I hope everyone had a delightful Thanksgiving day or Turkey Day if you are a part of my family. You may have noticed that some of the other authors have been filling my voids with some excellent posts. We have quite a few consistent readers, and I hope that this blog has become a reliable educational resource. As always, I am overly busy, but I plan on writing a lot more than I have recently. The ECG tutorial will continue, I promise.

PURPOSE OF REVIEW: Tissue-type plasminogen activator is the only pharmacological treatment approved for acute ischemic strokes but is administered to less than 5% of the patients. Excessive prehospital and in-hospital delays and lack of stroke center coverage are major issues that negatively impact stroke care. New strategies are being developed and evaluated to increase the number of tissue-type plasminogen activator-treated patients. RECENT FINDINGS: Factors that limit rapid access to acute stroke care are discussed, including those influencing time intervals from stroke onset to hospital admission. We also describe strategies that hold promise to reduce prehospital delays and increase access to acute stroke treatment. SUMMARY: The shortening of prehospital delays requires education of patients and health professionals and optimization of transport strategies. Future developments may include video conferencing offering telestroke expertise, strategies (i.e. therapeutic interventions) that might help to treat acute stroke patients with tissue-type plasminogen activator, and prehospital selection of candidates for endovascular therapies.

Photo courtesy of Unity VFD, Pa.

You are a medic student currently volunteering for a fire department but work as an EMT. You are on the computer at the fire station studying for class when you get a call for a single vehicle MVC with unknown injuries. You and another EMT, Bill, who is more experienced than you, as well as a first responder, Rick jump in the SUV/QRV and respond. An ALS ambulance is enroute from the same service you work at, with a 15 minute ETA. This will be exciting, you think. You are driving, pulse racing and anxious, palms sweating, thinking of how you will handle the call, listening to PD on the scanner regarding the call. The car was found by passers-by; unknown time of accident. You look in the rear view mirror and notice Rick is looking pretty anxious. You look over at Bill, who is sitting calmly, pulling a piece of chewing gum from a wrapper. He offers you a piece and while you take one, he states, “The patient will either be DOA or GOA.” He then listens to the PD on the radio say they found the patient next to a tree and appears to be unresponsive. Then they say is appears DOA. Bill looks at you, raises his eyebrows, and says, “see; told you.”

You arrive to the flashing red and blue lights of PD and see a car crumpled off the road and about 15 feet in the tree line, a cop frantically waving a flashlight. You stop briefly to look at the car to get an idea of MOI, and then jog over to the cop, standing over a crumpled young man in his early 20s if that. Though there is poor lighting, it appears obvious there is no circulation. There is a lot of blood around him and blood on the tree. It appears he may have been unrestrained, ejected and took a header into the tree. Rick, holding the jump bag, is standing next to you with a look of shock. The patient has an obvious head injury, but not incompatible with life. You reach down and feel for a pulse, The skin temperature is close to the cool ambient temperature of the night. You tell Rick to retrieve the AED while Bill walks over after doing a scene survey for other patients. He is sure there aren’t any. He asks you what is going on and you tell him you have a traumatic arrest. He looks at the car, and then to Rick running back with the AED, then shakes his head, and calmly gets on the radio to cancel the ALS. As Rick runs up with the AED, out of breath, Bill tells him it won’t be necessary.

Photo credit www.consumershero.com

Photo courtesy, injuryboard.com

In this section, I will be discussing DOA and TOR guidelines and procedures. I am one who shies away from protocols as they keep you from thinking, but they also help protect you from liability if you follow them. Protocols do not always fit every situation and do not have to be followed to the letter, but medical command is necessary when you feel you need to deviate from them. Every state and province is different, review your regional protocols after reading what I say hear. Though I will be presenting generally accepted guidelines, many regions are still unique in their protocols. Let’s start with DOA procedures.

The manner of death, place of death, and local legal procedures dictate the type of procedures to be followed. For example, a murder victim will be handled by the police. Your role will simply be to determine if the patient really is dead or if resuscitation efforts will be useful. If the victim is a terminally ill patient who died with family and hospice nurse present, chances are, your locality puts most of the responsibility on the shoulders of EMS. A death at a home will involve family consoling and involve more reporting procedures than say, an MVC where all you will do is confirm death and go back in service.

Criteria, known as “medical futility criteria” were developed for EMS to prevent withhold or withdraw resuscitation efforts in hopeless situations where there is little chance, if any in complete resuscitation of the patient. These criteria included appropriate duration of resuscitation efforts and recommended procedures for on-scene pronouncement of death (Pepe, et al, 2001). Today, professional guidelines exist for EMS for basic and advanced providers (Bailey, et al, 2000), and they appear to be effective (Kamarainen et al, 2007).

Patients found dead on arrival (DOA) are much the same as TOR only instead of ceasing life support, it is simply withheld. An assessment needs accomplished as well as a decision made as whether or not to attempt resuscitation efforts and notification procedures are almost exactly the. same, often including interactions with family. Resuscitation should be withheld if obvious signs of death, are present, such as:
· Decomposition
· Rigor mortis
· Dependent livitity
· Submersion greater than 1 hour, regardless of temperature

• ...and injuries incompatible with life such as incineration and decapitation/transection

Photo courtesy connect.jems.com

For trauma patients, we need to look at the mechanism and type of injury. Generally blunt injuries are not candidates for resuscitation, regardless of rhythm, while penetrating injuries could be resuscitated as long as the injury is not inconsistent with life (Pepe, et al, 2001), however many regions don’t include this in their DOA protocols. An unwitnessed traumatic arrest should not be resuscitated nor should a traumatic arrest in entrapped patient with severe injury that is not compatible with life. Obviously an MCI where seriously ill patients outnumber EMS personnel is another situation where cardiac arrest should not be attempted, except in cases of multiple patients of lightning strikes, unless they meet the other criteria above.
There are a couple of exceptions. Pregnant women who arrest after trauma, and the arrest was witnessed by EMS providers, should be resuscitated and transported to closest receiving facility for the benefit of the fetus. Hypothermia is another exception, and remember these patients can be stiff. But if the body temperature is the same as the ambient temperature and there are other signs of death, or the body tissue or chest wall is frozen solid, resuscitation should not be attempted.

So can BLS providers determine whether cardiac arrest victims should or not be resuscitated? Though some states may not allow it, the general consensus in the literature and most state protocols is YES. If the victim meets the criteria listed above, ALS can be cancelled. Of course, if there is any doubt, err on the side of the patient, start resuscitation efforts and call medic command. Medic command may order termination of efforts.
What about ALS providers? Experts agree attempts at resuscitation should not be attempted on an asystole patient with unwitnessed non-trauma cardiac arrest or a penetrating injury, but many regions, like my state of Pa., does not include these in their protocols, though it is common practice here to not resuscitate them. A little bit of critical thinking and decision making is required, and the help of medical command consult, who often agree with medic decisions to not attempt resuscitation in these cases.

Photo courtesy of stevespak.com

Another reason to withhold resuscitation and or terminate it is when family produces a valid out of hospital DNR or advanced directives, or official DNR bracelet or necklace is found on the patient. We all know about DNRs and why we should honor them. Not honoring them is violating their consent, though they are now dead. However, what do we do if the family cannot produce the official copy but insists one is present? Start resuscitation, get a SAMPLE history, and call medical command for instructions. As an ALS provider, if the pt is terminally ill and the pt is in asystole, the pt. will not be a candidate for resuscitation but medic command must be contacted if protocols are gray in this area. Chances are, command will agree to withhold resuscitation.

Photo courtesy of Cityhigh.org; Dory Sanders, City High intern with coroner's office

Now that the patient is determined not to be a candidate for resuscitation, what else needs done? Again, it depends on the situation. At a crime scene, your only responsibility is to determine the patient is DOA. You need to preserve the scene as much as possible, leave and go back in service and the police will handle the rest. An MVC is much the same, only you may be tasked with notifying the coroner, though the police usually do this. At a residence, things are different. You will most likely have to get a SAMPLE history and then call the patient’s family MD to ask if he or she will sign the death certificate. Jurisdictions differ in this procedure. If the MD is willing to sign it, your next call will be the coroner. If the MD will not sign the death certificate, death is suspicious or family requests it, the coroner’s office will have to send out their staff to retrieve the body. Again, these actions differ with local. If someone from the coroner’s office is coming for the patient, someone has to wait with the body. Legally it a police responsibility, but the EMS usually do this out of courtesy to keep PD back in service and since the EMS handle the call from the beginning anyway. This unfortunately keeps a truck out of service, but this is opportune for a supervisor or BLS QRV person to free up the ambulance.

Termination of Resuscitation Procedures

As I stated in part 1, it is unethical now to transport cardiac arrest patients and adds to UNNECESSARY risk to EMS crews transporting them as they are unrestrained in the back and the ambulance going lights and sirens is at risk for MVC. The on scene care will be not much different than that performed in the ED, and there is usually no additional benefit to transporting the patient to the ED. Besides, CPR performed during patient packaging and transport is much less effective than CPR done on scene, though this can be alleviated with automatic CPR machines, though these are expensive and not consistently used in the US.

Since the late 90s, most EMS services have protocols to terminate resuscitation efforts in the field and surveys show most medics seem comfortable with the concept. Yet, I still see EMS providers transporting cardiac arrest patients. I have tried to find data on those arrest patients that are transported as opposed to those that get resuscitation efforts and subsequent pronouncement, but data is almost nonexistent (Morrison, et al, 2008). When I ask EMS providers who continue to transport cardiac arrest patients why they do it, I am given a variety of answers that boil down to lack of confidence in notifying the family and consoling them, lack of confidence in deciding when to cease life saving efforts, and not wanting to take time out on scene helping the family or waiting for a coroner (thought this time is not much longer than transport, report, clean-up and restocking).

Though this is generally an ALS concept, the option is available to BLS as well. For instance many protocols recommend that after 3 “no shock advised” messages on an AED and ETA to hospital or ALS is >15 minutes, contact medical command for termination. The same holds true for traumatic arrests where bystanders or first responders started CPR. EMTs can call medical command to request termination. Of course all the factors regarding the arrest and MOI will have to be obtained and relayed to medical command to aid in the decision to terminate. As stated above, BLS can terminate when official DNR documentation is presented.

For ALS, most guidelines recommend medics consulting medical command for TOR if there is no positive response to approximately 20 minutes of ALS care including ventilation with advanced airway, good vascular access and several rounds of resuscitation drugs. In remote or wilderness situations, when medical command cannot be contacted, medics can terminate on their own if there is no ROSC after 30 minutes (hypothermia excluded), transport to an ED will take longer than 30 minutes or the providers are too exhausted to continue.

Photo courtesy of CBC news; Paramedics should make call on resuscitation for cardiac arrest

Though these are not absolute, the following conditions should be CONSIDERED as exclusions to TOR:
· Drug OD
· Electrocution or lightning strike
· Hypothermia
· Near-drowning
· Pediatrics (Data obtained by Hickey, Cohen, Stausbaugh, and Dietrich (1995) showed peds still arrest when arriving in ED usually don't survive, either)
· Public place
· Environment where bystanders do not accept the idea of TOR

The procedures are to ensure the patient is in fact dead with no breathing, no femoral and carotid pulses, and asystole or idioventricular rhythm less than 10-60 on the monitor. Efforts must continue until command gives the order to terminate. This requirement may differ in various regions. From this point on, the procedures are much the same as for a DOA.

• Document the time of death at the time of TOR.


• If a crime scene, leave tube and catheters in place, keep away and preserve the scene and hand over to police (who should have been called as soon as a crime scene was recognized


• Inform family and friends who are present and provide grief consoling and don’t leave until family has adequate support


• Notify the PCP and ask if willing to sign death certificate
  


• Contact coroner (if an autopsy will be performed, leave all resuscitation adjuncts in place, leave patient in position


• If no autopsy, place patient in position that appears comfortable and clean up debris from the resuscitation


• Assist the family calling other family, friends, clergy and funeral director


• Consider calling the local organ donation program as many arrest victims can donate corneas, skin grafts or bone grafts.


• Sometimes the EMS will transport bodies as a service to aid the local coroner or funeral director. I have been tipped well for doing these, however, EMS is not designed for body transport as it is counter to original role of EMS and keeps a vehicle out of service
• Proper documentation-some services and regions have forms for DOAs and TORs

References sited:

American Heart Association (AHA), (2000), 2000 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 2: Ethical Aspects of CPR and ECC, Circulation.

American Heart Association (AHA), (2005), 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 2: Ethical Issues, Circulation. 2005;112:IV-6 – IV-11

Bailey ED, Wydro GC, Cone DC. (2000), Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest. National Association of EMS Physicians Standards and Clinical Practice Committee, Prehosp Emerg Care. 2000 Apr-Jun;4(2):190-5.

Commonwealth of Massachusetts, OEMS, (2009) Appendix C: Cessation of Resuscitation

Hickey RW, Cohen DM, Strausbaugh S, Dietrich AM. (1995)"Pediatric patients requiring CPR in the prehospital setting.", Annals in Emergency Medicine 1995 Apr;25(4):495-501.

Kämäräinen A, Virkkunen I, Yli-Hankala A, Silfvast T., (2007), Presumed futility in paramedic-treated out-of-hospital cardiac arrest: an Utstein style analysis in Tampere, Finland, Resuscitation. 2007 Nov;75(2):235-43. Epub 2007 Jun 5.

Morrison LJ, Bigham BL, Kiss A, Verbeek PR., (2008) Termination of resuscitation: a guide to interpreting the literature. Resuscitation. Dec;79(3):387-90. Epub 2008 Sep 20.
Morrison LJ, Visentin LM, Vermeulen M, Kiss A, Theriault R, Eby D, Sherbino J, Verbeek R., Inter-rater reliability and comfort in the application of a basic life support termination of resuscitation clinical prediction rule for out of hospital cardiac arrest, ResuscitationVolume 74, Issue 1, July 2007, Pages 150-157

Pennsylvania Statewide Advanced Life Support Protocols, (2008) Termination Of Resuscitation, 3091-1 thru 3091-2

Pennyslvania Statewide Basic Life Support Protocols, (2008), Dead on Arrival, 322-1, Out-of-hospital Do Not Resuscitate, 324-1, Cardiac Arrest-General, 331-1 thru 331-3, Cardiac arrest-Traumatic, 332-1

Pepe PE, Swor RA, Ornato JP, Racht EM, Blanton DM, Griswell JK, Blackwell T, Dunford J; Turtle Creek Conference II., (2001) Resuscitation in the out-of-hospital setting: medical futility criteria for on-scene pronouncement of death, Prehosp Emerg Care. 2001 Jan-Mar; 5(1):79-87.

Photo courtesy of Las Vegas Review-Journal

Recently I was the assisting Paramedic for a neighboring service on a cardiac arrest call. Immediately after determining the patient was in a possible witnessed cardiac arrest, CPR was started and the monitored showed asystole. Within a couple of minutes, before IV access was obtained or intubation attempted the medic started shouting, “let’s load and go!” I looked at my partner dumbfounded, and asked the medic if he was sure he did not want to try for ROSC and consider TOR later. It was his call and he said his service transports all arrests. Of course I had to approach their supervisors, and they denied that claim. Recently, at a PALS class, all the medics in their class stated they transport all arrests except the obvious DOAs. Again, I was dumbfounded, so I thought I would discuss this issue here.

Photo Courtesy of www.life-save.org

In fact, now it is no longer acceptable to transport cardiac arrest patients to the hospital (Grudzen, 2006). It is considered unethical for many reasons (AHA, 2000): It ties up a needed bed in an overcrowded ED; it ties up needed members in the ED who must continue the resuscitation; it incurs unnecessary hospital charges; it increases time that EMS crews are not available for another call; it gives the family a false sense of hope and causes them much inconvenience in coming to a crowded ER out of touch with their loved one. It can also be dangerous for the family driving to the hospital in a stressed state of mind (Dick, 2007), and most importantly, dangerous to the public and EMS crew travelling to a hospital lights and sirens with attendants providing resuscitation efforts in the back, unrestrained.

Courtesy of gayaruangkepelbagaim.wordpress.com

Photo courtesy of Michael Ging at photo.net

According to a survey done by Smith (2005), about half of EMS providers felt that their role should include notifying the family of the death, but “three-quarters reported they had not been trained adequately to make a death notification.” She and Feldman (2004) evaluated the change in behavior of EMS providers following death education training were more confident and planned to change their behavior at the scene of death. There are many training programs offered to EMS. However, there is no standardized or required grief support training for EMS, and it is severely deficient in initial EMS training. Cudos should go out to the AHA for including death notification in their 2000 Guidelines PALS video. Since most ALS providers need PALS training, their only grief support training was provided in this video. Still, death notification and grief support training is not consistent and lacking.