The Research
Drennan I, Case E, Verbeek P, et al. A comparison of the Universal TOR Guideline to the absence of prehospital ROSC and duration of resuscitation in predicting futility from out-of-hospital cardiac arrest. Resuscitation. 2017;111:96-102.
The Science
The authors wanted to determine how well the Universal Termination of Resuscitation (TOR) Guideline could predict survival from cardiac arrest.
The TOR recommends that resuscitation be terminated in the field when all three of the following are true: 1) EMS didn’t witness the arrest; 2) return of spontaneous circulation (ROSC) didn’t occur despite resuscitation attempts; and 3) the patient was never defibrillated. Specifically, the authors wanted to discover the survival rate of patients who were transported solely based on failing to obtain ROSC.
Data were extracted from the Resuscitation Outcomes Consoritum PRIMED database, which was created to study the effect of an impedance threshold device (ITD) and/or immediate vs. delayed defibrillation.
Between 2007 and 2011 there were 36,543 cases of cardiac arrest. Of these, 9,467 (26%) were transported without ROSC. Patients without ROSC for whom the TOR recommend termination at the scene had a survival rate of 0.7% compared to 3.0% of patients for whom the TOR recommended transport.
The authors concluded that transporting cardiac arrest patients based solely on the absence of ROSC isn’t appropriate and encourage EMS agencies to utilize the TOR fully to identify the best candidates for survival.
Doc Wesley comments:
Deciding who should be transported and who should be terminated on scene is one of the most difficult decisions for EMS providers. The TOR has been validated showing that when all three conditions are met, terminating resuscitation in the field is appropriate.
Let’s examine one of the truly concerning results in this study that the authors don’t address. Although the authors were focused on the dismal survival rate of those transported despite being recommended for termination by the guidelines, there were 4,040 patients for whom the TOR recommended transport but were instead terminated on scene by EMS-84.6% of them were defibrillated and 15.3% were witnessed arrests.
I can imagine countless scenarios where EMS would transport a cardiac arrest victim without ROSC: Family dynamics, scene safety, poor confidence in deciding to terminate and lack of on-line medical control availability are a few.
I would like to know why over 4,000 patients for whom the TOR guidelines recommended transport were instead terminated, when these patients are the most likely to survive. Transporting patients who ultimately die is an over-triage that most systems are willing to accept, but failing to transport patients for whom the TOR guidelines predict improved survival is unacceptable.
Medic Wesley’s Comments:
Looking at the ROC database, we’re provided with a ton of information on many issues of resuscitation. The study of over 36,000 patients provides us with valuable tools for the prehospital setting of cardiac arrest patients.
As Doc stated, the TOR is a three-step method for determining the likelihood of survival. But is it a guideline or a rule?
The medical research community puts very little in the “can’t or won’t” category when determining who “should or can” be transported.
Sometimes the least likely candidate for resuscitation is the one who survives, and the patient who meets all the criteria for what should be a save ends up dying.
We’re provided with scientific guidelines to assist us in making extremely difficult decisions in prehospital cardiac arrest patients. Sometimes something tells us we should keep trying despite the science-based score that we’re provided. That’s why it’s a guideline and not a rule. It allows us to sleep a little better some nights when we question whether we should have done more.
Although science supports us with guidelines, the heart and soul of the provider is often the rule.
