Comparison of Helsinki and European Resuscitation Council “do not attempt to resuscitate” guidelines, and a termination of resuscitation clinical prediction rule for out-of-hospital cardiac arrest patients found in asystole or pulseless electrical activity

What should we consider when applying termination of resuscitation rules?

“…The TOR rule does not specify a time limit for EMS to declare "no ROSC" despite resuscitation attempts, and due to this vagueness, it should specify protocols, algorithms, and results for OHCA patients in accordance with local EMS systems (8,9,(17)(18)(19). The AHA guidelines made an addition of requiring 3 full rounds of CPR and automated external defibrillator analysis before EMS can declare "no ROSC" in the field (10).…”

“…The advanced life support (ALS) TOR rules recommend considering the termination of resuscitation when the 3 BLS TOR criteria are met and no bystander cardiopulmonary resuscitation (CPR) was provided (7). The application of the BLS/ALS TOR rule was validated in North American and European sites, and the results consistently showed high specificity and PPV (8,9). Based on these studies, the 2015 American Heart Association (AHA) Guidelines Update for CPR and Emergency Cardiovascular Care (ECC) recommend that regional and local EMS authorities use the BLS TOR rule to develop protocols for terminating resuscitative efforts in adult victims of cardiac arrest in areas where ALS is not available or may be significantly delayed (10).…”

Part 3: Ethics

“…30 This clinical prediction rule consistently generates the highest specificity and positive predictive values when compared to previous guidelines. 29 It is recommended that regional or local EMS authorities use the BLS termination rule to develop protocols for the termination of resuscitative efforts by BLS providers for adult victims of cardiac arrest in areas where advanced life support is not available or may be significantly delayed (Class I, LOE A). The reliability and validity of this rule is uncertain if modified (Class IIb, LOE A).…”

Impact of Changes in Resuscitation Practice on Survival and Neurological Outcome After Out-of-Hospital Cardiac Arrest Resulting From Nonshockable Arrhythmias

“…3,14,15 At present, OHCA is largely attributable to nonshockable arrhythmias-asystole and pulseless electric activity-from which survival is especially poor and for which few if any interventions are effective. 10,16,17 In particular, the impact of community-wide treatment strategies incorporating changes in CPR guidelines for what is now a majority of patients with nonshockable OHCA is uncertain. 10,11 Also at issue is whether treatments that benefit ventricular fibrillation/ tachycardia might be less beneficial for nonshockable arrests.…”