Case Review
After responding to a reported unconscious person, Medics Davis and Mills find a 68 year old male in cardiac arrest. Davis begins chest compressions while Mills attaches the monitor/defibrillator. The ECG displays asystole. Davis resumes chest compressions.
Before the end of the first two-minute cycle of CPR, Engine 23 arrives and the firefighters take over CPR. Mills establishes IV access and Davis inserts a supraglottic airway and verifies its correct position. The end-tidal carbon dioxide reading is 12 mm Hg and Davis confirms that the firefighters are performing high-quality chest compressions. As the two-minute CPR cycles ends, Mills determines the patient remains in asystole.
During the next 10 minutes, the resuscitation team delivers a total of two milligrams of epinephrine and prepares the patient for transport to a local hospital. The patient’s wife asks the engine officer if all of these efforts are really necessary. She states the patient always said he wanted to die in his own home. The officer explains to the wife that their medical protocols require the medics to transport the patient to the hospital.
About 25 minutes after arriving on the scene, the medics arrive at the hospital and the patient is immediately produced dead. Later in the station, the crew discusses the apparent futility of transporting that patient to the hospital. No one at the table can ever remember a patient surviving neurologically intact after arriving at the hospital with CPR in progress.
Study Review
Researchers in two large urban United States cities examined survival rates for patients who suffered an out-of-hospital cardiac arrest and were transported to the hospital without ever having achieved return of spontaneous circulation (ROSC) (Wampler, Collett, Manifold, Velasquez, & McMullan, 2012).
Over a three year period from 2008 through 2011, researchers accessed both the in-house cardiac arrest database containing cases from the San Antonio Fire Department and the Cardiac Arrest Registry to Enhance Survival (CARES) data registry that houses cases managed by the Cincinnati Fire Department. The researchers only included cases where the cardiac arrest was presumed to be of cardiac etiology. Local medical protocols dictated the care in each city.>
Since this was a retrospective study, there was no attempt to standardize medical care provided by the EMS responders in each city.
Results
During the study period, paramedics in the two cities attempted to resuscitate 2,483 patients, with about 80% of the cases coming from San Antonio. The researchers measured a variety of demographic and response variables and found the cases in each city were similar with respect to age, gender, and whether someone on scene witnessed the onset of the arrest.
However, a significantly greater percentage of patients in San Antonio were Hispanic (52% vs. 1%), received bystander CPR (46% vs. 35%), and achieved ROSC in the field (40% vs. 23%).
On the other hand, a significantly greater percentage of patients in Cincinnati were African American (46% vs. 11%) and presented in a shockable rhythm (25 vs. 14%).
Of the 2,483 cases of out-of-hospital cardiac arrest, 1,589 (64%) never achieved ROSC in the field. Only 11 (0.69%) of those patients achieved ROSC at the hospital and survived to hospital discharge. All 11 survivors who never achieved ROSC in the field occurred in the Cincinnati cohort.
The onset of the arrest was witnessed by bystanders in eight of those cases while two additional cases arrested in the presence of EMS personnel. Eight patients presented to EMS in a shockable rhythm. When the hospital discharged the patients, six of the 11 survivors had good neurological outcome, defined as a Cerebral Performance Categories (CPC) scale score of one (Cummins et al., 1991).
What This Means for You
If patients do not achieve ROSC in the field, survival to hospital discharge is rare. Researchers in Tennessee found that 0.8% of patients who failed to achieve ROSC in the field survived to hospital discharge and both of those patients were discharged to nursing homes with severe neurological deficits (Kellermann, Staves, & Hackman, 1988).
A follow-up study conducted in the same city years later involving 1068 cases of out-of-hospital cardiac arrest found that only 0.4% of patients who did not achieve ROSC survived to hospital discharge (Kellermann, Hackman, & Somes, 1993). A Houston study involving 1461 patients who suffered an out-of-hospital cardiac arrest found that 952 did not achieve ROSC at the scene and only 6 (0.6%) survived to hospital discharge (Bonnin, Pepe, Kimball, & Clark, 1993). All six of those patients had refractory ventricular fibrillation.
In a study involving 24 BLS EMS agencies in 12 rural and urban regions of Ontario, Canada (Morrison et al., 2006), only 0.5% of patients who did not achieve ROSC before transport, did not receive a prehospital shock, and had a cardiac arrest that was not witnessed by EMS survived to hospital discharge, well below the suggested 1% threshold for a physician to declare a medical intervention to be futile (Schneiderman, Jecker, & Jonsen, 1990).
Transporting a patient with CPR in progress is not without risk. Less than half of all chest compression performed in the back of a moving ambulance meet the guidelines for proper hand placement and compression depth (Stone & Thomas, 1995).
The inability to provide chest compressions that meet depth recommendation severely impacts ROSC rates (Bohn et al., 2011; Kramer-Johansen et al., 2006). About 60% of all ambulance crashes involving a fatality occur while the ambulance is traveling with the lights and sirens activated (Kahn, Pirrallo, & Kuhn, 2001). During a crash, EMS personnel providing patient care while riding in the patient compartment are three times more likely to suffer a serious or fatal injury than the driver.
Given these realities, EMS agencies and Medical Directors should consider implementing local termination of resuscitation policies and protocols.
The latest American Heart Association (AHA) Guidelines recommend two different strategies for field termination of resuscitation efforts (Morrison et al., 2010). For exclusively BLS systems, EMS personnel should consider field termination when three termination criteria exist: (a) no EMS professional witnessed the onset of arrest; (b) no ROSC after three full rounds of CPR and AED analysis; and (c) no shock delivered by the AED.
For ALS systems, the AHA recommends that advanced-level providers consider field termination when four criteria exist: (a) no one witnessed the onset of the arrest; (b) no bystanders performed CPR prior to EMS arrival; (c) the patient never achieved ROSC after full ALS implementation; and (d) no shock delivered by an AED. In October 2011, the National Association of EMS Physicians (2011) issued a position paper on field termination of resuscitation efforts stating that EMS personnel should consider field termination when three criteria exist: (a) no EMS professional witnessed the onset of the arrest; (b) there was never a shockable rhythm present; and (c) the patient never achieved ROSC on scene.
Limitations
Despite the prospective nature of data collection in this study, the researchers had no control over any of the variables that affects patient outcome, such as response intervals or CPR quality. As such, there is always a possibility that something other than the absence of field ROSC explains the poor survival. However, the results of this study are consistent with others.
The authors report that the datasets did not contain complete information about the nature of the emergency response. As a result, the researchers could not verify that response intervals were the same in both cities. The fact that a significantly greater percentage of patients in Cincinnati presented in a shockable rhythm (25% vs. 14%) suggest that response intervals were shorter in that city compared to San Antonio.
Summary
It is very rare for a patient who suffers an out-of-hospital cardiac arrest and fails to achieve ROSC in the field to survive long enough for discharge from the hospital. If patients are to recover, EMS personnel must restore a heartbeat before transporting the patient to a hospital.
In instances where the patient does not achieve ROSC prior to transport, EMS personnel should consider termination of all resuscitation efforts in the field.
References
- Bohn, A., Weber, T. P., Wecker, S., Harding, U., Osada, N., Van Aken, H., & Lukas, R. P. (2011). The addition of voice prompts to audiovisual feedback and debriefing does not modify CPR quality or outcomes in out of hospital cardiac arrest--a prospective, randomized trial. Resuscitation, 82(3), 257-262. doi:10.1016/j.resuscitation.2010.11.006
- Bonnin, M. J., Pepe, P. E., Kimball, K. T., & Clark, P. S. Jr. (1993). Distinct criteria for termination of resuscitation in the out-of-hospital setting. Journal of the American Medical Association, 270(12), 1457-1762. doi:10.1001/jama.1993.03510120079035
- Cummins, R. O., Chamberlain, D. A., Abramson, N. S., Allen, M., Baskett, P. J., Becker, L., Bossaert, L., Delooz, H. H., Dick, W. F., Eisenberg, M. S., Evans, T. R., Holmberg, S., Kerber, R., Mullie, A., Ornato, J. P., Sandoe, E., Skulberg, A., Tunstall-Pedoe, H., Swanson, R., & Thies, W. H. (1991). Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: The Utstein Style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation, 84(2), 960-975. doi:10.1161/01.CIR.84.2.960
- Kahn, C. A., Pirrallo, R. G., & Kuhn, E. M. (2001). Characteristics of fatal ambulance crashes in the United States: An 11-year retrospective analysis. Prehospital Emergency Care, 5(3), 261-269.
- Kellermann, A. L., Hackman, B. B., & Somes, G. (1993). Predicting the outcome of unsuccessful prehospital advanced cardiac life support. Journal of the American Medical Association, 270(12), 1433-6. doi:10.1001/jama.1993.03510120055030
- Kellermann, A. L., Staves, D. R., & Hackman, B. B. (1988). In-hospital resuscitation following unsuccessful prehospital advanced cardiac life support: ‘Heroic efforts’ or an exercise in futility? Annals of Emergency Medicine, 17(6), 589-594. doi:10.1016/S0196-0644(88)80398-6
- Kramer-Johansen, J., Myklebust, H., Wik, L., Fellows, B., Svensson, L., Sørebø, H., & Steen, P. A. (2006). Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: A prospective interventional study. Resuscitation, 71(3), 283–292. doi:10.1016/j.resuscitation.2006.05.011
- Morrison, L. J., Kierzek, G., Diekema, D. S., Sayre, M. R., Silvers, S. M., Idris, A. H., & Mancini, M. E. (2010). Part 3: Ethics: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122(18 Suppl 3), S665-S675. doi:10.1161/CIRCULATIONAHA.110.970905
- Morrison, L. J., Visentin, L. M., Kiss, A., Theriault, R., Eby, D., Vermeulen, M., Sherbino, J., Verbeek, P. R. & the TOR Investigators. (2006). Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. New England Journal of Medicine, 355(5), 478–487. doi:10.1056/NEJMoa052620
- National Association of EMS Physicians. (2011). Termination of resuscitation in nontraumatic cardiopulmonary arrest [National Association of EMS Physicians position statement]. Prehospital Emergency Care, 15(4), 542. doi:10.3109/10903127.2011.598621
- Schneiderman, L. J., Jecker, N. S., & Jonsen, A. R. (1990). Medical futility: Its meaning and ethical implications. Annals of Internal Medicine, 112(12), 949-954
- Stone, C. K., & Thomas, S. H. (1995). Can correct closed-chest compressions be performed during prehospital transport? Prehospital and Disaster Medicine, 10(2), 121-123.
- Wampler, D. A., Collett, L., Manifold, C. A., Velasquez, C., & McMullan, J. T. (2012). Cardiac arrest survival is rare without prehospital return of spontaneous circulation. Prehospital Emergency Care, 16(4), 451-455. doi:10.3109/10903127.2012.695435
The author has no financial interest, arrangement, or direct affiliation with any corporation that has a direct interest in the subject matter of this presentation, including manufacturer(s) of any products or provider(s) of services mentioned. Send correspondence concerning this article to Kenneth W. Navarro, The University of Texas Southwestern School of Health Professions, 6300 Harry Hines Blvd, MC 9134, Dallas, Texas 75390-9134. E-mail: kenneth.navarro@utsouthwestern.edu
