Termination of resuscitation in the prehospital setting: A comparison of decisions in clinical practice vs. recommendations of a termination rule. (March 2016)

• Record Type: Journal Article
• Authors: Verhaert, Dominique V.M.; Bonnes, Judith L.; Nas, Joris; Keuper, Wessel; van Grunsven, Pierre M.; Smeets, Joep L.R.M.; de Boer, Menko Jan; Brouwer, Marc A.
• Is Part Of: Resuscitation. Volume 100(2016)
• Page Start: 60
• Page End: 65
• Publication Date: 2016-03
• Subjects: Out-of-hospital cardiac arrest -- Resuscitation orders -- Termination of resuscitation -- Clinical practice -- Guidelines; Resuscitation -- Periodicals; Resuscitation -- Periodicals; Réanimation -- Périodiques; Electronic journals; 616.025
• DOI: 10.1016/j.resuscitation.2015.12.014
• Languages: English
• ISSNs: 0300-9572

Abstract

Abstract: Background: Of the proposed algorithms that provide guidance for in-field termination of resuscitation (TOR) decisions, the guidelines for cardiopulmonary resuscitation (CPR) refer to the basic and advanced life support (ALS)-TOR rules. To assess the potential consequences of implementation of the ALS-TOR rule, we performed a case-by-case evaluation of our in-field termination decisions and assessed the corresponding recommendations of the ALS-TOR rule. Methods: Cohort of non-traumatic out-of-hospital cardiac arrest (OHCA)-patients who were resuscitated by the ALS-practising emergency medical service (EMS) in the Nijmegen area (2008–2011). The ALS-TOR rule recommends termination in case all following criteria are met: unwitnessed arrest, no bystander CPR, no shock delivery, no return of spontaneous circulation (ROSC). Results: Of the 598 cases reviewed, resuscitative efforts were terminated in the field in 46% and 15% survived to discharge. The ALS-TOR rule would have recommended in-field termination in only 6% of patients, due to high percentages of witnessed arrests (73%) and bystander CPR (54%). In current practice, absence of ROSC was the most important determinant of termination [aOR 35.6 (95% CI 18.3–69.3)]. Weaker associations were found for: unwitnessed and non-public arrests, non-shockable initial rhythms and longer EMS-response times. Conclusion: While designed to optimise hospital transportations, application of the ALS-TOR rule would almost double our hospital transportation rate to over 90% of OHCA-cases due to the favourable arrest circumstances in our region. Prior to implementation of the ALS-TOR rule, local evaluation of the potential consequences for the efficiency of triage is to be recommended and initiatives to improve field-triage for ALS-based EMS-systems are eagerly awaited.