Prehospital termination of resuscitation in cases of refractory out-of-hospital cardiac arrest

Department of Emergency Medicine, University of Michigan, Ann Arbor, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 10/2008; 300(12):1432-8. DOI: 10.1001/jama.300.12.1432
Source: PubMed


Identifying patients in the out-of-hospital setting who have no realistic hope of surviving an out-of-hospital cardiac arrest could enhance utilization of scarce health care resources.
To validate 2 out-of-hospital termination-of-resuscitation rules developed by the Ontario Prehospital Life Support (OPALS) study group, one for use by responders providing basic life support (BLS) and the other for those providing advanced life support (ALS).
Retrospective cohort study using surveillance data prospectively submitted by emergency medical systems and hospitals in 8 US cities to the Cardiac Arrest Registry to Enhance Survival (CARES) between October 1, 2005, and April 30, 2008. Case patients were 7235 adults with out-of-hospital cardiac arrest; of these, 5505 met inclusion criteria.
Specificity and positive predictive value of each termination-of-resuscitation rule for identifying patients who likely will not survive to hospital discharge.
The overall rate of survival to hospital discharge was 7.1% (n = 392). Of 2592 patients (47.1%) who met BLS criteria for termination of resuscitation efforts, only 5 (0.2%) patients survived to hospital discharge. Of 1192 patients (21.7%) who met ALS criteria, none survived to hospital discharge. The BLS rule had a specificity of 0.987 (95% confidence interval [CI], 0.970-0.996) and a positive predictive value of 0.998 (95% CI, 0.996-0.999) for predicting lack of survival. The ALS rule had a specificity of 1.000 (95% CI, 0.991-1.000) and positive predictive value of 1.000 (95% CI, 0.997-1.000) for predicting lack of survival.
In this validation study, the BLS and ALS termination-of-resuscitation rules performed well in identifying patients with out-of-hospital cardiac arrest who have little or no chance of survival.

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    • "This study reported the positive predictive value of patient mortality of those who agreed to the criteria to be 99.5%. Sasson et al. [3] reported that in instances of no shock prior to transport, no witnessing of the arrest by bystanders or emergency medical personnel, and no CPR administered by a bystander, the survival rate of advanced life support recipients subjected to termination of resuscitation criteria performed in the absence of ROSC was 5 out of 2592. Additionally, 1,192 patients subjected to advanced life support termination criteria were all expired. "
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    • "One can never be certain, even in large-scale studies, that a treatment is beneficial (better than no treatment or an alternative treatment); therefore, one submits observations to the test of reasonableness. A good example of the application of our quantitative proposal is the publication of a Basic Life Support guideline based on empirical outcomes of out-of-hospital attempted CPR whose recommendation for terminating efforts followed the quantitative threshold we proposed (Sasson et al. 2008). The notion of reasonableness is accepted in another major sector of society where a person’s life may be at stake: American courts of law. "
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