Out-of-hospital cardiac arrest termination of resuscitation with ongoing CPR: An observational study

Abstract

Introduction

Termination of resuscitation guidelines for out-of-hospital cardiac arrest can identify patients in whom continuing resuscitation has little chance of success. This study examined the outcomes of patients transferred to hospital with ongoing CPR. It assessed outcomes for those who would have met the universal prehospital termination of resuscitation criteria (no shocks administered, unwitnessed by emergency medical services, no return of spontaneous circulation).

Methods

A retrospective cohort study of consecutive adult patients who were transported to hospital with ongoing CPR was conducted at three hospitals in the West Midlands, UK between September 2016 and November 2017. Patient characteristics, interventions and response to treatment (ROSC, survival to discharge) were identified.

Results

227 (median age 69 years, 67.8% male) patients were identified. 89 (39.2%) met the universal prehospital termination of resuscitation criteria. Seven (3.1%) were identified with a potentially reversible cause of cardiac arrest. After hospital arrival, patients received few specialist interventions that were not available in the prehospital setting. Most (n = 210, 92.5%) died in the emergency department. 17 were admitted (14 to intensive care), of which 3 (1.3%) survived to hospital discharge. There were no survivors (0%) in those who met the criteria for universal prehospital termination of resuscitation.

Conclusion

Overall survival amongst patients transported to hospital with ongoing CPR was very poor. Application of the universal prehospital termination of resuscitation rule, in patients without obvious reversible causes of cardiac arrest, would have allowed resuscitation to have been discontinued at the scene for 39.2% of patients who did not survive.

Introduction

Ambulance services in England respond to over 60,000 out-of-hospital cardiac arrests (OHCA), each year [1]. Resuscitation is attempted in around half of cases and return of spontaneous circulation (ROSC), at time of hospital transfer, is achieved in only 25.8% [2]. Reported estimates for survival to hospital discharge and favourable neurological outcomes are 9.4% and 8.5%, respectively [3]. Most survivors of OHCA achieve ROSC early in the resuscitation attempt [4], whereas poor survival is typical for patients in whom ROSC is not achieved and transport to hospital with ongoing CPR is required [5].

Transportation with ongoing CPR has recognised risks for both patients and Emergency Medical Services (EMS) personnel. Interruptions of CPR are associated with worse survival [6]. Previous studies have demonstrated the inability to provide high quality manual CPR during the extrication of patients on a stretcher, both down stairs and through confined corridors [7]. Additionally, adverse CPR quality has been recognised due to critical acceleration forces, occurring during ambulance transport, particularly at slower speeds [8]. As such, extrication and transportation to hospital may hinder resuscitation success versus remaining on scene [9]. Furthermore, ongoing CPR during transport typically requires the provider to be unrestrained. This increases the risk of injury in the event of a collision [10], as well as potential injuries due to high forces of acceleration and deceleration whilst travelling unrestrained [11].

Termination of resuscitation (TOR) guidelines for OHCA have been derived to identify patients in whom continuing resuscitation has little chance of success. TOR at the scene of OHCA occurs in approximately one third of cases in England [12]. In the UK, the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Recognition of Life Extinct (ROLE) Clinical Practice Guideline [13] informs clinicians responding to OHCA of TOR decisions (Appendix 1). ROLE allows TOR if the patient remains asystolic after 20 min of advanced life support (ALS), in the absence of a special circumstance (e.g. pregnancy, suspected poisoning or drug overdose). In patients not fulfilling the ROLE criteria, continued resuscitation is expected.

Resuscitation Council (UK) guidelines suggest that there is little to be gained from transporting patients to hospital, who have not obtained ROSC on scene [14]. Basic life support (BLS), common to pre and in-hospital settings, remains the key to successful resuscitation, over more advanced procedures [6]. The universal prehospital termination of resuscitation clinical prediction rule [15,16] identifies patients, who despite resuscitation attempts, do not achieve ROSC prior to transport and do not require shocks, where the arrest was not witnessed by EMS personnel. Prospective validation of this rule, among patients with OHCA of presumed cardiac aetiology, demonstrated 100% positive predictive value (PPV) for death, suggesting it may be reasonable to stop resuscitation and avoid the risk and resource implications of transfer to hospital with ongoing CPR [17].

This study sought to explore patient characteristics, interventions provided and outcomes in patients transferred to hospital with ongoing CPR. A secondary aim was to determine how many transported patients, would fulfil the universal prehospital termination of resuscitation criteria.