Are EMTs wasting time with resuscitation efforts?
Study suggests benefits to terminating CPR earlier
A new study attempts to validate the argument that emergency medicine services (EMS) not staffed by paramedics could reduce the number of hopeless ambulance trips to the hospital if emergency medical technicians (EMTs) were allowed to end resuscitation efforts sooner in patients who are in cardiac arrest.
But an emergency medicine physician with experience in medical direction of EMS says, because even a small fraction of a percent of those "hopeless" cases could survive, the public would demand all attempts be made to save them.
According to statistics included in a recent New England Journal of Medicine report, some two-thirds of cardiac arrest patients taken to hospitals by EMTs eventually die, and most probably could be declared dead at the scene. According to Laurie J. Morrison, MD, of the University of Toronto, only one in 500 people survived to be discharged from the hospital if EMTs were not able to restart their circulation, rescue workers were not present when the heart stopped, or the patients' hearts were not shocked by automatic defibrillators.
Morrison says revising guidelines to let EMTs know when to give up could result in a decrease in the rate of transportation to the hospital from 100% of patients to 37.4%.
According to James Hubler, MD, JD, FCLM, FAAEM, FACEP, clinical assistant professor of surgery at the University of Illinois College of Medicine department of emergency medicine and EMS medical director for the Peoria (IL) Area EMS System, the idea of allowing EMTs to "call" patients earlier is not a new one, particularly in places where the nearest hospital might be 30 minutes or more away.
However, that doesn't make the proposal any easier when statistics show that some of the people who would be pronounced dead at the scene under such a rule survived when resuscitation efforts were not discontinued.
"It's a protocol used in some systems; because even when [a paramedic] gives them medications, there's not much more that they can get at the hospital, particularly if you've started an IV and secured the airway," he says. Pronouncing so-called hopeless patients dead at the scene "will improve safety, because you don't have ambulances racing to the hospital, with anxious drivers and the risk of accidents, when the person is basically dead."
Morrison says that some 60% of Americans and Canadians live in areas served by emergency rescue personnel who have only basic lifesaving (BLS) skills and are not authorized to do anything but start resuscitation efforts, load the patient, and drive however far it is to the nearest hospital.
Paramedics with advanced training can give drugs and start IVs, and already are authorized to stop resuscitation once they have consulted a physician.
Not only does requiring EMTs to transport and continue resuscitation in these patients create hazards for rescue workers and other motorists and tie up ambulances, which could otherwise be answering more calls, it can create false hope for the families of these patients, who think their loved one has a chance to survive.
A new three-item clinical prediction rule may help emergency medical personnel decide when to terminate BLS resuscitative efforts in cases of out-of-hospital cardiac arrest.
Three-point prediction rule proposed
The rule recommends that in the absence of advanced cardiac life support, EMTs may consider the termination of basic life support resuscitative efforts if: 1) there is no return of spontaneous circulation before transportation to the ED is initiated; 2) the patient received no defibrillator shocks before transportation is initiated; 3) and the cardiac arrest was not witnessed by emergency personnel.
Morrison's study, which included 24 EMS systems in Ontario, looked at cases involving 1,240 adults with presumed cardiac arrest who were treated by EMTs trained in the use of automated external defibrillators. Of the 776 patients for whom the prediction rule called for termination of basic life support, four survived (0.5%).
"The rule had a specificity of 90.2% for recommending transport of survivors to the emergency department, and had a positive predictive value for death of 99.5% when termination was recommended," the authors report.
But that survival rate — four out of 776, fewer than one-half of 1% of the total — is enough to give EMS medical directors pause.
"If you have 0.5% survival, you aren't going to be able to predict who will survive — it's all retrospective," suggests Hubler. "I think society says that if they might survive, resuscitate them all the way. The flipside is, I think the definition of 'survival' should be being discharged from the hospital neurologically intact."
Hubler speculates that the survivors noted in Morrison's study are perhaps in a persistent vegetative state "or so neurologically impaired that their quality of life is not good."
Of the 1,240 patients, only 41 in all survived — 3%. All were given CPR at the scene, defibrillated, and taken to a hospital.
Age at time of arrest shouldn't matter
Hubler says a related question that arises when termination of out-of-hospital resuscitation comes up is whether more efforts should be spent when the patient is young and healthy, especially if the patient is a child.
"Old or young, the same protocols should apply — three rounds of medications and resuscitation, and then decide," he says. "In pediatric patients, the literature shows that people try to overresuscitate them, and do resuscitation much longer. That's because it's less acceptable and harder emotionally to give up.
"But the evidence is that the length of resuscitation doesn't improve outcomes. Three rounds of drugs and resuscitation, rather than continuing CPR for an hour and getting blood pressure but not brain activity — you don't have better outcomes by continuing resuscitation longer."
The American College of Emergency Physicians (ACEP) guidelines state that under certain well-defined circumstances, resuscitative efforts may be discontinued in the prehospital setting for pulseless patients who do not respond to an adequate trial of resuscitation therapy.
Patients for whom resuscitative efforts may be discontinued in the prehospital setting, according to ACEP, include patients who are asystolic or are in a wide-complex pulseless bradycardic rhythm with a rate less than 60, are normothermic, and fail an adequate trial of resuscitation therapy. Adequate resuscitation therapy may include airway management, CPR, medications, defibrillation, and pacing, ACEP guidelines state.
Sources/Resource
For more information:
- James Hubler, MD, JD, FCLM, FAAEM, FACEP, clinical assistant professor of surgery, department of emergency medicine, University of Illinois College of Medicine at Peoria; OSF Saint Francis Medical Center, Peoria, IL; EMS medical director for the Peoria (IL) Area EMS System. E-mail: James.R.Hubler@osfhealthcare.org.
- Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. NEJM 2006; 355:478-487.