Comparison of Termination-of-Resuscitation Guidelines for Basic Life Support: Defibrillator Providers in Out-of-Hospital Cardiac Arrest

Ong, Marcus Eng Hock; Jaffey, James; Stiell, Ian G.; Nesbitt, Lisa

doi:10.1016/j.annemergmed.2005.05.012

Cited by 66 publications

(27 citation statements)

References 30 publications

(37 reference statements)

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“…None of them achieved the standard in general principle of medical futility, that is, less than 1% chance of survival of a given treatment 15. The result was inconsistent with studies carried out in North American and European sites, which stated the TOR rules with misclassified rate from 0% to 0.5%,5 6 8 10 with the best results both specificity and PPV reaching 100% in the Cardiac Arrest Registry to Enhance Survival (CARES) database 8. There are two possible reasons for the discrepancies.…”

Section: Discussionmentioning

confidence: 91%

Predictive performance of universal termination of resuscitation rules in an Asian community: are they accurate enough?

Chiang

Chang

et al. 2013

Emerg Med J

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Introduction Prehospital termination of resuscitation (TOR) rules have not been widely validated outside of Western countries. This study evaluated the performance of TOR rules in an Asian metropolitan with a mixed-tier emergency medical service (EMS). Methods We analysed the Utstein registry of adult, non-traumatic out-of-hospital cardiac arrests (OHCAs) in Taipei to test the performance of TOR rules for advanced life support (ALS) or basic life support (BLS) providers. ALS and BLS-TOR rules were tested in OHCAs among three subgroups: (1) resuscitated by ALS, (2) by BLS and (3) by mixed ALS and BLS. Outcome definition was in-hospital death. Sensitivity, specificity, positive predictive value (PPV), negative predictive value and decreased transport rate (DTR) among various provider combinations were calculated. Results Of the 3489 OHCAs included, 240 were resuscitated by ALS, 1727 by BLS and 1522 by ALS and BLS. Overall survival to hospital discharge was 197 patients (5.6%). Specificity and PPV of ALS-TOR and BLS-TOR for identifying death ranged from 70.7% to 81.8% and 95.1% to 98.1%, respectively. Applying the TOR rules would have a DTR of 34.2–63.9%. BLS rules had better predictive accuracy and DTR than ALS rules among all subgroups. Conclusions Application of the ALS and BLS TOR rules would have decreased OHCA transported to the hospital, and BLS rules are reasonable as the universal criteria in a mixed-tier EMS. However, 1.9–4.9% of those who survived would be misclassified as non-survivors, raising concern of compromising patient safety for the implementation of the rules.

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Section: Discussionmentioning

confidence: 91%

Predictive performance of universal termination of resuscitation rules in an Asian community: are they accurate enough?

Chiang

Chang

et al. 2013

Emerg Med J

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“…Consistent with previous studies for the TOR rules, 10,11,21,22 a sensitivity of ≥99% for favorable 30-day neurological outcome was used to determine the minimum prehospital and EMS responder resuscitation durations; we also calculated the maximum prehospital and EMS responder resuscitation durations associated with a sensitivity of 100% and a negative predictive value of 100%. Compared with previous sample sizes (1240-13 684 patients 10,11,21,22 ), our larger sample size (283 183 patients) provided >80% power (1-side α=0.05) with a misclassification rate <1%. All statistical analyses were performed with SPSS software (version 16.0J).…”

Section: Methodsmentioning

confidence: 99%

“…This is a difficult question to answer because community systems of emergency care vary around the world, and ethical and cultural norms must be considered. It is clear that field termination reduces transport to the hospital, 10,11,[21][22][23]25,26 but the optimal prehospital resuscitation duration has not previously been established. Our results demonstrate that prehospital resuscitation efforts to achieve favorable neurological outcome should be continued for at least 40 minutes from call receipt, inclusive of bystander and EMS responder resuscitation efforts, and for at least 33 minutes from scene arrival for EMS responder resuscitation efforts exclusively.…”

Section: Discussionmentioning

confidence: 99%

Duration of Prehospital Resuscitation Efforts After Out-of-Hospital Cardiac Arrest

et al. 2016

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Background— During out-of-hospital cardiac arrest, it is unclear how long prehospital resuscitation efforts should be continued to maximize lives saved. Methods and Results— Between 2005 and 2012, we enrolled 282 183 adult patients with bystander-witnessed out-of-hospital cardiac arrest from the All-Japan Utstein Registry. Prehospital resuscitation duration was calculated as the time interval from call receipt to return of spontaneous circulation in cases achieving prehospital return of spontaneous circulation or from call receipt to hospital arrival in cases not achieving prehospital return of spontaneous circulation. In each of 4 groups stratified by initial cardiac arrest rhythm (shockable versus nonshockable) and bystander resuscitation (presence versus absence), we calculated minimum prehospital resuscitation duration, defined as the length of resuscitation efforts in minutes required to achieve ≥99% sensitivity for the primary end point, favorable 30-day neurological outcome after out-of-hospital cardiac arrest. Prehospital resuscitation duration to achieve prehospital return of spontaneous circulation ranged from 1 to 60 minutes. Longer prehospital resuscitation duration reduced the likelihood of favorable neurological outcome (adjusted odds ratio, 0.84; 95% confidence interval, 0.838–0.844). Although the frequency of favorable neurological outcome was significantly different among the 4 groups, ranging from 20.0% (shockable/bystander resuscitation group) to 0.9% (nonshockable/bystander resuscitation group; P <0.001), minimum prehospital resuscitation duration did not differ widely among the 4 groups (40 minutes in the shockable/bystander resuscitation group and the shockable/no bystander resuscitation group, 44 minutes in the nonshockable/bystander resuscitation group, and 45 minutes in the nonshockable/no bystander resuscitation group). Conclusions— On the basis of time intervals from the shockable arrest groups, prehospital resuscitation efforts should be continued for at least 40 minutes in all adults with bystander-witnessed out-of-hospital cardiac arrest. Clinical Trial Registration— URL: http://www.umin.ac.jp/ctr/ . Unique identifier: 000009918.

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“…The survival rate would have been 0.04–0.08% in the subgroups in which resuscitation was contraindicated by the guidelines. Still, the authors were concerned about the ethical and legal dilemmas associated with the DNAR guidelines (9). Another study suggested that resuscitation should be withheld in unwitnessed arrests with asystole as the initial rhythm and no bystander‐cardiopulmonary resuscitation (CPR) based on a survival rate of 0% among 279 patients (10).…”

mentioning

confidence: 99%

Medical futility in asystolic out‐of‐hospital cardiac arrest

Väyrynen

Kuisma

Määttä

et al. 2007

Acta Anaesthesiol Scand

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Resuscitation should be withheld in cases of unwitnessed asystole, excluding cases of hypothermia and near-drowning. The prognosis is poor if the FRU response time is over 10 min or the ALS response time is over 10-15 min in bystander-witnessed arrests. The decision of whether or not to attempt resuscitation should not be influenced by the presence of bystander-CPR. Early initiation of ALS should be prioritised in the treatment of out-of-hospital asystole.

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Comparison of Termination-of-Resuscitation Guidelines for Basic Life Support: Defibrillator Providers in Out-of-Hospital Cardiac Arrest

Cited by 66 publications

References 30 publications

Predictive performance of universal termination of resuscitation rules in an Asian community: are they accurate enough?

Predictive performance of universal termination of resuscitation rules in an Asian community: are they accurate enough?

Duration of Prehospital Resuscitation Efforts After Out-of-Hospital Cardiac Arrest

Medical futility in asystolic out‐of‐hospital cardiac arrest

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