First of all, since this the third consecutive similarly headlined column, I hereby promise this will be the last time I use this title (at least for awhile). Readers may recall that in the process of describing the ambulance transport of a deceased child, I received some requests for a discussion regarding transport of patients in cardiac arrest. And so, in the spirit of J.K. Rowling, we begin the conclusion of this series.
A middle age (the exact age was unknown) male collapsed after grabbing the arm of a friend while stating he was in pain. Forty minutes prior to the arrival of EMS, the patient became unresponsive. At some point in this time interval, cardiopulmonary resuscitation (CPR) was started by friends in the home.
Rescuers discovered the patient in a very small home, pulseless and apneic. The pupils were fixed and dilated. There was no evidence of any other obvious physical abnormality or trauma on assessment. Other occupants in the home were unable to provide any history as to what specifically had happened to the patient and, additionally, had no knowledge of the patient s past medical history.
In order to create more space to fully assess and treat the patient, he was moved out of the home and CPR was immediately begun at that time. Monitor analysis suggested possible fine ventricular fibrillation and the patient received 120 Joules biphasic. Asystole resulted and was confirmed.
The patient was then intubated and the tube was confirmed with standard techniques. The initial end tidal carbon dioxide (ETCO2) was 14 mmHg and later declined to 2 mmHg.
CPR continued as recommended intravenous (IV) administrations of epinephrine, atropine and sodium bicarbonate were provided. None of these interventions resulted in any change.
The patient was loaded into the ambulance and transported emergently to a hospital less than five minutes from the scene.
The emergency department (ED) staff continued the rescuscitative efforts for less than ten minutes before pronouncing the patient dead.
A 51-year-old male was noted by family to stop breathing while in his sleep. They had first observed a possible seizure followed by a complete loss of responsiveness. A friend noted that no pulse was present and, at that time, 9-1-1 was called. Bystanders began CPR. It was later estimated the patient had been pulseless for over five minutes before CPR was started.
History available to the responders indicated the patient had some type of cancer, substance abuse and chronic respiratory problems. He had allegedly used a type of stimulant drug as well as alcohol and later had complained of chest pains.
EMS crews confirmed the above physical findings and took over CPR. A quick look monitor assessment suggested asystole - which was confirmed. After establishment of an IV line, recommended dosages of epinephrine and atropine were given on six different occasions. Naloxone was also administered. None of these medications had any effect.
One oral intubation attempt was unsuccessful. A supra-glottic rescue airway was then placed. Bilateral breath sounds were noted as well as the qualitative presence of ETCO2. The blood glucose was 121.
After a nearly thirty minute scene time, the patient was transported emergently over twelve minutes to an emergency department. The patient was pronounced dead less than ten minutes after arrival.
These two cases are fairly representative of many cardiac arrest cases in the United States rapidly transported to an emergency department. Both outcomes of these cases are typical of patients likely to have received less than optimal pre-EMS arrival CPR.
Despite the vast amount of publicity, training, political posturing and dollars spent on community CPR, the survival rates are poor. In 1993, Kellerman and his colleagues 1 demonstrated a prehospital return of circulation (pulse regained) in 29% of 1,068 cardiac arrest patients treated by the Memphis Fire Department. But only 8% of the total cardiac arrest patients encountered left the hospital alive.
In the Kellerman study, 71% of the arrest victims did not regain a pulse in the field. Nevertheless, they were all transported emergently to a hospital. Of these patients, only three (0.28%) survived to hospital discharge. All three had moderate to severe neurologic deficits.
In 1993, an article by Bonin 2 suggested annual costs in the United States associated with EMS transports of non-responding patients in cardiac arrest approached $500 million.
What follows is a review of some of the literature accompanied by my editorial opinion regarding CPR initiation the field and subsequent transport to a hospital. It is by no means a fully comprehensive look at the practice but enough to make some supportable recommendations.
Why not just transport all cardiac arrest patients and let the hospitals deal with them?
1. In addition to the estimated annual cost for transport of cardiac arrest patients of $500 million (in 1993 dollars), there are other serious factors besides the price tag to consider.
2. When these patients are taken to the hospital, it is extremely common to proceed Code (Lights and Siren). Inherent with Code 3 are all of its risks including the enhanced risk collisions with other vehicles and injury to unrestrained patient care providers in the ambulance 3,4. Crashes involving Code 3 vehicles result in a much greater rate of serious injury to its occupants than emergency vehicles involved in crashes - not using lights and siren.5 Since the likelihood of patient salvage is essentially zero when there is no return of circulation in the field, we get all the risk of Code 3 operation with no benefit to the patient.
3. Multiple studies have shown that the actual time - savings in the majority of Code 3 returns to a hospital is extremely small over non-lights and siren transports. So, once again, we gain little in time and, as a result, nothing in patient benefit.
4. Ambulance resources are occupied (and may be occupied for very prolonged periods depending on the circumstances) and unavailable for other necessary calls.
5. Studies have suggested that the average cardiac arrest patient consumes nearly three hours of emergency department (ED) time - post pronouncement when no clinical care is being rendered. Additionally, the dead body occupies a bed until it is moved to the morgue. In todays very busy ED s, time and bed space are precious commodities.
The first question we must ask ourselves when addressing the appropriateness of ambulance transport of the cardiac arrest patient is, Can we provide benefit?
Even more important is who defines benefit? In the circumstance of cardiac arrest, benefit (like beauty ) is in the eye of the beholder.6 A good argument can be made that prehospital benefit in these situations is limited to a very small subset of arrest patients.
A parallel ethical concept at work is futility. When is it futile to attempt resuscitation? Who defines futility? My idea of futility may not be the same as your idea of futility.
Benefit and futility play a role in both the consideration of field initiation of CPR as well as the continuation and subsequent transport of a patient in whom CPR has already been initiated. While the question of initiation of CPR can occasionally be problematic, I believe continuation (or cessation) is the crux of everyday dilemmas in EMS.
Initiation of CPR in the Field
With regard to the initiation of CPR, most of us in EMS are aware of the legal doctrine of implied consent. This standard is based on the premise that an unresponsive patient would likely consent to lifesaving treatment if able to provide information to rescuers. Therefore, all things being equal, we assume the patient would choose to be resuscitated, if able to communicate. Most patients want to live.
Withholding initiation of CPR requires credible available evidence to counter implied consent. Credible evidence can be broadly categorized as either legal or medical in nature. Examples of legal evidence countering informed consent include the instruments we are most familiar with:
- Advance Directive Forms.
- Do Not Resuscitate Orders (DNR).
- Physician s Orders for Life Sustaining Treatment (POLST). POLST is a set of portable orders, originally developed in Oregon and gaining popularity in other states. These orders are carried with the patient and specify what medical interventions are to be undertaken and what are not to be undertaken.
- Evidence of Enrollment in Hospice. In the vast majority of cases, patients participating in a hospice program do not anticipate any benefit from heroic measures. Commonly, DNR orders are part of a Hospice enrollment.
- Other legally appropriate documents clearly stating the patients desire to not undergo CPR.
Legal methods of refusing CPR all involve the concept of decision-making on the part of the patient, or legal guardian, in advance of the arrest event. Interestingly, a number of articles suggest that patients frequently change their minds about their code status. This makes the question of valid legal evidence even more challenging for EMS. All we can do is make our best effort at determining the presence of legal evidence countering informed consent and ultimately, to act based on what is at hand.
Legal evidence of a patient s wishes supersedes that of on-scene family or any facility staff that might be involved in the patient s chronic care. Having said that, we know it is common to encounter family or staff members wishing everything be done in the face of legitimate legal documentation of the patient s desires otherwise. There is no uniform, easy answer for this circumstance that I am aware of. In these situations, I strongly recommend on-line discussion with medical control to work through the particular details.
Credible medical evidence indicating the withholding of CPR include signs of obvious death. However, medical evidence may also consist of the presence of end-stage disease raising the specter of the futility of any heroic interventions. Withholding CPR solely on the basis of the determination of the existence of end-stage disease is extremely problematic in EMS and in the emergency department at the present time. Depending on specific protocols, in general, CPR should be initiated in these patients unless other factors indicate the patient wishes otherwise.
Continuation of CPR in the Field
Most of the controversy involving CPR in EMS does not center on the initiation of CPR. More often the difficulty involves continuation of CPR and the corollary: when to discontinue or cease efforts in the field.
Unlike the situations described in which initiation of CPR has been previously addressed by the patient or the legal surrogate, most patients we encounter in EMS suffering a cardiac arrest have not specified their wishes ahead of the event. In fact less than 10% of the population, including those with terminal diseases, have created any type of advance directive instructions. 7 In these cases, based on the doctrine of implied consent, we assume the patient wants to live and CPR is initiated.
But a realistic discussion of the factors involved in cessation of CPR begins well before there is any patient contact by EMS. Overall survival rates from cardiac arrest rates depend to a large degree on factors that may, or may not, be in place in a community. In systems with the highest rates of survival to hospital discharge (up to 25% of all arrest patients), the Chain of Survival described in 1992 by the American Heart Association (AHA) is solidly entrenched 8. The four components of the Chain of Survival are:
- Rapid access to emergency medical care (e.g. 9-1-1 availability).
- Widespread public training in CPR.
- Early defibrillation.
- Prompt availability of Advanced Cardiac Life Support.
Understanding the strengths and weaknesses in the links of the Chain of Survival in the community gives an EMS provider a sense of what the expected survival might be in the broadest sense. For example, in our region public training in CPR is spotty. Therefore, I would predict that our cardiac arrest survival rates are less than ideal and likely approach the 8% cited in the Kellerman study above.
Identified weaknesses in the Chain of Survival can be a springboard to improvements in local or regional emergency cardiac care. Embarking on enhanced 9-1-1 services, improved public education in CPR or increased placement of automatic external defibrillators (AEDs) are examples of partnering between EMS agencies and communities to foster greater health of the citizens.
Once CPR has been initiated in a specific patient, the key is identification of factors that might predict at least a return of circulation. (Note that return of circulation does not in any way equal survival to hospital discharge).
Once again, the Kellerman study provides insight. In this article, the factors that appeared to be associated with a return of circulation in the field included:
- The cardiac arrest was witnessed - either by bystanders or EMS.
- The presenting cardiac rhythm was ventricular fibrillation (or shockable on an AED).
Many other papers have specifically noted that the absence of bystander CPR is also associated with failure to establish a return of circulation.
Most studies and current versions of AHA Guidelines agree that the inability to establish a return of circulation in the cardiac arrest patient in the field is the primary reason to cease CPR and avoid ambulance transport to a hospital.
The debate partially centers on how long efforts should continue before the determination is made of inability to reestablish circulation. The 1992 AHA Guidelines address this time interval with this statement:
Resuscitation may be discontinued in the prehospital setting when patient is non-resuscitatable in after an adequate trial of ACLS .
The paper by Bonin and his group suggests a time maximum of 25-30 minutes of advanced cardiac life support. A panel of experts in 2001 concluded that a time limit of 30 minutes was reasonable and that the patient should be treated on scene until either the 30 minute limit was reached or the patient demonstrated a return of circulation or developed a shockable rhythm. 9
Protocols in effect in my county include the following verbiage related to time limits of resuscitative efforts:
No return of spontaneous pulse or respiration during 30 minutes of CPR; or the patient remains in aystole for at least 10 minutes (30 minutes for pediatric patients) after successful intubation and medications and no reversible causes are indentified.
As seen in the AHA Guidelines above, many authors do not specify a time for provision of either basic or advanced life support interventions.
Once EMS providers have determined that return of circulation or a shockable rhythm is not likely to occur, most experts recommend involvement of the on-line medical direction when possible or available - to officially pronounce the patient dead. Clearly, there is nothing unique about a physician s ability to declare death. But often this is a legal requirement, as well as one mandated in many EMS systems protocols.
Cardiac Arrest Patients Due to Trauma
Generally, the outcome for patients in cardiac arrest due to trauma is substantially worse than non-trauma causes. In a 2003 study, Stockinger and McSwain noted a 3.7% survival rate to hospital discharge in trauma patients suffering from cardiac arrest. 10 Penetrating trauma victims did substantially worse than hanging or drowning victims. The authors recommended that victims of penetrating trauma without evidence of any respiratory rate, systolic blood pressure and a Glasgow Coma Scale of 3 be declared dead at the scene and have no CPR initiated.
In 2003 the Guidelines for Withholding or Termination of Resuscitation in Prehopsital Traumatic Cardiopulmonary Arrest were published in a variety of journals.11 These recommendations are most readily accessed by going to the National Association of EMS Physicians (NAEMSP) web site at www.NAEMSP.org and following links to the association s policies. These guidelines are too extensive to review in this article, but the first one reads as follows:
Resuscitation efforts may be withheld in any blunt trauma patient who, based on out-of-hospital personnel s thorough primary patient assessment is found apneic, pulseless, and without organized ECG activity upon the arrival of EMS at the scene.
These guidelines do not specifically cover pediatric trauma patients, although it is generally believed that trauma arrest outcomes are similar in children compared to adults. Also, the guidelines discuss the need to consider the presence of hypothermia, lightning strikes, drowning and hanging mechanisms. If any of these historical factors are present, a more liberal approach to CPR initiation is recommended.
Pediatric Cardiac Arrest Patients
While I acknowledge that kids are not just little adults, the reality is the prognosis for children in cardiac arrest is no better than adults. In fact, outcomes are usually worse. As a result, as a general rule, the factors leading to termination of resuscitation discussed above are applicable to children. Obviously, there are emotional and parental considerations that can make the scene of the pediatric patient in arrest more difficult. These factors will be discussed below.
Special Situations Related to the Cardiac Arrest Patient
In an Annals of Emergency Medicine article entitled Factors Influencing Hospital Transport of Patients in Continuing Cardiac Arrest, published in 1998, Hicks and colleagues evaluated specifics occurring at the scene that might have prompted transport of patients unlikely to respond to CPR.12
Sixty-eight patients were identified that met study criteria in that CPR continued throughout transport to a hospital. The main reasons for continued CPR (in order of decreasing frequency) were arrest in a public place, arrest occurring in the ambulance - or on the way to the ambulance, environmental factors, possible reversible patient factor present, persistent ventricular fibrillation, airway difficulties, no intravenous access, family unable to accept field termination, cultural or language barrier, EMS physician ordered transport, obesity, road hazard present.
This paper attempted to consider realistic scene criteria and pressures that might encourage, if not force, an EMS crew to transport a patient in cardiac arrest knowing that the chance of resuscitation was virtually nil.
The authors then incorporated what they learned into a protocol allowing for the presence of some of these non-clinical factors impacting the care of the cardiac arrest patient.
The article concluded that any protocol dealing with the initiation or continuation of CPR must, necessarily, allow for provider judgment in the specific scene they might find themselves in. For example, in the case of a pediatric arrest patient, family emotions might make cessation of CPR impossible on scene. Or in another case, a crew might be threatened with bystander violence - if CPR were terminated. Transport in such cases may be needed just for the safety of the crew.
These concepts raise three questions:
- In cases like these would the transport require lights and siren given the known risk of Code 3 operation? The answer is probably not. Code 3 status might be used to leave the scene and then cancelled once enroute.
- Can CPR be stopped in an ambulance for patients demonstrating no return of circulation? I believe the answer is yes.
- What should be the disposition of the body when pronounced in an ambulance?
At the time of this paper, the EMS agencies involved did not have a protocol for pronouncement of death in the ambulance. But as a result of the publication, the authors created an addition to their protocols allowing transport of patients pronounced dead in an ambulance to either the Medical Examiner s Office or to an emergency department pending arrival of the coroner. (I assume that agreements were created that freed ED staff from any requirement to complete death paperwork in these circumstances).
The net effect of this protocol change was to shorten turn around times for these ambulances that were forced to transport patients with CPR in progress.
I am personally aware of at least one other agency that utilizes a Morgue Transport Protocol for situations in which the patient has CPR stopped while in an ambulance. I would think there are protocols like these in systems across the United States and around the world--but I don t know that, factually. In our system we do not have such a protocol.
Public Perception and Cardiac Arrest in the Field
We have spent decades trying to convince the public that we want to save lives and we tell them to call us when they need help. I think we still want them to call us (but we d prefer it if they didn t call us for hang nails).
Consequently, deciding to not initiate or to terminate CPR frequently in the public s view, may well be a new experience for the citizens we serve- to say the least. Although, I don t have a source for the following figures, a sample of the public was surveyed a few years ago regarding their perceptions of survival after cardiac arrest. They believed the survival rate was about 60%! A simultaneous review of the medical dramas on television at the time revealed an on screen cardiac arrest survival rate of you guessed it 60%. So, I think it is safe to say that public expectations regarding cardiac arrest outcomes are not the same as ours in EMS.
One other factor related to dealing with the public involves the psychosocial needs of the family and bystanders after a patient has been pronounced dead and is going to be left on scene. If you are like me, you got virtually no training on how to deal with these difficult situations. We just learned by the seat of our pants.
If the trend continues in leaving more cardiac arrest victims on scene, who is training EMTs and paramedics to deal with the shock and grief of the living?
BLS versus ALS
Many studies (but not all) evaluating the withholding or cessation of CPR from an ALS perspective address or require the presence of ALS providers. This is likely due to medical/legal fears that the highest level of care be available to assess a patient before a decision is made with regard to CPR. However, in large areas of the country, ALS may not be on scene in any reasonable time frame. Therefore, BLS judgment has to be a factor.
The medical literature suggests that a patient s inability to generate a return of circulation in the absence of a shockable rhythm (after a period of good CPR, as discussed above) merits consideration of cessation of CPR with the agreement of medical control.13, 14
In light of what we have reviewed, I thought it might be helpful to incorporate the major concepts into two sample protocols (one for BLS systems and one for ALS systems). What follows are just ideas from me on what might work a jumping off point for future improvements. As is always the case, agencies need to coordinate this with their medical direction.
Protocol for Management of the Patient in Cardiopulmonary Arrest
Basic Life Support Providers
- Initiate CPR (or take over from bystanders if already initiated) unless credible legal or medical evidence exists to the contrary.
- Attach AED and assess for shockable rhythm and treat accordingly.
- Continue high quality CPR as indicated by current AHA guidelines.
- a) If no shockable rhythm is indicated and patient appears to continue to be unresponsive, apniec and pulseless, administer CPR for ___________minutes. Reassess for shockable rhythm as indicated by current guidelines.
- b) If the above time limit is exceeded without change in condition, and ALS personnel will not be available, contact medical control for pronouncement.
Factors to consider making response to CPR less likely:
- Non-witnessed arrest.
- No bystander CPR administered.
- Blunt or penetrating trauma without detectable vital signs (consider not initiating CPR).
Transport Considerations for Non-Responding Patients:
- Transport is not indicated if the criteria in b are met unless;provider judgment suggests remaining on scene is not safe, or appropriate.
- In the event transport is deemed necessary, non-lights and siren mode (Code 2) is indicated unless circumstances dictate otherwise.
- If transport is initiated in the non-responding patient, strongly consider seeking pronouncement of the patient via medical control enroute. In such cases, transport status must be downgraded to Code 2 if not already and the ultimate destination will be the Medical Examiner s Office (if available) or the emergency department.
- Hypothermic and/or drowning and lightning strike patients may require longer CPR efforts than in other situations. Coordinate the planned duration of CPR with individually in these cases with medical control .
Protocol for Management of the Patient in Cardiopulmonary Arrest
Advanced Life Support Providers
- Initiate CPR (or take over from bystanders if already initiated) unless credible legal or medical evidence exists to the contrary.
- Begin ALS assessment and treatment per current AHA guidelines.
- Continue high quality CPR as indicated by current AHA guidelines.
- a) If the patient appears to be in asystole, pulseless electrical activity (PEA) or other lethal, non-shockable rhythm while remaining pulseless, and apneic continue CPR for __________ minutes. Reassess the patient as appropriate.
- b) If the above time limit is exceeded without change in condition, contact medical control for pronouncement.
The rest of the protocol as outlined in the BLS version above would then apply to the ALS one.
One Loose End
This is obviously a complicated subject and I can assure you it took me longer than I thought to put it together.
I think everything is pretty self-explanatory with the exception of, perhaps, the question of success or failure of standard procedures performed on the cardiac arrest patient. What I mean by this is: Does the patient in cardiac arrest who can t be intubated or have an IV successfully inserted require transport when he or she would ordinarily not be transported?
While there may be debate on this question, I don t think so. Currently we have many ways to manage airways adequately without actual tracheal intubation. Therefore, lack of successful intubation itself should not require transport as long as some other device is working effectively. Inability to effectively open an airway at all - would be an exception to this. If other skilled help were not available to help with the airway on scene, a transport might be indicated - especially if the distances were short.
Likewise, failure to establish an IV should not generally, mandate a transport. Drugs rarely make a significant difference in these cases. Additionally, intraosseous (IO) lines are a very effective replacement and should be utilized by ALS crews very early in the call if an IV is not possible. Lastly, if no IV or IO lines are obtainable, drugs can still be administered via the endotracheal tube.
In the two cases presented at the beginning of the column, I think it s clear that application of the principles we have reviewed would have likely prevented unnecessary Code 3 transports in both situations.
1. Kellerman AL, Hackman BB, Somes G: Predicting the outcome of unsuccessful prehospital advanced cardiac life support. JAMA. 270(12):1433-1436, 1993.
2. Bonnin MJ, Pepe PE, Kimball KT, et al: Distinct criteria for termination of resuscitation in the out-of-hospital setting. JAMA. 270(12):1457-1462, 1993.
3. Custalow CB, Gravutz CS: Emergency vehicle collisions and potential for preventive intervention. Prehosp Emerg Care. 8(2):175-84, 2004.
4. Clawson JJ, Martin RL, Cady GA, Maio RF: The wake effect emergency vehicle related collisions. Prehosp Disast Med. 12:274-7, 1997.
5. Saunders CE, Heye CJ: Ambulance collisions in an urban environment. Prehosp DisastMed. 9(2):118-24, 1994.
6. SUPPORT Principal Investigators: A controlled trial to improve care for seriously ill hospital patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA. 257:59-63, 1992.
7. Herlitz J, Engdahl J, Svensson L, et al: Can we define patients with no chance of survival after out-of-hospital cardiac arrest? Heart. 90:1114-1118, 2004.
8. Emergency Cardiac Care Committee and Subcommittees: American Heart Association. Guidelines for cardiopulmonary resuscitation and emergency cardiac care. JAMA. 268:2171-2183, 1992.
9. Abramson N, de Vos R, Fallat M, Finucane T, et al: Ethics in emergency cardiac care. Ann Emerg Med. 37:S196-S2000, 2001.
10. Stockinger ZT, McSwain NE: Additional evidence in support of withholding or terminating cardiopulmonary resuscitation for trauma patients in the field. J Am Coll Surg. 198:227-231, 2004.
11. The National Association of EMS Physicians (NAEMSP) Standards and Clinical Practice Committee and the American College of Surgeons Committee on Trauma: Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest. www.naemsp.org.
12. Hick JL, Mahoney BD, Lappe M: Factors influencing hospital transport of patients in continuing cardiac arrest. Ann Emerg Med. 32:19-25, July 1998.
13. Morrison LJ, Visentin LM, Kiss K, et al: Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 355:478-87, 2006.
14. Verbeek PR, Vermeulen MJ, Ali FH, et al: Derivation of a termination of-resuscitation guideline for emergency medical technicians using automated external defibrillators. Acad Emerg Med. 9(7):671-8, July.