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BLS Termination of Resuscitation

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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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Posted · Report post

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.

R/r 911

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[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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http://content.nejm.org/cgi/content/extract/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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Posted · Report post

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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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; (please take into consideration that all AEDs need to be reprogramed to new standards it is a just a plastic brain after all!) and (3) the cardiac arrest was not directly witnessed by EMS responders. Please tell me that this is not ALL the criteria used, where is hypothermia? CAN BE is clear as freaken MUD!

I doubt that this would be used for anything other than a standard medical cardiac arrest, but either way you'll need to patch for the pronouncement...

“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.”

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

0.5% with NO ACLS trial, that is 25% of the national average save rate WITH ACLS in some places so YES , that deserves an ACLS trial, maybe still no transport without ROSC after ACLS trial but at least a trail. I do not believe in transporting those who have no chance of being revived, but I do not approve of leaving behind those that could be, and I think the families of those 4 survivors in that TINY sample of patients would agree! Kinda like saying the hypothermic patient showed no signs of life and was stiff as a board so why warm them, just pronounce...

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0.5% with NO ACLS trial, that is 25% of the national average save rate WITH ACLS in some places so YES , that deserves an ACLS trial, maybe still no transport without ROSC after ACLS trial but at least a trail. I do not believe in transporting those who have no chance of being revived, but I do not approve of leaving behind those that could be, and I think the families of those 4 survivors in that TINY sample of patients would agree! Kinda like saying the hypothermic patient showed no signs of life and was stiff as a board so why warm them, just pronounce...

Cancelling ALS I can't say I would agree with if they are close, but that 0.5% chance of survival was (from my understanding at least) when the pts were transported to the nearest ED where they presumably received ACLS. It is not a fair comparison to make between someone with less than a 0.5% chance of surviving compared to a hypothermic pt who most likely has a greater chance.

Not everyone can be saved. Should ALS work the traumatic VSA pt who was dead when the crew arrived with three rounds of drugs before pronouncing just because there might possibly be some slight minute little chance of the person ROSCing?

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YES to BLS. I have no problem with BLS no initiating a code with obvious signs of death (assuming proper training). As far as canceling a code, nope unless there are other circumstances why would ANYONE cancel a code. And by other I mean mass casualty or serious system resource problems. No level should ever cancel working a code and call it. We are here to up the chance of survival, no matter how little. Now if there are three people and you can up two significantly by lowring or calling it for another thats one thing. But on a normal call to a normal code with no obvious signs then ANYONE should work it. If there is any doubt work it. I'm well versed with ACLS studies and CPR studies, and with new AHA bullshit they perhaps are below what a standard should be, but still we have to try. The medications used in ACLS have shown no signicant variation in the outcome of a standard code, and no change in a traumatic code, yet we still do it because it may have a improved chance. WORK EVERY CODE. As far as safety, good driving means you never exceed a posted speed limit even when hot, change tones, slow and honk at intersections etc... But for codes we get police to clear to the hospital so we can expidite code 3 and ignore normal rules, this way we dont create the increased risk to others to save the one. I hate to hear that any of you would not work a code simply because of the likely hood of outcome. Our protocols call for 2 obvious signs of death before we decide not to work it to be clear TWO guarantees that there is no hope. One guarantee there is no hope and were still working it. There are few circumstances where working a code would require system resources that could be better used elsewhere. Next thing your going to tell me that my grandfather who has had 2 heart attacks and a stroke (with NO problems acquired from them, amazing eh?) should not be resuscitated because his chances are crap?!?! Is a baby more important??? What if the guy is a monk meditating and is just out of it but fine and we have no idea?

WORK THE CODE.

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So EMSBrian how many successful codes have you seen ? I mean successful by having patients functioning outside the hospital confines.

I cancel codes all the time.. Why? They are futile. period. If one is aystole and have been down greater than 8 minutes . they are not going to respond to pharmacological agents and IF they do, they will be in a vegetative state. Have you ever taken care of a patient in a post-arrest state ? Probably not... Try taking care of one for about 2-4 weeks in ICU. The patients meanwhile will have post arrest seizures every other hour due to the anoxia during the event or the massive cerebral edema caused by hyperventilation during resuscitation. Now, if they do so happen to survive .. without drooling for the rest of their remainder lives, they will be a cardiac crippled. Confined to bed rest, so they now can get pneumonia or multiple sepsis from the decub or the other few thousand bugs out there.. to slowly go into renal failure, then organ system shut down.... then die.

So before we get the "hero" syndrome, our actions or even lack of has long outstanding repercussions. Not only physical but financially as well at $3000.00 to $10,000 a day.

If I was to introduce a surgery or even any medical procedure that would extend a life only 0.5% of the time.. would we preform it... NO! It would be categorized as useless and non-worthy.

Unfortunately, part of this job is to look at the whole picture ... not snippits. Yes, resuscitate if there is any question but let's be realistic. Why work a code to bring expectations and enormous costs to only cease immediately upon arrival at the ER ? What did we prove and perform ?

Far as the family being better in the ER .. that is B.S! I can attest working in the ER & field & being the bearer of bad news on both sides of the fence, it is much easier on the family at home. Hopefully, the ER will allow family to view resuscitation efforts (yes, it is important to them). Yes, the patient is now the family... so do your job, contact the minister, other family members, get them something to drink.. the LEO and M.E. should be able to take over by then until the other parties arrive.

R/r 91

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