Termination Of Resuscitative Efforts Research Articles

Mechanical chest compressions for cardiac arrest in the cath-lab: when is it enough and who should go to extracorporeal cardio pulmonary resuscitation?

BackgroundTreating patients in cardiac arrest (CA) with mechanical chest compressions (MCC) during percutaneous coronary intervention (PCI) is now routine in many coronary catheterization laboratories (cath-lab) and more aggressive treatment modalities, including extracorporeal CPR are becoming more common. The cath-lab setting enables monitoring of vital physiological parameters and other clinical factors that can potentially guide the resuscitation effort. This retrospective analysis attempts to identify such factors associated with ROSC and survival.MethodsIn thirty-five patients of which background data, drugs used during the resuscitation and the intervention, PCI result, post ROSC-treatment and physiologic data collected during CPR were compared for prediction of ROSC and survival.ResultsEighteen (51%) patients obtained ROSC and 9 (26%) patients survived with good neurological outcome. There was no difference between groups in regards of background data. Patients arriving in the cath-lab with ongoing resuscitation efforts had lower ROSC rate (22% vs 53%; p = 0.086) and no survivors (0% vs 50%, p = 0.001). CPR time also differentiated resuscitation outcomes (ROSC: 18 min vs No ROSC: 50 min; p = 0.007 and Survivors: 10 min vs No Survivors: 45 min; p = 0.001). Higher arterial diastolic blood pressure was associated with ROSC: 30 mmHg vs No ROSC: 19 mmHg; p = 0.012).ConclusionAortic diastolic pressure during CPR is the most predictive physiological parameter of resuscitation success. Ongoing CPR upon arrival at the cath-lab and continued MCC beyond 10–20 min in the cath-lab were both predictive of poor outcomes. These factors can potentially guide decisions regarding escalation and termination of resuscitation efforts.

326 Chest Compression Fraction and Ventilation Rate Among Patients With Cardiopulmonary Arrest in an Urban, Academic Emergency Department

Cardiopulmonary resuscitation (CPR) guidelines place importance on achieving a chest compression fraction greater than 0.6, accompanied by a ventilation rate of 10 breaths per minute, to optimize perfusion during cardiac arrest and increase the likelihood of survival. We reviewed video of emergency department (ED) patients in cardiac arrest to evaluate the ability of the resuscitation team to adhere to these CPR targets. We conducted a retrospective observational video review of consecutive adults in cardiac arrest who received CPR in the ED of an urban, academic medical center from January 1, 2016, to July 31, 2017. All CPR was directed by senior resident and faculty emergency physicians in a dedicated resuscitation room with ceiling-mounted, motion-activated audiovisual recording. Patients were excluded from analysis if the video recording was incomplete or unavailable. We determined the delivered rate of manual ventilations as well as the chest compression fraction (CCF), defined as the fraction of time the patient received chest compressions while in cardiac arrest until return of spontaneous circulation, termination of resuscitative efforts, or 15 minutes of continuous CPR had passed. We evaluated the length of, and reason for, all pauses in chest compressions. Mechanical CPR was routinely used precluding evaluation of chest compression rate and depth during CPR. Complete video was available for 91 of 139 patients (65%) in cardiac arrest who received CPR. The study patients had a median age of 57 years (IQR 47-65), 73% were male, 19% had a shockable rhythm initially, and 91% received only mechanical CPR in the ED. The median total CPR time was 14 minutes (IQR 8.4-15, range 0.4-15.3). The median CCF was 0.93 (IQR 0.89-0.96). We observed 298 discrete pauses in chest compressions; the median pause duration was 13 seconds (IQR 8-23) and the median number of pauses per patient was 2 (IQR 2-4, range 0-15). There was variability in the duration of CPR pauses, on average, by the task(s) accomplished during the pause [Table]. For the 85 patients receiving manual ventilation during CPR (primarily delivered by respiratory therapists), the mean ventilation rate was 10 breaths/minute, which was similar with the use (10 +/- 2 breaths/min, n=68) or non-use (11 +/- 3 breaths/min, n=17) of an electronic respiratory metronome with a light that blinked every 6 seconds. CPR performance in this ED largely met and surpassed guideline-recommended best practices regarding chest compression fraction with adherence to ventilation rate. CPR was paused most frequently to assess for return of spontaneous circulation using palpation of pulses and point-of-care ultrasound concurrently, for a median duration of 15 seconds.

Validation of a Universal Rule for Termination of Resuscitation in the Field

Survival rates for patients with out-of-hospital cardiac arrest remain below 10%. Investigators in Canada conducted a retrospective, external validation of a previously described decision rule (JW Emerg Med Aug 25 2006) that recommends termination of resuscitation efforts in the field if all three of the following criteria are met: no shock delivered, …

Termination of resuscitative efforts: medical futility for the trauma patient.

Despite years of research on the resuscitation of the patient with critical traumatic injuries, controversy remains surrounding the criteria to waive initiation of resuscitation in the pre-hospital setting or to terminate such efforts in the emergency department. The decision to initiate or continue resuscitation on moribund trauma patients is associated with considerable costs. Ambulance transport using lights and sirens carries potential risk. Emergency department thoracotomy, with exposure to high risk bodily fluids, involvement of numerous staff, and usage precious blood products, is a procedure that has fewer and fewer indications. This review presents guidelines to help determine when to initiate resuscitation for the critically injured trauma patient and when to cease these efforts in the emergency department. Since there are economic, societal, and ethical implications, each system should establish their own criteria, using these guidelines as a basis.

Resuscitation decision index: a new approach to decision-making in prehospital CPR

Retrospective and prospective studies have been undertaken to assess physicians’ practice-patterns by studying cardiopulmonary resuscitation (CPR) case summaries. Most summaries reveal similar influences by the physician, patient and situation-related variables on the patterns of resuscitation. The initiation of resuscitation efforts is addressed frequently, but, very few studies discuss the topic of termination of resuscitation. Prehospital emergencies are addressed very rarely. The objective of this study was to introduce a new methodological approach towards initiation and termination of resuscitation efforts in prehospital situations. The subject studied were the physicians’ decisions concerning initiation/withholding, termination/withdrawal and the resulting early survival rates. The result is termed the ‘Resuscitation decision index’ (RDI). The ‘RDI’ could be a tool allowing comparisons on a quantitative level, between different EMS systems or disciplines and giving an insight into the decision process. The ‘RDI’ can enhance audit of resuscitation. The process of decision-making can be used to help future theoretical decision-making strategies.

Prehospital resuscitation practices: A survey of prehospital providers

Numerous factors affect decision making in the prehospital provision of resuscitative care. This study was undertaken to determine current practices involved in the initiation, continuation and termination of resuscitative efforts, and the impact of advance directives, in the prehospital resuscitation setting. This cross-sectional mailed questionnaire surveyed 3807 members of the National Association of Emergency Medical Technicians. The study instrument included questions regarding the termination and withholding of resuscitative efforts in the prehospital setting, as well as survival rates, local protocols and compliance with advance directives. Of 1546 respondents (41% response rate), with a mean 9.0 years of experience, most (89%) indicated that they would withhold resuscitative efforts in the presence of an official state-approved advance directive. However, very few providers would withhold resuscitative efforts if only an unofficial document (4%) or verbal report of an advance directive (10%) were available. Providers with more than 10 years experience were more likely to withhold resuscitation attempts in the presence of only a verbal report of an advance directive (p = 0.02, Chi-square), and were more likely to withhold resuscitation attempts in situations they considered futile (p = 0.001, Chi-square). Most (77%) respondents have local EMS guidelines for termination of resuscitation in the prehospital setting, but 23% of those consider existing guidelines to be inadequate. The majority of prehospital providers stated that they honor official state-approved advance directives, but do not follow directives from unofficial documents or verbal reports of advance directives. More experienced providers stated that they withhold resuscitative efforts more often in futile situations, or in the presence of unofficial advance directives. Advance directives should be utilized more uniformly among patients who wish to forgo resuscitative efforts in the event of cardiac arrest. Because many local protocols are judged to be inadequate, we support the institution of improved clinical guidelines regarding the prehospital termination of resuscitative efforts.

Lung Compliance Following Cardiac Arrest

To determine lung compliance in patients who had out-of-hospital cardiac arrests. A prospective, observational study of patients suffering nontraumatic cardiopulmonary arrest and requiring CPR at one university hospital ED. Following termination of resuscitation efforts, lung compliance was measured. Measurements were made while inflating the lung from 250 mL to 2,000 mL (in 250-mL increments) using a calibrated supersyringe. Airway flow and pressure were measured at the endotracheal tube with a pneumotachograph and a pressure transducer. Flow and pressure signals were recorded by a respiratory monitor and used to construct pressure-volume curves for calculation of lung compliance. The 25 cardiac arrest patients (17 men, eight women) had a mean (+/- SD) age of 65 +/- 7 years. Mean lung compliance was 0.051 +/- 0.011 L/cm H2O. Lung compliance was smaller at low lung volumes, suggesting the presence of alveolar collapse. Compliance values from 500 mL to 1,500 mL were similar. Compliance also diminished with increasing duration of CPR. One previous publication suggested that lung compliance following resuscitation is 0.022 L/cm H2O. The results of this study, using the accepted standard measurements of static lung compliance, suggest that true compliance is twice this value. This finding has important ramifications for future research on ventilation during resuscitation and current ventilation standards.

Out-of-Hospital CPR-Reply

In Reply. —The letter from Dr Jolly addresses a very important issue and we concur with his remarks. Implementing a policy that would allow for on-scene termination of resuscitation efforts may not be so easy in many communities. The traditional expectation of the public has been that the EMS system was established primarily to transport patients to a hospital. However, this simplistic perception of the role of EMS is rapidly evolving. 1 The provision of out-of-hospital care does not always necessitate hospital transport, particularly in sophisticated EMS systems with intensive and expert medical supervision. 1-3 Nevertheless, because of traditional public expectations, field termination policies would require the clear support (and widespread education of the public) by the EMS medical director. Communities such as Seattle and Milwaukee, Wis, have always allowed for termination of resuscitative efforts at the scene. In these EMS programs, the physician leadership and overall survival rates have