cultures will be useful in determining the feasibility of TOR rules for COVID-19 patients worldwide.

Blood gas analyses could not improve the termination of resuscitation criteria to predict subsequent recovery of spontaneous circulation in patients with out-of-hospital cardiac arrest: A diagnostic accuracy study

Background: The prehospital termination of resuscitation (TOR) rule including unwitnessed arrest, no shock administered, no prehospital return of spontaneous circulation (ROSC) parameters was widely accepted as a prediction model for survival to hospital discharge in patients with out-of-hospital cardiac arrest (OHCA). We hypothesized that blood gas analysis findings that can be achieved within minutes during resuscitation at emergency department (ED) in combination with conventional TOR criteria can improve prediction of ROSC in the ED.

Can We Define Termination Of Resuscitation Criteria In Out-Of-Hospital Hanging?

Objective: Survival rate of cardiac arrest due to hanging (H-CA) victims is low. Hence, this leads to the question of the utility of resuscitation in these patients. The objective was to investigate whether there are predictive criteria for survival with a good neurological outcome or predictive criteria for non-survival or survival with a poor neurological outcome enabling us to define the termination of resuscitation rules in these patients. Methods: Between July 1, 2011 and January 1, 2016, we included 1,689 out-of-hospital cardiac arrests due to hanging. We compared the characteristics of survivors with a good neurological outcome at day 30 with the others. Results: The study population was mainly composed of males with a median age of 48 [37–60]. The overall survival was 2.1%, among which 48.6% had a good neurological outcome. Survivors benefited more often from immediate basic life support than the rest of the subjects, which was corroborated by the shorter no-flow durations. We did not record any difference in terms of advanced cardiac life support initiation frequency and technique between survivors with a good neurological outcome and the rest. Nevertheless, ACLS duration was longer in survivors with a good neurological outcome than in others. Conclusions: Basic life support (BLS) was the decisive criterion for 15/17 survivors. However, a detailed analysis showed 2 survivors presenting no BLS before the arrival of mobile medical teams and non-shockable rhythms who survived at day 30 with a good neurological outcome. These results lead us to consider that mobile medical team intervention and ACLS attempt are not futile, and the benefit justifies the cost. Thus, we cannot define any rule for the termination of resuscitation.

Out-of-hospital cardiac arrest without return of spontaneous circulation in the field: Who are the survivors?

BackgroundReturn of spontaneous circulation (ROSC) in the field is a vital determinant contributing to survival from out-of-hospital cardiac arrest (OHCA). However, nearly one third of survivors at the Dallas-Fort Worth (DFW) Resuscitation Outcomes Consortium (ROC) site did not obtain ROSC in the field. MethodsA retrospective, observational analysis was performed on all adult patients with non-traumatic OHCA treated on scene and transported to hospital, who did not gain ROSC in the field at DFW ROC site between 2006 through 2011.We described the demographics, pre-hospital characteristics and outcomes of all enrolled cases. Those patients without ROSC in the field, who did and did not meet Termination of Resuscitation (TOR) criteria in the field, were also compared. ResultsAmong a total of 5099 treated and transported non-traumatic OHCA cases, 83.2% (4243) were included in this study as patients without ROSC gained in the field, of which 66.6% (2827) met TOR criteria but still were treated and transported; 1.9% (79) survived to hospital discharge. Further analysis showed that 39.2% (31) of survivors met TOR rule, accounting for 1.1% of those patients who should have been declared dead in the field. Shockable initial rhythms, EMS-witnessed arrest, bystander CPR and age were factors significant to predict survival from OHCA without ROSC in the field. Of concern, 1.7% (47) of patients who met TOR presented initially shockable rhythms but no shocks were delivered in the field. ConclusionsWe suggest that all treated non-traumatic OHCA patients should be transported to hospital.

Termination of Resuscitation Criteria for Out-of-Hospital Cardiac Arrest

Survival from out-of-hospital cardiac arrest (OHCA) is low, and OHCA victims should not be transported if resuscitation attempts would be futile. The

Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: An observational cohort study

BackgroundSome Emergency Medical Services currently use just one component of the Universal Termination of Resuscitation (TOR) Guideline, the absence of prehospital return of spontaneous circulation (ROSC), as the single criteria to terminate resuscitation, which may deny transport to potential survivors. ObjectiveThis study aimed to report the survival to hospital discharge rate in non-traumatic, adult out-of-hospital cardiac arrest (OHCA) patients transported to hospital without a prehospital ROSC. MethodsAn observational study of OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport to hospital with ongoing resuscitation. Multivariable logistic regression was used to determine the association of each variable with survival to hospital discharge. ResultsOf 20,207 OHCA treated by EMS, 3374 (16.4%) did not have a prehospital ROSC but met the Universal TOR guideline for transport to hospital with ongoing resuscitation. Of these patients, 122 (3.6%) survived to hospital discharge. Survival to discharge was associated with initial shockable VF/VT rhythms (OR 5.07; 95% CI 2.77–9.30), EMS-witnessed arrests (OR 3.51; 95% CI 1.73–7.15), bystander-witnessed arrests (OR 2.11; 95% CI 1.18–3.77), and public locations (OR 1.57; 95% CI 1.02–2.40). ConclusionIn OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport with ongoing resuscitation survival rates were above the 1% futility rate. Employing only the lack of ROSC as criteria for termination of resuscitation may miss survivors after OHCA.

Re-examining outcomes after unsuccessful out-of-hospital resuscitation in the era of field termination of resuscitation guidelines and regionalized post-resuscitation care

BackgroundDismal prognosis after failed out-of-hospital resuscitation has previously been demonstrated. Changes in resuscitation and post-resuscitation care may affect patient outcomes. We describe characteristics and outcomes of patients with out-of-hospital cardiac arrest (OOHCA) transported to specialty cardiac centers after failure of out-of-hospital interventions. MethodsIn Los Angeles (LA) County, patients with non-traumatic OOHCA with return of spontaneous circulation (ROSC) are transported to specialized cardiac care centers. Outcomes are reported to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report patient characteristics and outcomes for the subset of patients treated at these specialty centers in whom initial ROSC was achieved in the ED. The primary outcome was neurologically intact survival, defined by a cerebral performance category (CPC) score of 1 or 2. Results105 patients transported to the SRC after failure to achieve ROSC with out-of-hospital resuscitation were successfully resuscitated in the ED. The median age was 68 years (IQR 57–78); 74 (70%) were male. The presenting rhythm was ventricular fibrillation or ventricular tachycardia in 40 patients (38%) and 86 (82%) were witnessed. Twenty-two patients (21%) survived to hospital discharge. Of the 103 patients with known CPC scores, 13 (13% [95% CI 7–21%]) survived to hospital discharge with a CPC score of 1 or 2. No patient who survived with good neurologic outcome met criteria for termination of resuscitation in the field. ConclusionFailure of out-of-hospital resuscitation is not universally predictive of poor neurologic outcome.

External validation of termination of resuscitation guidelines in the setting of intra-arrest cold saline, mechanical CPR, and comprehensive post resuscitation care

BackgroundThe development of advanced life support (ALS) termination of resuscitation (TOR) guidelines for out-of-hospital cardiac arrest (OHCA) seeks to improve the efficiency of scarce pre-hospital resources. However, as pre-hospital treatment for OHCA evolves and survival improves, these TOR guidelines must be reevaluated in the contemporary context of emergency medical services (EMS) providing access to advanced resuscitation care. MethodsRetrospective review of all adult (>18 years old), non-traumatic, OHCA patients (defined as patients with absence of pulse who received either CPR and/or defibrillation) treated by EMS in Richmond, VA, from January 1, 2009 to December 31, 2010. In addition to standard ALS, intra-arrest cold saline, mechanical CPR, and transportation to a comprehensive post-resuscitation center (CPRC) was provided. Patient treatment and outcomes were recorded via prehospital patient care reports and data were evaluated against previously established criteria for termination of resuscitation in an ALS EMS system. According to the aforementioned previously described criteria for TOR, patients meeting a single criterion for transport are recommended to be transported emergently to a comprehensive post-resuscitation care facility. Conversely, patients failing to meet any of the TOR criteria can be presumed to be expired without exception. Survival at 180 days was presumed when death could not be verified from publically reportable sources. ResultsOf the 322 OHCA patients enrolled, the majority were male (59%), unwitnessed (52%), received no bystander CPR (67%), and presented in a non-shockable initial rhythm (79%), with an average age of 62.5 years. Overall survival was 17%, 14%, 12%, and 11% at 7, 14, 30, and 180 days, respectively. Of the 75 patients for which TOR guidelines recommended termination, none survived yielding both 100% specificity (95% CI 100–92.8%) and positive predictive value (95% CI 100–94.1%). However, TOR guidelines recommended transport of 208 of the 283 patients who died within 30 days, resulting in a sensitivity of 26.5% (95% CI 34.5–23.4%). ConclusionThe TOR guidelines continue to have a reliable positive predictive value for death even in the setting of advanced EMS resuscitation methods and access to a CPRC. However, as the potential for survival from OHCA improves, the efficiency gained from their use is impacted greatly.

Impact of termination of resuscitation for out-of-hospital cardiopulmonary arrest in Japan

What can one anticipate from the introduction of termination of resuscitation (TOR) for patients suffering out-of-hospital cardiopulmonary arrest (OHCA) in Japan? Irrespective of whether patients have made a living will requesting that medics do not attempt resuscitation, efforts are made to resuscitate over 90% of OHCA patients in Japan [1,2]; the number of people resuscitated exceed 120,000 every year. The 2010 American Heart Association (AHA) Guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) defined the criteria for TOR; this initiative may help reduce the number of unnecessary hospital transports by 40 to 60% and hold down medical costs [3].

Assessment of termination of trauma resuscitation guidelines: are children small adults?

Background Guidelines for termination of resuscitation in prehospital traumatic cardiopulmonary arrest (TCPA) have recently been published for adults. Clinical criteria for termination of care include absent pulse, unorganized electrocardiogram (ECG), fixed pupils (all at the scene), and cardiopulmonary resuscitation (CPR) greater than 15 minutes. The goal of this study was to evaluate these guidelines in a pediatric trauma population. Methods Pediatric trauma patients with documented arrest were included in the study. Data assessed were duration of CPR, ECG rhythm, pulse assessment, pupil response, transport times, and standard injury criteria (eg, mechanism of injury). Survivors were compared to nonsurvivors using descriptive statistics, χ 2, and Pearson correlation. Results Between 2000 and 2009, 30 patients were identified as having had a TCPA. Of the 30 with a prehospital TCPA, there were 9 females and 21 males (0.2-18 years old). The average (SD) injury severity score was 35.4 (20.6). Twenty-four patients (80%) did not survive. Severe traumatic brain injury was associated with nonsurvivors in 78%. One-way analysis of variances demonstrated that CPR greater than 15 minutes ( P = .011) and fixed pupils ( P = .022) were significant variables to distinguish between survivors and nonsurvivors, whereas ECG rhythm ( P = .34) and absent pulse ( P = .056) did not, 42 ± 28 minutes for nonsurvivors and 7 ± 3 minutes for survivors. Conclusion Criteria for termination of resuscitation correctly predicted 100% of those who died when all the criteria were met. More importantly, no survivors would have had resuscitation stopped. Duration of CPR seems to be a strong predictor of mortality in this study.

Terminating Resuscitation for Cardiac Arrests Outside of the Hospital

Transport Medicine| July 01 2008 Terminating Resuscitation for Cardiac Arrests Outside of the Hospital AAP Grand Rounds (2008) 20 (1): 4. https://doi.org/10.1542/gr.20-1-4 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Terminating Resuscitation for Cardiac Arrests Outside of the Hospital. AAP Grand Rounds July 2008; 20 (1): 4. https://doi.org/10.1542/gr.20-1-4 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All AAP SitesAll PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP News Search Advanced Search Topics: cardiac arrest, resuscitation Source: O’Brien E, Hendricks D, Cone D. Field termination of resuscitation: analysis of a newly implemented protocol. Prehosp Emerg Care. 2008;12(1):57–61; doi:10.1080/10903120701707989 The authors, from Yale-New Haven Medical Center in New Haven, CT, performed a retrospective review of all adult out-of-hospital cardiac arrest (OOHCA) patients transported to two emergency departments (ED) during a 3.5-year interval to determine how often patients were transported despite meeting termination-of-resuscitation (TOR) protocols for traumatic and nontraumatic OOHCA. Emergency Medical Services (EMS) and ED records were evaluated to assess for the presence of TOR protocol criteria and to determine whether the patients should have been transported or pronounced dead on the scene. Records were also examined for extenuating circumstances that may have prompted the transport despite meeting TOR criteria. The outcome measures were survival to discharge from the hospital and survival... Copyright © 2008 by the American Academy of Pediatrics2008 You do not currently have access to this content.

Independent Evaluation of an Out‐of‐hospital Termination of Resuscitation (TOR) Clinical Decision Rule

Recently, investigators described a clinical decision rule for termination of resuscitation (TOR) designed to help determine whether to terminate emergency medical services (EMS) resuscitative efforts for out-of-hospital cardiac arrests (OOHCA). The authors sought to evaluate the hypothesis that TOR would predict no survival for patients in an independent cohort of patients with OOHCA. This was a retrospective cohort analysis conducted in the state of Arizona. Consecutive, adult, OOHCA were prospectively evaluated from October 2004 through October 2006. A statewide OOHCA database utilizing Utstein-style reporting from 30 different EMS systems was used. Data were abstracted from EMS first care reports and hospital discharge records. The TOR guidelines predict that no survival to hospital discharge will occur if 1) an OOHCA victim does not have return of spontaneous circulation (ROSC), 2) no shocks are administered, and 3) the arrest is not witnessed by EMS personnel. Data were entered into a structured database. Continuous data are presented as means (+/-standard deviations [SD]) and categorical data as frequency of occurrence, and 95% confidence intervals (CIs) were calculated as appropriate. The primary outcome measure was to determine if any cohort member who met TOR criteria survived to hospital discharge. There were 2,239 eligible patients; the study group included 2,180 (97.4%) patients for whom the data were complete; mean age was 64 (+/-11) years, and 35% were female. The majority of patients in the study group met at least one or more of the TOR criteria. A total of 2,047 (93.8%) patients suffered from cardiac arrest that was unwitnessed by EMS; 1,653 (75.8%) had an unwitnessed arrest and no ROSC. With respect to TOR, 1,160 of 2,180 (53.2%) patients met all three criteria; only one (0.09%; 95% CI = 0% to 0.5%) survived to hospital discharge. The authors evaluated TOR guidelines in an independent, statewide OOHCA database. The results are consistent with the findings of the TOR investigation and suggest that this algorithm is a promising tool for TOR decision-making in the field.

Field Termination of Resuscitation: Analysis of a Newly Implemented Protocol

Introduction. Earlier work has shown the safety of termination-of-resuscitation (TOR) protocols for traumatic andnontraumatic out-of-hospital cardiac arrest (OOHCA). This study examined the implementation of these protocols in one urban/suburban EMS system. The objective was to determine how often patients are transported to the ED despite meeting TOR criteria. Methods. All adult OOHCA patients transported to two EDs during a 3.5-year interval were retrospectively identified through dispatch andhospital records. EMS andED records were evaluated to assess for the presence of TOR protocol criteria andto determine whether the patients should have been transported or pronounced dead on scene. Records were also examined for documentation of mitigating circumstances that might have prompted transport despite meeting TOR criteria. Results. 865 OOHCA patients were identified; 235 met study criteria. Of these, 131 (56%) met TOR criteria but were transported anyway. All expired in the ED or in the hospital (131/131 = 100%, 95% CI: 97.7–100) Of the 43 traumatic OOHCA patients, 27 (63%) met TOR criteria, yet were transported, andall expired in the ED (27/27 = 100%, 95% CI: 89.5–100). Of the 192 nontraumatic OOHCA patients, 104 (54%) met TOR criteria, yet were transported, andall expired in the ED or in the hospital (104/104 = 100%, 95% CI: 97.2–100). In no case was a mitigating circumstance documented to justify transporting a patient meeting TOR criteria. Conclusions. Termination-of-resuscitation protocols are not being implemented as intended in this EMS system: more than half of cardiac arrest patients meeting criteria for termination of resuscitation were transported anyway. These protocol violations result in emergency transport to the ED for a substantial number of patients for whom continued resuscitative efforts are futile: no patient who met TOR criteria in this sample survived to discharge.

Implementation of an out-of-hospital termination of resucitation policy

Objective. To evaluate the implementation of an out-of-hospital termination of resuscitation policy in an urban EMS setting.Methods. A descriptive study characterizing the implementation of an out-of-hospital termination of resuscitation policy in the Chicago EMS system. It includes a retrospective telemetry record review analyzing the utilization and compliance with the policy. The newly implemented policy involved field termination of resuscitation for all nontraumatic, adult cardiac arrest victims presenting in asystole who were not responsive to a standard trial of resuscitation.Results. Over the three-month study period, 228 resuscitations of adult, nontraumatic cardiac arrest victims were identified and submitted for review. The group of 142 cardiac arrest victims who presented in asystole and received resuscitative efforts were categorized into four groups. Group I included 34 cardiac arrests for which resuscitation was terminated in the field following policy criteria. Group II included eight cardiac arrests for which resuscitation was terminated but the patients did not meet criteria for termination of resuscitation. Group III included 84 cardiac arrests for which resuscitation was not terminated because the patients did not meet criteria for out-of-hospital termination. Group IV included 16 cardiac arrests for which resuscitative efforts were continued, although the patients met indications for field termination.Conclusions. Field termination of resuscitation is practical in the setting of asystole unresponsive to aggressive resuscitative efforts. The implementation of such an out-of-hospital termination of resuscitation policy is complicated by many problems and is best accomplished by a gradual implementation process. Through this process all members of the EMS community can address practical and ethical issues and grow comfortable with the ongoing evolution of out-of-hospital therapy.