POTD: EMS Termination of Arrest (NYC)
Today’s POTD is thanks to Dr. Friedman and influenced by a cardiac arrest case last week. In very short summary, an elderly male with a history of COPD witnessed (?) cardiac arrest on the street and was ultimately brought to the ED with ongoing CPR after 40 minutes of ACLS in the field. Asystole/PEA. They were already intubated on arrival, and ROSC was achieved ~10min after arriving to the ED.
We were debriefing the case afterwards when the comment came up that EMS didn’t terminate in the field because it was in the street, and if the arrest had happened in the home they would have called for termination. Which prompted the question: When do pre-hospital providers consider termination of resuscitation vs. transport to the hospital?
Termination of Resuscitation shall be considered for cardiac arrests with all of the following criteria:
Patient Characteristics
• Age ≥ 18 years old
• Arrest etiology is non-traumatic or is not due to any of the following:
• Drowning
• Hypothermia
• Suspected pregnancy
• Lightning injury/electrocution
• Suspected overdose
• Hanging/asphyxia
Resuscitation Components:
• Unwitnessed arrest without bystander CPR
• At least 30 minutes of EMS resuscitation time, including at least ALS resuscitative care for 20 minutes
• No return of spontaneous circulation (ROSC) during resuscitation at any time
• No defibrillation is performed during resuscitation at any time
• Rhythm remains in asystole or PEA (rate < 40) throughout resuscitation
• Arrest does not take place in a public area
Important Exceptions to TOR Guidelines
1. Resuscitation attempts should be immediately terminated upon presentation of a valid DNR (Do Not Resuscitate) order. TOR criteria do not need to be met to halt resuscitation when a patient’s DNR status is identified.
The following DNR orders may be accepted by prehospital providers (other DNR orders cannot be honored in the prehospital setting):
a. New York State Department of Health (DOH) Out-of-Hospital DNR form or DNR bracelet.
b. MOLST (Medical Orders for Life-Sustaining Treatment) form indicating DNR status. c. Physician’s DNR order in the medical chart when the patient is in the medical care facility under the physician’s care.
We all know that out-of-hospital cardiac arrests (OHCA) have very poor outcomes at baseline, whether for neurologically intact survival or even just survival until discharge. These numbers are even worse for PEA/Asystole. UpToDate estimates that, for asystole, 10% of OHCA survive until discharge, with 5% surviving with good neurological function. For PEA, the numbers were ~20% survival and ~10% with good neurological function.
Two important factors that are known to improve outcomes are (1) immediate, well performed compressions (most of the time initiated by a bystander) and (2) early defibrillation for shockable rhythms. These factors appear to be heavily involved in the decision making to terminate arrest in the above EMS protocol.
As Q likes to say (and others, I’m sure, but I live with Q), there’s good medicine in these EMS protocols. Personally, I haven’t read many of them, but I’ll be paying more attention from now on.
Lastly, some guidelines on when EMS will initiate CPR.
CPR shall be initiated on all patients who are not breathing (apneic) and pulseless unless the patient has any of the following conditions:
• Extreme dependent lividity
• Rigor mortis
• Tissue decomposition
• Obvious mortal injury
• Valid do not resuscitate (DNR) order or medical orders for life-sustaining treatment (MOLST) form or eMOLST (Appendix C: Do Not Resuscitate (DNR) / Medical Orders for Life Sustaining Treatment (MOLST)
• Terminal illness is not a contraindication to CPR
• Cardiac arrests secondary to drowning, hanging, or electrocution shall be treated as non-traumatic cardiac arrests
Pediatric:
• CPR is required for pediatric patients with severe bradycardia (heart rate < 60 beats/min AND signs of shock or altered mental status)
• If available, pediatric AED/monitor pads and cables shall be used for all pediatric patients age < 9 years
• If pediatric AED/monitor pads and cables are not available, the adult AED/monitor pads and cables shall be used
• CPR shall be continued until any of the following conditions are present
• Return of spontaneous circulation (ROSC)
• Resuscitative efforts have been transferred to providers of equal or higher level of training
• Qualified, licensed physician assumes responsibility for the outcome of the patient
Thanks,
David
https://www.uptodate.com/contents/prognosis-and-outcomes-following-sudden-cardiac-arrest-in-adults