Termination-of-resuscitation rule for emergency department physicians treating out-of-hospital cardiac arrest patients: an observational cohort study

Abstract

IntroductionThe 2010 cardiopulmonary resuscitation guidelines recommend emergency medical services (EMS) personnel consider prehospital termination-of-resuscitation (TOR) rules for out-of-hospital cardiac arrest (OHCA) following basic life support and/or advanced life support efforts in the field. However, the rate of implementation of international TOR rules is still low. Here, we aimed to develop and validate a new TOR rule for emergency department physicians to replace the international TOR rules for EMS personnel in the field. This rule aims to guide physicians in deciding whether to withhold further resuscitation attempts or terminate on-going resuscitation immediately after patient arrival.MethodsWe analyzed data prospectively collected in a nationwide Utstein-style Japanese database between 2005 and 2009, from 495,607 adult patients with OHCA. Patients were divided into development (n = 390,577) and validation (n = 105,030) groups. The main outcome measures were specificity, positive predictive value (PPV), and area under the receiver operating characteristic (ROC) curve for the newly developed TOR rule.ResultsWe developed a new TOR rule that includes 3 criteria based on the results of multivariate logistic regression analysis for predicting a 1-month death after OHCA: no prehospital return of spontaneous circulation (adjusted odds ratio [OR], 25.8; 95% confidence interval [CI], 24.7–26.9), unshockable initial rhythm (adjusted OR, 2.76; 95% CI, 2.54–3.01), and unwitnessed by bystanders (adjusted OR, 2.18; 95% CI, 2.09–2.28). The specificity, PPV, and area under the ROC curve for this new TOR rule for predicting 1-month death in the validation group were 0.903 (95% CI, 0.894–0.911), 0.993 (95% CI, 0.992–0.993), and 0.874 (95% CI, 0.872–0.876), respectively.ConclusionsWe developed and validated a new TOR rule for emergency department physicians consisting of 3 prehospital variables (no prehospital ROSC, unshockable initial rhythm, and unwitnessed by bystanders) that is a >99% predictor of very poor outcome. However, the implementation of this new rule in other countries or EMS systems requires further validation studies.

Improved Survival With Favorable Neurological Outcome in Elderly Individuals With Out-of-Hospital Cardiac Arrest in Japan – A Nationwide Observational Cohort Study –

“…This suggests that, to reduce futile resuscitation with limited medical resources, the oldest age group (≥95 years) might be taken into consideration to improve present TOR rules, which are already include an unwitnessed status. 1, 39 However this rationale is fraught with ethical and legal factors and needs further investigations because end-of-life decisions are complex and do-not-resuscitate orders and living wills are generally not used in Japan.…”

The incidence of “load&go” out-of-hospital cardiac arrest candidates for emergency department utilization of emergency extracorporeal life support: A one-year review

“…16 The designated criteria are supporting advanced resuscitation efforts and a transport under on-going CPR by disregarding the termination-of-resuscitation-rules. [20][21][22][23] The ERC-guideline 2010 recommends criteria to consider termination of OHCA according the 'basic life support termination of resuscitation rule'. The rule includes criteria like no ROSC, no shockable rhythm and no witnessed collapse by EMS personnel.…”

Relationship Between the Duration of Cardiopulmonary Resuscitation and Favorable Neurological Outcomes After Out‐of‐Hospital Cardiac Arrest: A Prospective, Nationwide, Population‐Based Cohort Study

“…However, the 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care and the 2015 AHA Guidelines Update for CPR and Emergency Cardiovascular Care did not specify the appropriate duration of CPR to be conducted before out‐of‐hospital resuscitation efforts could cease . Moreover, initial shockable rhythm has been shown to be a crucial prehospital variable for predicting favorable neurological outcomes after OHCA . Therefore, we hypothesized that the appropriate duration of CPR before terminating resuscitation efforts is ≈30 minutes.…”