Termination of Resuscitation: Best Practices from the Field to the ED to Inpatient

Termination of Resuscitation: Best Practices from the Field to the ED to Inpatient Jeffrey M. Goodloe, MD, NRP, FACEP, FAEMS Medical Director, Medical Control Board EMS System for Metropolitan Oklahoma City & Tulsa, Oklahoma Professor & EMS Section Chief, Department of Emergency Medicine University of Oklahoma School of Community Medicine

Resuscitation of the Suddenly Dead We spend most of our thoughts about how to achieve success but what about when to reliably recognize futility in continuing?

Termination of Resuscitation: When We Know That We Know When It s When To Say When (or Do We?)

How to Make Sure Singing Occurs When We Quit Resuscitative Efforts

Questions How long should we perform resuscitation in sudden death that continues despite care? What variable is the best indicator of futility in an ongoing resuscitation? What is the best place for family members during resuscitation?

EMS System for Metropolitan Oklahoma City & Tulsa 2017 Activity 1,100 square miles Population 1.6 million day 1.2 million night 214,496 calls (+3%) 157,008 transports (+5%) 73 % transports (+2%)

Cardiac Arrests OKC & Tulsa Typical Year 1400 attempted resuscitations 840 (approx 60%) primary cardiac etiology 714 (approx 85%) NOT witnessed by EMS 180 (approx 25%) in VF on EMS arrival 126 (approx 70%) admitted to hospital 38 (approx 30%) patients discharged alive Doesn t include survivors w/ initial asystole or PEA Bystander witnessed with CPR & VF on EMS arrival: 25-40% survival (95%+ CPC 1 or 2)

What s the Scope of the Issue? 295,000 Out of Hospital Cardiac Arrests/Yr in US 60% EMS attempts resuscitation (every 3 mins!) Over 90% do not survive to hospital discharge YOU SHOULD HAVE DOUBLE SEQUENTIAL DEFIBRILLATED ME

And that s not counting sudden deaths in hospital!

Termination of Death after Accurate Determination of Death! OK Medical Examiner slide for involuntary bowel release

Here s happiness at 0Dark:30..

and it s not just a Texas EMS thang

When should we stop CPR?

Field Futility of Resuscitation OKC/Tulsa CPR should not be initiated (or continued if initiated by bystanders prior to arrival) by first responders, EMTs, and paramedics in the following clinical conditions representing obvious death (regardless of cause of cardiac arrest): No pulse AND No spontaneous respirations AND Pupils fixed (unreactive to light) AND One or more of the following: Rigor mortis. Decapitation. Decomposition Dependent lividity.

Field Blunt Traumatic Arrest OKC/Tulsa CPR should not be initiated (or continued if initiated by bystanders prior to arrival) by first responders, EMTs, and paramedics in the following clinical conditions: No pulse AND No spontaneous respirations AND No organized ECG activity (asystole or PEA <40 beats per minute)

Field Penetrating Traumatic Arrest OKC/Tulsa CPR should not be initiated (or continued if initiated by bystanders prior to arrival) by first responders, EMTs, & paramedics in the following clinical conditions: No pulse AND No spontaneous respirations AND Pupils fixed (unreactive to light) AND No spontaneous movement AND No organized ECG activity (asystole or PEA <40 beats per minute)

Field Adult Non-Traumatic Arrest An adult patient who is found in asystole or PEA upon ALS arrival may be considered a candidate for field termination of resuscitation if they do not respond to full resuscitation efforts AND: 1) Location of cardiac arrest is a private residence or healthcare facility (e.g. nursing home). 2) ALS resuscitative efforts (CPR, successful placement of advanced airway, successful vascular access IV or IO, and medication administration) have been continuously performed for 20 (twenty) minutes without return of spontaneous circulation (ROSC) or conversion of asystole or PEA to Ventricular Fibrillation/Ventricular Tachycardia at any time during the 20 minutes of advanced life support. 3) The cardiac arrest did not occur in absolute or relative hypothermia. 4) The cardiac arrest did not occur due to apparent toxic agent exposure. 5) End-tidal CO2 is less than 20 mmhg at the time of termination of resuscitation.

Public Body Disposition?

Additional ToR Considerations Family expectations Safety of crew and public if resuscitation halted Factors inhibiting safe patient movement Non-English-speaking family/cultural barriers Private physician order to continue resuscitation Correctable causes of arrest yet untreated

Family Support Considerations Clergy Crisis workers Social workers Ensure termination of resuscitation can be achieved in an efficient, humane manner.

Physician Contact Field termination of cardiac arrest resuscitation may be based on an attending or on-line medical control physician s order, either by direct voice communication or in writing. The order is based upon the physician s decision that the patient s condition is terminal, cardiovascular unresponsiveness has been established despite optimal out-of-hospital ALS emergency medical care, and biologic death has occurred. The paramedic s decision to stop the resuscitation shall be based on this physician s order.

Prehosp Emerg Care. 2011 Oct-Dec;15(4):547-554.

EMS ToR Literature 1980s Retrospective So death looking back looks like 1985 editorial by Eisenberg and Cummins First formal recommendation for EMS ToR Avoidance of needless and wasteful ED resus. Guidelines - not hard & fast rules Importance of physician consult for joint decision

EMS ToR Literature - 1980s 1988 Kellerman 240 OOH cardiac arrests 32 ROSC in ED and admitted 4 survived to discharge (1.7%) 2 neurologically intact (ROSC prior to ED arrival) Failure of field ROSC associated with poor outcome

EMS ToR Literature - 1980s 1989 Bonnin & Swor 244 OOH non-traumatic cardiac arrests 12 Excluded etiology, family, or records 21/51 with field ROSC discharged (41%) 1/181 without field ROSC discharged (.55%) neuro intact, PEA, no field definitive airway If full ACLS & definitive airway & no ROSC, ToR Editorial indicates 1st EBM for EMS ToR

EMS ToR Literature 1990s 1991 Gray et al. 185 OOH cardiac arrests no ROSC transported 16 (9%) got ROSC in ED and admitted No survivors to discharge $181,000 in care for the 16 admitted ED resuscitation for these types of pts not worthwhile & consumes precious institutional and economic resources without gain

EMS ToR Literature 1990s 1993 Kellerman et al 1068 OOH cardiac arrest patients 3 pts without ROSC in field discharged from hosp Only 0.4% dc rate & none neuro intact Field ROSC sens 96% & neg pred value of 99.6%

Houston FD Outcomes Study Prospective study for non EMS ROSC outcomes 1,322 pts; 952 non EMS ROSC; 6 (0.6%) dc home All 6 dc to home had refractory VF Survival predictors for unwitnessed OOH CA: Full ACLS with definitive airway management 5 mins of ROSC at 60+ bpm Refractory VF/VT ROSC within 25 mins (30 mins if VF/VT)

Traumatic CA ToR Resources Prehosp Emerg Care. 2003;3:141-6.

OOH Traumatic Cardiac Arrest Survival predictors extrapolated from thoracotomy research Typically small n and much smaller survivor #s Limits validity of conclusions Consistently grim results (<5% survival)

Initial EMS Rhythm Prediction of Survival of OOH Traumatic CA Battistella et al. 0/212 asystole 0/134 bradycardic PEA (<40 complexes/min) 16/16 survivors had initial spont circulation & subsequent PEA 80-150 sinus complexes/min

Initial EMS Rhythm Prediction of Survival of OOH Traumatic CA Multiple other studies with similar findings to Battistella: Asystole or brady PEA @ EMS arrival = no survivors

Duration of Traumatic Arrest as Survival Prediction Tool Fulton 0/245 if CA >10 mins or 2 nd CA Mattox 0/100 if chest compressions > 3mins Pasquale 2/3 survivors < 5mins; 1/3 <15 mins isolated chest penetrating wound Collectively: 15 + mins CA = no survivors

Role of capnography in ToR Mid 1990s.etCO2 10mmHg assoc poor outcome Promising No clear recommendation Have we been able to get more definitive than that?

Qualitative to Quantitative EtCO2

Eagles EtCO2 Criteria in ToR Effect of mechanical CPR devices Likely raise criterion from <10mmHg to <20mmHg? We have a number of systems that use very divergent criteria, or none at all... we will look back at this time in future years and many of us will smile at our ignorance... until then, I think we should describe who does what, without naming the specific systems... 20 minutes for little to no CO2 is common but not universal. Corey Slovis, March 2009

Los Angeles EtCO2 Survival Prediction Adult, nontraumatic OOHCA 2006-2007 in LA What predicts failure to get ROSC? (97% PPV) Male Unwitnessed arrest No bystander CPR Non-VF Initial EtCO2 10 mmhg EtCO2 falling > 25% Prehosp Disaster Med. 2011 Jun; 26(3): 148-50

Additional help from the literature? Validating a termination rule set Barriers to implementing termination Utility of focused training

Morrison et al ALS Rule

Morrison et al BLS Rule

NAEMSP 2008 Attendee Focus Groups 3 Basic Themes Resulted Pay incentivizes transport State mandates transport Very limited ToR allowed Local norms preclude easy implementation

Benefit of Education? Ponce et al. PEC Oct-Dec 2010 14(4) 537-42 Focused training does improve EMS professionals comfort with ToR in presence of family

How long is too long to resuscitate? British Columbia Ambulance Service University of BC Dept of EM Estimate impact of prognostication bias Over 5600 adult OOHCA 46% ROSC; 12% survival Median ToR 27.0 mins (IQR 19.0-35.0 mins) Increase to 40 mins +17 survivors (10 intact) <1% miss if increase to 28 mins resuscitation Grunau et al. Prehosp Emerg Care 2018;22:198-207

Which of the following is most appropriate when talking to family? a. We found him in asystole. b. He underwent CPR. c. We found him in cardiac arrest. d. He was not breathing on his own and his heart was not beating.

After terminating the resuscitation, the most appropriate statement is: a. He has died. b. He didn t make it. c. He has passed. d. He has gone to a better place.

You are informing a surviving spouse that resuscitation was unsuccessful. He/She is sitting in a chair. You should: a. Sit on the floor. b. Stand to his/her side. c. Sit in a chair. d. Stand in front of him/her.

Benefits to family witnessing resuscitation include all EXCEPT: a. Better understanding severity of condition. b. Appreciation of care received. c. Controlling the timing to end resuscitation. d. Decreasing frustration and helplessness.

Families that witness resuscitation: a. File more lawsuits. b. Rarely interfere with treatment. c. Make the resuscitation last longer. d. Have more post-traumatic stress.

Successful practices in family witnessed resuscitation include all EXCEPT: a. Assigning one person to communicate with family. b. Clearly identifying family using ID tags or other visible devices. c. Briefing family members. d. Encouraging family to touch the patient.

Take Home Points Where do we still need to go? Validated ToR models do exist See? Shock? ROSC? If no, no transport (Morrison BLS) 2015 AHA/ILCOR standards advocate ToR We have obligations that support ToR: Safety for EMS professionals & traveling public Advancing the science of medical practice Fiduciary stewardship Future investigations: Effects of mechanical CPR, better CPR, more precise EtCO2 prediction models, additional arrest variables to predict safe/reliable termination?

Questions How long should we perform resuscitation in sudden death that continues despite care? 20+ Minutes What variable is the best indicator of futility in an ongoing resuscitation? End-tidal CO2 What is the best place for family members during resuscitation? Bedside

The yin parting thought In cardiac cessation the odds in favor of resuscitation decrease with each minute that passes before proper measures are applied. The stakes are high a human life. The half-hearted attempts at resuscitation should be replaced by early and bold attempts at resuscitation The feeling that once the heart has stopped the patient is gone and nothing will help should be replaced by the knowledge that a human life can and may be saved, and any attempt is justifiable. JAMA August 29, 1942

The yang parting thought Not all patients should have cardiopulmonary resuscitation attempted. Some evaluation should be made before proceeding. The cardiac arrest should be sudden and unexpected. The patient should not be in the terminal stages of a malignant or chronic disease, and there should be some possibility of a return to a functional existence Jude JR, Kouwenhoven WB, Knickerbocker GG. JAMA 1961;178(11): 1063-70

TULSA OKLAHOMA CITY Contact Info: jeffrey-goodloe@ouhsc.edu Office of the Medical Director 405-297-7173