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BLS Termination of Resuscitation


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#1 BEorP

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Posted 28 December 2006 - 03:23 PM

Surprisingly I wasn't able to find a thread on this already... maybe I missed it.

The news release can be found here:
http://www.sunnybrook.ca/news?id=403

I have bolded some parts that I feel are important.

Proposed guidelines could improve dignity of patients and families and enhance safety of paramedic crews

TORONTO, ON – Prehospital care experts at Sunnybrook Health Sciences Centre have validated a guideline that emergency medical service (EMS) responders trained in the use of automatic defibrillation can use to identify patients who will not survive after suffering a cardiac arrest. The study, which examined over 1200 adult patients suffering an out-of-hospital cardiac arrest, appears in the New England Journal of Medicine’s August 3rd issue.

For many years termination of resuscitation (TOR) protocols have existed for paramedics trained in advanced cardiac life support care including defibrillation, intravenous drugs and advanced airway management. However, for EMS responders trained solely in defibrillation, all patients required transport to the nearest emergency department for ongoing resuscitation efforts, which were almost always unsuccessful. As a result, large numbers of patients with little or no potential for survival are regularly transported to emergency departments. The continued resuscitation effort and emergency transfer negatively impacts the patient’s family, the receiving emergency department and the EMS system.

“The family is forced to begin the grieving process in a busy emergency department often lacking privacy and dignity rather than in the comfort of their own home,” says Dr. Laurie Morrison, lead investigator on the study and director of the Prehospital and Transport Medicine Research Program. “Many studies have shown that families’ long term grief adjustment is as good or better with in-the-home termination of resuscitation. In addition transporting patients by speeding ambulance can cause motor vehicle injuries resulting in injury to other drivers, pedestrians and EMS personnel.”

The Termination of Resuscitation guideline determines that resuscitation can be stopped if all of the following are true: (1) no return of pulse is achieved; (2) no shock to the heart was given; and (3) the cardiac arrest was not directly witnessed by EMS responders. During the study’s trial, current procedures for cardiac resuscitation did not change. Patients who fit the criteria were documented and followed-up over a six month period.

The main results of the study showed there was a 99.5 per cent probability that patients who fit all three criteria would not survive if transported to the nearest emergency department. Implementation of the guideline would result in only 37 per cent of patients requiring transport to the emergency department rather than the current practice of 100 per cent.

“We did not expect to find that the guideline would show a 100 per cent probability of not surviving since there are so many unique factors associated with each cardiac arrest,” says Dr. Richard Verbeek, a co-author of the study and medical director for the Sunnybrook-Osler Centre for Prehospital Care. “That is why emergency medical responders must contact an emergency physician to discuss each individual call when the guideline is used. The emergency physician will take into account other clinical aspects of the call before any final decision to terminate resuscitation is made. This guideline helps to determine when ongoing resuscitation will not be successful, but also does not deny potentially viable patients full resuscitation and the best chance for survival.”

Past research has demonstrated that over 96 per cent of out-of-hospital cardiac arrest patients do not survive and are pronounced dead upon arrival at the hospital. This low survival rate is primarily due to the fact that very few bystanders in Canada provide CPR in the initial stages of cardiac arrest. In many cases, when CPR is performed the patient’s heart is more likely to attain a recoverable rhythm, which makes it easier to resuscitate the patient.

“I see the results of this study, not only as a way to focus our resources more effectively, but also as a strong indication of how vital it is for members of the public to receive training in CPR and to overcome their fear to provide CPR to a stranger or a loved one who suffers a cardiac arrest,” says Dr. Morrison. “It’s no myth, CPR could mean the difference between life and death.”

The trial involved 24 regional EMS systems across Ontario. The TOR guideline is currently going through an implementation trial. Eight communities are involved in this stage, and will be looking at the guideline’s impact on the system, providers and various stakeholders.



Thoughts?
Do you want an EMT-B pronouncing your family member? What about a Primary Care Paramedic?
And EMT-Bs, do you want that responsibility? What about PCPs, would you rather have an ACP or doctor tell them their family member is dead?

[sub:c2cdc4a374]Edit: I know this may more appropriately be a BLS topic, but I'd like the thoughts of ALS providers and anyone so hopefully it is alright to leave it in the general EMS discussion[/sub:c2cdc4a374]
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#2 Ridryder 911

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Posted 28 December 2006 - 03:44 PM

I have no problem with BLS declaring death on patients if there had been no resuscitation efforts prior to arrival with time delay>4 minutes, and the above criteria has been made as well.

I believe we in EMS are too mind set in performing resuscitative efforts for ourselves and not realizing that it will not matter if we do not have early intervention prior to EMS arrival.

As the study describes nearly 100% fatal... that not good odds. We need to stand back and see what we are doing that is wrong and what we need to do to change outcomes.

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#3 tniuqs

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Posted 28 December 2006 - 06:14 PM

[I believe we in EMS are too mind set in performing resuscitative efforts for ourselves and not realizing that it will not matter if we do not have early intervention prior to EMS arrival.



NOW this statement is so very, very true and insightful...... but, let us mention in passing that "fear of legal repercussions" this is a mitigating fact as well, this should seriously be reviewed before implimentation "carte banche" this would undoubtedly open up a huge can of worms.

As the study describes nearly 100% fatal... that not good odds. We need to stand back and see what we are doing that is wrong and what we need to do to change outcomes.


Yes so very true, or at least review the recient and flawed "OPALS" study. This is quoted by many politicians to reduce funding for EMS and decrease coverage models for ALS, so logically the reduction of services will result in increased response times, this is NOT rocket surgery, the comparison was "in field' vs "in hospital" arrest survival (apples and oranges) (see lettemans comentary back in other threads re: OPALS)

In addition transporting patients by speeding ambulance can cause motor vehicle injuries resulting in injury to other drivers, pedestrians and EMS personnel.”


Now this statemet is very worrysome to me, just why is this occuring or is this just a passing comentary by the writer, any stats on this or studies? Is it mandated that "lighting it up" is a protocol? Let us look at EMS MVC in a new light, perhaps reviewing the transport of the types of patients, and the many factors involved, ie type of patient, experiance of operator +++.

“The family is forced to begin the grieving process in a busy emergency department often lacking privacy and dignity rather than in the comfort of their own home,” says Dr. Laurie Morrison, lead investigator on the study and director of the Prehospital and Transport Medicine Research Program. “Many studies have shown that families’ long term grief adjustment is as good or better with in-the-home termination of resuscitation.


Ok I call bs on this: how exactly one quantify grieving in the first place? ...this is absolute Psyco babble....in my area in ER, clergy is called, social workers, family notified by police and a quiet room provided. So just leave the lonely significant others at home relying on just what? At home with a blood stained carpet and other lovely reminders like the body in the bedroom waiting for the coroner for hours....this is absolute nonsense squared!

“We did not expect to find that the guideline would show a 100 per cent probability of not surviving since there are so many unique factors associated with each cardiac arrest,” says Dr. Richard Verbeek, a co-author of the study and medical director for the Sunnybrook-Osler Centre for Prehospital Care. “That is why emergency medical responders must contact an emergency physician to discuss each individual call when the guideline is used. The emergency physician will take into account other clinical aspects of the call before any final decision to terminate resuscitation is made. This guideline helps to determine when ongoing resuscitation will not be successful, but also does not deny potentially viable patients full resuscitation and the best chance for survival.”

“I see the results of this study, not only as a way to focus our resources more effectively, but also as a strong indication of how vital it is for members of the public to receive training in CPR and to overcome their fear to provide CPR to a stranger or a loved one who suffers a cardiac arrest,” says Dr. Morrison. “It’s no myth, CPR could mean the difference between life and death.”


Hey don't the co authors talk, they have their answer...sheesh.
This was the part that should be highlighted!
Any suggesting that CPR be taught in the schools?
Any suggestion or introduction at a provincial level for funding as an incentive for easy access and low cost for CPR training?
Or give a tax break to a busness or personal income tax.


So: To answer the question:

Do you want an EMT-B pronouncing your family member? What about a Primary Care Paramedic?
And EMT-Bs, do you want that responsibility? What about PCPs, would you rather have an ACP or doctor tell them their family member is dead?


I don't want Anyone telling me a family member is dead, but thats just me.


cheers
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#4 dzmohr

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Posted 28 December 2006 - 06:24 PM

http://content.nejm....act/355/21/2257


To the Editor: We do not believe that Morrison et al. (Aug. 3 issue)1 focused on the right question in the Termination of Resuscitation (TOR) trial. If saving lives is the issue, the question is: What can early, adequate advanced cardiac life support achieve? Basic life support — as provided in this study — will never result in "good" cardiopulmonary resuscitation, and transportation of the patient to the emergency department during basic life support is thus futile. With physician-staffed advanced cardiac life support systems, 40 to 50% of patients with out-of-hospital cardiac arrest have a return of spontaneous circulation, . . .


Don't shoot the messenger! I did not write the above and I do not buy the 40-50% -- HOWEVER .... Termination in the field for no return of pulses should NOT be based on no response to BLS regardless of if it is provided by, EMTs or Drs .... now no return of circulation after an ACLS trial, that has been a good standard for many years..

What IS it with Ontario and ALS? Remember the much touted OPALS study that "proved" that patients fared better with only BLS and ALS reduced survival rates? Right, how many times has THAT been debunked.

"Results Follow-up data were obtained for all 1240 patients. Of 776 patients with cardiac arrest for whom the rule recommended termination, 4 survived (0.5 percent). The rule had a specificity of 90.2 percent for recommending transport of survivors to the emergency department and had a positive predictive value for death of 99.5 percent when termination was recommended. Implementation of this rule would result in a decrease in the rate of transportation from 100 percent of patients to 37.4 percent. The addition of other criteria (a response interval greater than eight minutes or a cardiac arrest not witnessed by a bystander) would further improve both the specificity and positive predictive value of the rule but would result in the transportation of a larger proportion of patients."


Specificity of 90.2 percent --- four survive that met the BLS termination criteria with only BLS? Wonder what would have happened to the numbers had a round of ACLS been put in the mix early?

Don't get me wrong, I have nothing against Ontario, and I have nothing against BLS not initiating resuscitation with the classic signs of obvious death. In unwitnessed arrest, no bystander CPR and greater then 8 minute response time, the studies support a dismal prognosis and invite not initiating a code. But just because they do not have ROSC with CPR only in a nonshockable rhythm is no reason to cancel responding ACLS or, if it is closer, transport to the hospital for an ACLS trial in the absence of an advance directive.
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#5 BEorP

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Posted 28 December 2006 - 06:29 PM

Don't get me wrong, I have nothing against Ontario, and I have nothing against BLS not initiating resuscitation with the classic signs of obvious death. In unwitnessed arrest, no bystander CPR and greater then 8 minute response time, the studies support a dismal prognosis and invite not initiating a code. But just because they do not have ROSC with CPR only in a nonshockable rhythm is no reason to cancel responding ACLS or, if it is closer, transport to the hospital for an ACLS trial in the absence of an advance directive.


The 0.5% chance of survival is worth the risk and resources?
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