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Guidelines for termination-of-resuscitation of out-of-hospital cardiac arrest
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CHICAGO—Researchers have validated criteria that are used to identify patients with out-of-hospital cardiac arrest who have little or no chance of survival after resuscitation, according to a study in the September 24 issue of JAMA.

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“During the past 30 years, several research teams have sought to define objective clinical criteria to identify patients who likely will not benefit from rapid transport to the hospital for further resuscitative efforts. Despite this research, many emergency medical services (EMS) systems still urgently transport patients with refractory [not responding to treatment] cardiac arrest to the hospital for continued resuscitative efforts. Rapid transport with lights and siren may pose hazards for EMS personnel and the public and should occur only when the risks of high-speed transport are justified by the potential benefits to the patient,” the authors write.

Comilla Sasson, M.D., M.S., of the University of Michigan, Ann Arbor, and colleagues conducted a study to validate two out-of-hospital termination-of-resuscitation rules developed by the Ontario Prehospital Life Support (OPALS) study group, one rule for use by responders providing basic life support (BLS) and the other rule for those providing advanced life support (ALS). The researchers analyzed surveillance data submitted by emergency medical systems and hospitals in 8 U.S. cities that were part of the Cardiac Arrest Registry to Enhance Survival (CARES). The study included 5,505 adults with out-of-hospital cardiac arrest.

The BLS rules include: event not witnessed by emergency medical services personnel; no automated external defibrillator used or manual shock applied in out-of-hospital setting; and no return of spontaneous circulation in out-of-hospital setting. The ALS rules include the BLS rules plus: arrest not witnessed by bystander; and no bystander-administered cardio-pulmonary resuscitation.

The researchers found that the overall rate of survival to hospital discharge was 7.1 percent (n = 392). Of 2,592 patients (47.1 percent) who met BLS criteria for termination of resuscitation efforts, only 5 (0.2 percent) patients survived to hospital discharge. Of 1,192 patients (21.7 percent) who met ALS criteria, none survived to hospital discharge. The BLS rule had a positive predictive value of 0.998 for predicting lack of survival; the ALS rule had a positive predictive value of 1.000 for predicting lack of survival.

“Widespread implementation of either rule could materially reduce the risk posed to EMS personnel during high-speed transports, decrease pressure on overburdened EMS systems, allow emergency department staff to focus on patients who have greater odds of survival, and decrease admissions to the intensive care unit of patients with out-of-hospital cardiac arrest who have little or no chance of surviving to discharge,” the authors write.
(JAMA. 2008;300[12]:1432-1438. Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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