Review of:Strote J, Kohler P: “Transfer of care is associated with longer unsuccessful resuscitations.” American Journal of Emergency Medicine. 26(2):206-11, 2008.
The Science
This study compared the survival of traumatic and medical arrest resuscitation that was started in the field and continued in the emergency department (ED) with resuscitation that started in the ED. It was a retrospective review from King County, and they extracted the total resuscitation time.
Of the 132 patients who met the criteria, 71 (53.8%) arrested in the field. Mean overall resuscitation times were longer for arrests occurring in the field (44 minutes) compared with those in the ED (19 minutes). Mean time spent on ED resuscitation was no different for arrests occurring in the field (16 minutes) than in those in the ED (19 minutes).
They concluded, “Unsuccessful resuscitations were longer and beyond guideline recommendations when arrests occurred in the field and were transported.”
The Street
This study should probably have been titled, “Failure to Attain Field Return of Spontaneous Circulation (ROSC) in Cardiac Arrest is Reliable Predictor of Death”. Although that may seem like common sense, the implications are profound. The authors state that the American Heart Association and the American College of Surgeons have provided guidelines for when to cease resuscitation. Although this is true in the general sense, every code is different and the authors acknowledge societal, professional and ethical issues should be taken into account before “calling a code” in the field.
Regardless, the study demonstrated that even in the presence of these guidelines, ED resuscitation was continued as long as it would have been had it occurred in the ED. Why? Do ED docs not believe we’ve followed the protocols? Or is this simply part of the “We did everything we could” mentality?
Unfortunately, the authors of the study didn’t provide sufficient information related to the level of providers treating the field arrest. I believe including trauma arrests in this study confuses the issue, because there are a host of different concerns when deciding whether to attempt resuscitation of traumatic arrest victims.
Another issue with this article is that the authors don’t tell us if all the field arrests were urban or rural. Rural BLS providers are less likely to feel comfortable terminating resuscitation in the field.
Overall, I’m unclear what question the authors are trying to answer. They begin the paper by saying guidelines state we can stop after 25-30 minutes of attempted resuscitation. However, we know field termination may not always be appropriate. So, if we transport the patient isn’t it reasonable to expect a continued resuscitation attempt at the hospital? That’s what the authors found. The fact it didn’t make a clinical outcome difference to the arrest victim doesn’t mean it didn’t have a clinical outcome on the professional experience of the providers or the emotional experience of the victims’ families.
