Chronicles of EMS, A Seat at the Table takes on CPR effectiveness.  The Las Vegas video that they mention can be found below as well.  Keep up the good work Justin and Mark!

Side note - ILCOR, The International Liaison Committee On Resuscitation has not found any supporting evidence for the Autopulse.  They are the ones whom do the research for AHA.  Also, transporting patients without a pulse should be re-looked at by any agency performing this practice.  The initial treatment at the ER will not differ from the treatment we provide at the scene per ACLS guidelines.  Why not give the patient the best chance possible.  If they don't get a pulse back on scene, it is probably never going to come back--that's just the facts.

It's that time again.  As most of us Americans in the wide world of emergency medicine know, every five years the American Heart Association updates their recommendations.  Those recommendations happen to be the standard for most prehospital agencies, and hospital systems.  They say and we do.  So what are we going to be doing now?


This year should not be bringing about any mega changes.  The direction has stayed the same for the most part.

Where do the updates come from?


ILCOR - The International Liaison Committee on Resuscitation

Process for Evidence Evaluation

The publication of the 2010 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science with Treatment Recommendations (CoSTR) will represent the scientific consensus of experts from a variety of countries, cultures and disciplines. Internationally recognized experts were brought together by the International Liaison Committee on Resuscitation (ILCOR) to evaluate and form an expert consensus on all peer reviewed scientific studies related to CPR.

To achieve this goals, ILCOR is conducting systematic reviews and updates of scientific evidence supporting resuscitation treatment recommendations. More than 500 resuscitation scientific topics will undergo evidence-based review. This process represents the most comprehensive, systematic review of the resuscitation literature to date.

The worksheets posted at this site represent the first step of an international consensus evidence evaluation process that will culminate in the publication of the 2010 International Consensus on CPR and ECC Science with Treatment Recommendations. In addition, resuscitation council-specific guidelines will also be published based on this international science consensus. Worksheet authors and expert reviewers worked very hard to present the information objectively.

The information contained in these worksheets will be presented and discussed between now and early 2010. In early 2010, the International CPR Consensus Conference will convene to allow final presentation and discussion of these worksheets, leading to evaluation and consensus by respective ILCOR Task Forces.
Readers are cautioned that these worksheets are a preliminary review and do not represent any ILCOR Task Force or Resuscitation Council recommendations.

ILCOR recognizes that the integrity of the evidence evaluation process depends on successfully managing real and perceived conflict of interest. ILCOR has policies in place to manage conflict of interest.
The 2010 evidence evaluation and science review process will culminate with the International CoSTR Conference in early 2010, in Dallas, Texas.

A separate publication covering guideline recommendations will be published by each resuscitation council.

So what does this all mean?

The AHA is part of an international committee that uses a systematic review system to scan through all the most valuable research available.  The research is graded by how useful an unbiased it is, and then recommendations are made based upon a compilation of the results.  The package all of this up in a nice-looking book, packed with a bunch of fancy flow charts, tables, and algorithms, and we buy it.

Link to the questions asked for 2010


Time of old

Amiodarone - Back in 2000 Amiodarone was given a class IIb recommendation from AHA.  This was a push from, who else, the manufacturers of Amio.  This happened synchronously with the changing of Lidocaine from a class IIb to an indeterminate rating.  This occurred after a study showed that Amiodarone improved the number of cardiac arrest that regained pulses.  This was accepted by many, and all the better, Amio works in atrial and ventricular arrhythmias--yippee.

The facts:

• Amiodarone improved the amount of people that regained pulses, but not the amount of cardiac arrests that survived to discharge.  No more people are surviving on Amio compared to Lidocaine.   AHA knows this now, and has known this for a while.  

• AHA says that an "indeterminate" rating is no different from class IIb.  So why the change?  Because class IIb sounds a whole lot better when your selling a new drug.

So does this mean we are going back to lidocaine?  Not sure, because there isn't any evidence that lidocaine is any better either--should we confuse everyone more?  In fact, there is no evidence that any dysrhythmic does anything beneficial in cardiac arrest.  That's right, no quality evidence supporting beneficial effects of dysrhythmics.  Want some more?  NO DRUGS administered in cardiac arrest have any supporting evidence!

Olasveengen TM, Sunde K, Brunborg C, et al. Intravenous drug administration
during out-of-hospital cardiac arrest. JAMA 2009;302:2222-2229.

Despite the traditional use of intravenous medications such as vasopressors and antiarrhythmics for victims of cardiac arrest, there is actually very little evidence to support these therapies. On the contrary, a recent multicenter center study demonstrated that the use of intravenous medications that are advocated in standard advanced cardiac life support (ACLS) guidelines was ineffective at improving survival of patients with out- of-hospital cardiac arrest (1). Olasveengen and colleagues now add further support to the contention that the use of intravenous medications in victims of non-traumatic cardiac arrest is not associated with improvements in meaningful outcomes. The authors performed a prospective randomized trial of consecutive adults with non-traumatic cardiac arrest that were treated within their emergency medical services (EMS) system in Oslo between 2003 2008. Patients were randomized to either receive standard ACLS therapies with intravenous drug administration (IV group) or ACLS therapies without any intravenous drugs (no IV group). A total of 851 patients were included in the study, 418 patients in the IV group and 433 in the no IV group. The researchers found there was an increase in survival to hospital admission with return of spontaneous circulation in the IV group vs. the no IV group (32% vs. 21%, P < 0.001). However, there was no difference between the IV group vs. the no IV group in terms of survival to hospital discharge (10.5% vs. 9.2%, P = 0.61), survival with favorable neurological outcome (9.8% vs. 8.1%, P = 0.45), or survival at 1 year (10%  vs. 8%, P = 0.53). The results demonstrate that with the use of IV ACLS medications, patients simply die in the hospital rather than in the ED. Practically speaking, this amounts to increased intensive care unit bed utilization, hospital resource utilization, and expenses; but without any increase in meaningful survival. In this era of ED and hospital overcrowding and the increasing demand for cost-effectiveness in medical therapies, Stiell’s and Olasveengen’s studies should force us to consider that the use of IV medications for patients in cardiac arrest should be the exception rather than the rule…or guideline. 

1. Stiell IG, Wells GA, Field B, et al. Ontario Prehospital Advanced Life Support Study Group. Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med 2004;351:647-656.

Back to Amiodarone 2010:

CONSENSUS ON SCIENCE:
Evidence from 1 RCT demonstrates the benefit of amiodarone over placebo for shock refractory or recurrent VT/VF for the endpoint of survival to hospital admission, but not to survival to hospital discharge. Retrospective trials show that lidocaine may be more beneficial than placebo, but selection bias mars these trials. In trials that directly compare amiodarone to lidocaine, patients administered amiodarone generally do better in short term results (ie survival to hospital admission), but no trial has shown an improvement in overall survival (Dorian P 2002 p884, Somberg J 2002 p853). 

These trials were performed before the benefits of hypothermia was known, thus they did not incorporate this now proven therapy which improves survival after ROSC. Whether survival to hospital discharge and neurologic survival could be improved with amiodarone and subsequent hypothermia is not known. If that is the case then a stronger argument for amiodarone could be made; if that is not the case then an argument could be made to not give an AAD at all.

CPR Before Defibrillation

It was taught, back in 2005 by AHA, that we need to prime the pump.  It was theorized that performing early defibrillation has no benefit because the heart was not being adequately perfused.  This lead to a 2 minutes of CPR prior to shocking in an unwitnessed arrest rule.  This is what we, who are AHA compliant, are doing.

CONSENSUS ON SCIENCE:
Two randomized controlled trials (LOE I) (Baker 2008 p424; Jacobs 2005 p39) demonstrated no improvement in ROSC or survival to hospital discharge in patients suffering out-of-hospital VF or pulseless VT who received CPR by EMS personnel for a period of 1.5 to 3 minutes before defibrillation, regardless of EMS response interval being greater or less than 5 minutes. One case series study (LOE IV) (Campbell 2007 p229) also failed to demonstrate improvements in ROSC or survival to hospital discharge with bystander versus no bystander CPR before defibrillation.
One randomized controlled trial (LOE I) (Wik 2003 p1389) and clinical trial (LOE III) (Cobb 1999 p1182) identified overall similar findings however improvements in ROSC, survival to hospital discharge and neurological outcome were observed in patients where the EMS response interval was greater than 4 to 5 minutes.

Evidence from one LOE 1 study (Wik 2003, 1389), one LOE 3 study (Cobb 1999, 1182) and five LOE 5 studies (Berg 2004, 1352; Kolarova 2003, 2022; Menegazzi 1993, 235; Menegazzi 2004, 926; Niemann 1992, 281) support the strategy to delay defibrillation to give BLS first for 1,5 to 8 minutes, in particular when the delay to ambulance arrival exceeds 5 minutes and no BLS is given before ambulance arrival. Evidence from two LOE 1 studies (Baker 2008, 424; Jacobs 2005, 39), one LOE 3 study (Campbell 2007, 229) and nine LOE 5 studies (Berg 2004, 1352; Yakaitis 1980, 157; Menegazzi 2003, 261; Menegazzi 2000, 31; Seaberg 2001, 301; Kolarova 2003, 2022; Niemann 2000, 543; Menegazzi 1993, 235; Rittenberger 2008, 155) do not support this strategy and are neutral. One LOE 5 study (Indik 2009, 179) gave direct evidence for the opposite strategy

Level of evidence - all that LOE stuff you see above is a reference to the grade the mentioned study received by the reviewer.

LOE 1
Randomised Controlled Trials:
These studies prospectively collect data, and randomly allocate the patients to intervention or control groups. 

LOE 2
Studies using concurrent controls without true randomisation:
These studies can be:
· experimental - having patients that are allocated to intervention or control groups concurrently, but in a non-random fashion (including pseudo-randomisation: eg. alternate days, day of week etc), or
· observational – including cohort and case control studies
A meta-analysis of these types of studies is also allocated a LOE = 2. 

LOE 3
Studies using retrospective controls:
These studies use control patients that have been selected from a previous period in time to the intervention group. 

LOE 4
Case series: A single group of people exposed to the intervention (factor under study), but without a control group. 

LOE 5
As with other categories of Levels of Evidence, we have used LOE 5 to refer to studies that are not directly related to the specific patient/population. These could be different patients/population, or animal models, and could include high quality studies (including RCTs).

So according to the evidence, we may need more evidence.  However, there isn't much support to the current guidelines.  Once again, do we change this back and confuse more people when we are uncertain if outcomes will improve?


Cardiocerberal Resuscitation or Cardiopulmonary Resuscitation?

Should EMS be doing chest compression only CPR?  This is a good question when considering primary cardiac arrest.  We know that primary respiratory arrest should involve aggressive airway management.

CONSENSUS ON SCIENCE
Six fair to good LOE 5 animal studies (Berg 1993, 1907; Berg 1997, 1635; Berg 2001, 2464; Ewy 2007, 2525; Kern 1998, 179; Kern 2002, 645) have shown comparable or better outcomes with continuous chest compression CPR as compared with interrupted compressions for ventilation in nonasphyxial cardiac arrest and in concept support such a change in resuscitation strategy. However animal models do not necessarily mimic the anatomical or arrest features of humans, and for these reasons arguably may be less applicable to human resuscitation. Clinical evidence from three retrospective cohort LOE 3 studies in adults suffering from cardiac arrest (Bobrow 2007, 1158; Kellum 2006, 335; Kellum 2008, 244) showed that provision of chest compressions in the absence of rescue breathing by trained professional (EMS) providers led to an improvement in survival to hospital discharge compared to provision of chest compressions with rescue breathing. However, these studies had methodological shortcomings that limit the ability to determine whether the improvements in survival were attributable to the provision of chest compression-only CPR in the absence of rescue breathing, including the lack of randomization, the implementation of other resuscitation protocol changes that may have affected outcomes, or simply a stronger clinical emphasis on the provision of good CPR. The remainder of clinical studies addressing this issue evaluated the outcome from continuous chest compression versus interposed ventilation CPR by untrained laypersons (bystander CPR),and did not directly address provision of care by trained professionals.

So there are studies out there, just maybe not enough--once again.  There is also research on different compression:ventilation ratios showing promising data.  Guess we will find out what really happens in October.


More of the same


There is a lot more evidence out there advocating chest compressions.  No pulse checks, just compressions.  More and more compressions.  Push hard and push fast.  Good chest compressions.  Are you getting all of this?





Therapeutic hypothermia is gaining more popularity.  The evidence is outstanding.

CONSENSUS ON SCIENCE: 

Who to cool?
Evidence from one good randomized trial (LOE 1) (HACA, 2002, 549) and a pseudo-randomised trial (LOE 2) (Bernard, 2002,557) demonstrate improvement in neurological outcome after discharge from hospital in patients who had an out-of-hospital VF cardiac arrest, who were still comatose, and who were cooled within minutes to hours after return of spontaneous circulation to 32-34ºC for 12-24 hours. Two studies with historical control groups (LOE 3) showed improvement in neurological outcome after therapeutic hypothermia for comatose survivors of VF cardiac arrest (Belliard, 2007, 252; Castrejon, 2009, 733) One small (n = 30) randomized trial (LOE 1) showed reduced plasma lactate values and oxygen extraction ratios in a group (n =16) of comatose survivors after cardiac arrest with asystole or PEA who were cooled with a cooling cap (Hachimi-Idrissi, 2001, 275). Six studies with historical control groups (LOE 3) showed benefit after therapeutic hypothermia in comatose survivors of OHCA after all rhythm arrests (Bernard, 2007, 146; Oddo, 2006, 1865; Busch, 2006, 1277; Sunde, 2007, 29; Storm, 2008, R78; Don, 2009 3062). One studies with historical controls showed better neurological outcome after VF cardiac arrest but no difference after cardiac arrest from other rhythms (Bro-Jeppesen, 2009, 171). Two non-randomised studies with concurrent controls (Arrich, 2007, 1041; Holzer, 2006, 1792) indicate possible benefit of hypothermia following cardiac arrest from other initial rhythms in- and outof-hospital.

How to cool?
Nine case series (LOE 4) indicate that cooling can be initiated safely with intravenous ice-cold fluids (30 ml/kg of saline 0.9% or Ringer’s lactate) (Kliegel, 2005, 347; Kliegel 2007, 56; Bernard, 2003, 9; Virkkunen, 2004, 299; Kim, 2005, 715 ; Jacobshagen, 2009; Kilgannon, 2008; Spiel, 2009; Larsson, 2010;). Two randomised controlled trials (Kim, 2007, 3064; Kamarainen, 2009, 900), one study with concurrent controls (LOE 2: Hammer, 2009, 570) and three cases series (LOE 3) (Kamarainen,2008, 360;Kamarainen, 2008, 205) indicate that cooling with IV cold saline can be initiated in the pre-hospital phase.

More For Post-Arrest 


There is evidence that patients who are resuscitated from primary cardiac arrest should be immediately cathed.

The significance of this new literature cannot be overstated. If further studies confirm these findings, it would strongly argue for enormous changes in prehospital systems of care to recommend that all survivors of primary cardiac arrest should be immediately transported to hospitals that have the capability of performing urgent PCI in conjunction with therapeutic hypothermia. Based on the current literature, it certainly seems advisable that emergency health care practitioners that care for resuscitated victims of primary cardiac arrest should engage in conversations with cardiology consultants and urge them to take an aggressive approach to PCI in these patients.

What does this mean for us?  Post-arrest 12-lead ECGs for now.  In the future, this may mean that we bypass non-PCI facilities with our post-arrest patients.  If you think this will last long, you are wrong.  Post-arrest patients are high dollar patients.  Just think about all of the work-ups done on these patients.  Don't think that the non-PCI hospitals won't be rushing to find a way around this.  Will this mean more PCI centers?  Probably not, because all of the other cardio-intervention seeking patients end up with big medical bills too--but who knows.




Shocking Stuff

So even though AHA came out and said that their initial recommendation for biphasic defibrillators is not backed by any evidence, there may be an actual benefit to having them.  There is evidence supporting what I am about to tell you, but it may not make it into the 2010 update.  I think it will though.  It goes against what we have all learned.  Remember "I'm clear, you're clear, we're all clear!"

There is no harm to a rescuer performing chest compressions, when defibrillation is performed using a biphasic monitor.


That's right.  It has been said that more electricity passes through your body on one of those scales that checks your BMI than touching a patient when they are getting shocked.  It has to be a biphasic defibrillator though.

So that's all so far.  Go scan through the worksheets if you'd like.  There is a ton of good research available.  We can only assume, as of yet, what the final recommendations will be.  

One of the benefits of my software engineering job is access to a large corpus of journals through ScienceDirect. About once a month I pick a topic and pull the latest research. This month I did a journal search for "paramedic" AND 2010 which returned many interesting articles. One that particularly piqued my interest was Berdowski J, et al: Delaying a shock after takeover from the automated external defibrillator by paramedics is associated with decreased survival [1]. The authors found that when the paramedics switched from the AED to their monitor and a shock was delayed, for whatever reason, there was a decrease in patient survivability to discharge (ed: original copy did not appear to specify 'to discharge', current copy of article clearly states to discharge, updated).

Currently I work for two services in two different counties, one is a BLS industrial fire brigade and the other is an ALS combined Fire/EMS department. Both services have AEDs for their BLS providers with pads that are interchangeable with the monitors predominantly carried by the ALS units in their respective counties (Philips in one, Physio in the other). The standardization on pads obviously makes BLS to ALS patient handoff simpler during cardiac arrest. However, I had not considered at what point in resuscitation would be the most appropriate to make the pad switch.

The research showed that in nearly two thirds of the cases where a switch from the AED to the ALS monitor was made, the delivery of an appropriate shock was delayed. Barring equipment or operator malfunction, an AED and a paramedic are both going to defibrillate the same rhythms. Paramedics can still place the patient on their monitor with a 3-Lead even if they have not changed the pads over. The study authors concluded that the appropriate time to switch the pads would be after the AED delivers a shock or advises that no shock should be delivered.

The mechanics of a patient handoff from a BLS unit to an ALS unit during cardiac arrest are not something touched on in paramedic school or ACLS [2]. The handling of compressions versus defibrillation is rightfully stressed, but this appears to have missed another factor critical to patient survival. In retrospect this factor is obvious and thankfully easily correctable, perhaps simply through recognition. ACLS classes geared towards pre-hospital providers can add this into scenarios used for testing and EMS protocols can include text similar to:

Minimize interruptions in compressions or appropriate defibrillation delivery by first responders when initiating ALS treatments in cardiac arrest.

This minor change is low hanging fruit compared to the benefit to our patients!

References

1. Berdowski J, et al: Delaying a shock after takeover from the automated external defibrillator by paramedics is associated with decreased survival. Resuscitation 2010; 81: 287-292.
2. American Heart Association: 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 5: Electrical Therapies - Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing. Circulation 2005; 112: IV-35 – IV-46.

Every once in a while I will head over to Pubmed.com and run a quick search on prehospital. It is a good way to stay current in this ever-changing field. It is also good practice to stay relevant when advocating evidence-based medicine. Here are some abstracts from my most recent query. All are open for discussion, so please leave your comments.

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.

Photo courtesy of the NY Daily News

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

DNR Orders

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.

What if the patient, moments before arresting, decides to waive the DNR, or the patient’s surrogate wants to override it? Then in this situation, resuscitation should NOT be withheld. Consultation with medical command should be made, but will usually decide in favor of the surrogate unless the official capacity of the surrogate is in question. What if bystanders or first responders are doing CPR when you arrive? Continue CPR, call medical command and get approval for TOR. Many states don’t recommend command consultation in this instance.

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).

Photo courtesy of camperman999 from flicker

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

Photo courtesy of mr walker from flickr; two ODs here, one an arrest but assumed to be resuscitated by St. John's Ambulance crew

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.