R Esuscitation in the O Ut-of-Hospital S Etting : M Edical F Utility C Riteria for O N-Scene P Ronouncement of D Eath

Abstract

The complete and irreversible cessation of life is often difficult to determine with complete confidence in the dynamic environment of out-of-hospital emergency care. As a result, resuscitation efforts often are initiated and maintained by emergency medical services (EMS) providers in many hopeless situations. Medical guidelines are reviewed here to aid EMS organizations with respect to decisions about: 1) initiating or waiving resuscitation efforts; 2) the appropriate duration of resuscitation efforts; and 3) recommended procedures for on-scene or prehospital pronouncement of death (termination of resuscitation). In cases of nontraumatic cardiac arrest, few unassailable criteria, other than certain physical signs of irreversible tissue deterioration, exist for determining medical futility at the initial encounter with the patient. Thus, the general medical recommendation is to attempt to resuscitate all patients, adult or child, in the absence of rigor mortis or dependent lividity. Conversely, wellfounded guidelines now are available for decisions regarding termination of resuscitation in such patients once they have received a trial of advanced cardiac life support. In practice, however, the final decision to proceed with on-scene pronouncement of death for these patients may be determined more by family and provider comfort levels and the specific on-scene environment. For patients with posttraumatic circulatory arrest, the type of injury (blunt or penetrating), the presence of vital signs, and the electrocardiographic findings are used to determine the futility of initiating or continuing resuscitation efforts. In general, patients who are asystolic on-scene are candidates for on-scene pronouncement, regardless of mechanism. With a few exceptions, blunt trauma patients with a clearly associated mechanism of lethal injury are generally candidates for immediate cessation of efforts once they lose their pulses and respirations. Regardless of the medical futility criteria, specialized training of EMS providers and targeted related testing of operational issues need to precede field implementation of on-scene pronouncement policies. Such policies also must be modified and adapted for local issues and resources. In addition, although the current determinations of medical futility, as delineated here, are important to establish for societal needs, the individual patient's right to live must be kept in mind always as new medical advances are developed.

Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest

“…1,76,91,92,[98][99][100][101] Although the same justifications apply to children, especially in light of worse out-of-hospital resuscitation outcomes, children are routinely excluded from termination-of-resuscitation protocols, at least in the United States. 1 Approximately half of states have formalized termination of resuscitation in statute or protocol, but only a few apply them to children.…”

Death of a Child in the Emergency Department

“…Even with adults, however, the decision to make an on-scene pronouncement versus transport in settings of probable futility may be driven more by perceived family needs and provider comfort. 35 The little evidence that exists, however, speaks to the family benefit of stopping resuscitation; at least 2 studies in adult patients indicate that families may in fact adjust better after pronouncement on scene than with transport to a hospital. 36,37 No such data exist for children in the United States, but a Swedish study in adolescents with sudden cardiac death is supportive of pronouncement on scene as an option on the basis of parental report.…”

Pre‐hospital cardiac arrest and induction of mild hypothermia: studies on epidemiology and feasibility

“…Resuscitation is also recommended to be withheld in cases of unwitnessed arrest with initial cardiac rhythm of asystole, excluding cases of hypothermia and near-drowning (Kuisma and Jaara 1997b;Silfvast and Pettilä 2003;Väyrynen et al 2008a;Wyatt et al 1999). Otherwise EMS personnel generally initiate resuscitation in all prehospital cases of sudden cardiac arrest if the patient is not known to have a do not attempt resuscitation (DNAR)-order (ERC 2005;Pepe et al 2001).…”