Which of the following is a possible consequence of using medical terminology

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While EMS personnel do not pronounce death, they may be asked to determine if death is already present when arriving on the scene to a pulseless patient. The 2015 American Heart Association (AHA) guidelines recommend that EMS providers do not initiate resuscitation of any patient in the following scenarios:

• Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril

• Overt clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, decomposition)

• A valid advanced directive, a Physician Orders for Life-Sustaining Treatment (POLST) form indicating that resuscitation is not desired, or a valid Do Not Attempt Resuscitation (DNAR) order.

For patients who do not meet these criteria, resuscitation should initiate as soon as possible based on the nature of the cardiac arrest. OHCA, due to traumatic mechanisms, has very different underlying pathophysiology compared to medical causes and, therefore, will merit a separate discussion below. Once the decision to initiate resuscitation is made, both Basic Life Support (BLS) and Advanced Life Support (ALS) providers have training in managing cardiac arrest patients within their scope of practice and protocols.

Resuscitation in Non-Traumatic Cardiopulmonary Arrest

Once a patient suffers a cardiac arrest, the chance of achieving a return of spontaneous circulation (ROSC) ranges from 7.2 to 11%. Furthermore, studies have shown that the survival rate declines when the duration of CPR is greater than 10 minutes without ROSC and rapidly declines after 30 min. These lower rates may be attributable to rapid loss of neurological function secondary to hypoxia, the poor underlying prognosis from the pathology, or challenges in delivering optimal care in the prehospital setting. Even the use of automatic compression devices and other measures to optimize cardiopulmonary arrest treatment during ambulance transport has not been shown to improve outcomes. The argument has been that maintaining optimal CPR care on the scene may provide higher quality CPR, compressions, and ALS interventions than attempting to perform CPR while transporting to the hospital in a moving ambulance. For this reason, many departments have implemented policies for resuscitating in the field for a predetermined amount of time. 

Once the resuscitation has started, EMS personnel care for patients within their medical approved protocols. As more EMS personnel deliver CPR care on scene, EMS medical directors have been exploring protocols to guide EMTs and paramedics in how long to continue the resuscitation and when in that sequence to transport the patient. The use of termination of resuscitation (TOR) evidenced-based rules was first proposed in 2002 for BLS providers to predict with accuracy the likelihood of ROSC during continued resuscitation. Additional guidance has been proposed for ALS providers and incorporates the additional training ALS providers receive.  NAEMSP has endorsed these criteria and help guide local departments when crafting protocols. These guidelines have a higher than a 99% positive predictive value for accurately predicting no chance for survival. NAEMSP endorses the following criteria as evidence-based when making termination or resuscitation protocols:

• When emergency medical services personnel did not witness the event

• When there is no shockable rhythm identified by an automated external defibrillator (AED) or other electronic monitors

• When spontaneous circulation does not return in the out-of-hospital setting

While the current NAEMSP guidelines do not endorse any set time for EMS to perform resuscitation at the scene, Both the previous NAEMSP guidelines and the current European Resuscitation Council recommend 20 minutes of on-scene efforts before terminating efforts. This recommendation has led to many departments implementing rules for termination of resuscitation that include providing at least 20 minutes of on-scene CPR. Also, EMS agencies must have active physician oversight when making protocols and must consider the providers' training. 

Below is an example protocol from an active suburban/urban EMS service:

CPR may be terminated by ALS and BLS personnel when:

• A patient has in his or her possession (or at the bedside) a completed, legal Do Not Resuscitate Order (DNR)

• Spontaneous circulation has been restored (return of spontaneous circulation, ROSC), and effective spontaneous or assisted ventilation are achieved per current AHA guidelines.

• Resuscitation efforts have been transferred to a person(s) of no less skill than the initial providers.

• Rescuers are exhausted and physically unable to continue resuscitation.

• The patient meets the requirements for the Determination of Death protocol.

• The online medical control physician advises the termination of resuscitation.

Additionally, ALS personnel may terminate resuscitative efforts for cardiac arrest if ALL of the following criteria exist:

• The patient is 18 years or older.

• EMS has provided over 20 minutes of CPR

• Initial rhythm is asystole or PEA, confirmed in two leads on a printed rhythm strip.

• Rhythm remains in asystole or PEA throughout resuscitative efforts (no VFib or VTach)

• No return of spontaneous circulation (ROSC)

• No defibrillation is performed.

• EMS did not witness an arrest

• A secure airway is confirmed by digital waveform capnography. 

• Quantitative end-tidal CO2 (ETCO2) value is less than 10 mmHg despite effective CPR.

The AHA has endorsed the use of locally defined determination of death and termination of resuscitation protocols based on national guidelines, and they continue to expand to more agencies to improve emergency care. The National Association of EMS Physicians has also endorsed promoting protocols in all EMS systems that ensure high-quality emergency care in cardiac arrest.

Emerging evidence shows that select patients may benefit from newer technologies in the right systems, such as emergency department extracorporeal membrane oxygenation (ECMO). Medical directors and EMS agencies will need to continue to monitor these advancements as they may impact which patients may benefit from transport to the emergency department.

Resuscitation in Trauma

The pathophysiology of OHCA in trauma patients is very different from OHCA in non-trauma patients. While some patients, such as the elderly and those with chronic co-morbidities, may be predisposed to cardiac arrest, the traumatic event adds new pathology leading to different treatment approaches. Whether the arrest is due to a direct result of the injury such as blunt or penetrating trauma to the chest or due to other mechanisms such as hemorrhagic shock, outcomes are inferior with survival rates of less than 2%. For this reason, the NAEMSP, in conjunction with the American College of Surgeons Committee on Trauma (ACSCOT), released guidelines on withholding resuscitation in trauma patients in 2003 and updated in 2012:

• Where death is a predictable outcome

• Where injuries are incompatible with life, such as decapitation or hemicorporectomy

• For patients with blunt or penetrating trauma where there is evidence of prolonged cardiac arrest, including dependent lividity and rigor mortis

• For patients with blunt trauma who, on the arrival of EMS personnel, is found to be apneic, pulseless, and without organized cardiac activity

• For patients with penetrating trauma who, on the arrival of EMS personnel, is found to be pulseless and apneic and there are no other signs of life, including spontaneous movement, electrocardiographic activity, and pupillary response

While the termination of resuscitation (TOR) criteria for OHCA in non-traumatic patients has received extensive study, TOR research in trauma patients has been scarce. However, many causes of OHCA in trauma patients are due to acute blood loss and traumatic injuries that may be repaired with prompt surgical intervention. The NAEMSP-ASCOT 2012 update suggested that TOR protocols may be appropriate for EMS agencies. The TOR rules are predicated on EMS providers' ability to get patients to definitive care in a reasonable amount of time, which would take precedence over any on-scene measures due to the likely need for surgical intervention. EMS agencies will need to coordinate with their local trauma centers and assess their resources to develop TOR rules that are appropriate for their community. More research will be necessary before the widespread implementation of standard TOR rules in trauma patients.

Out of hospital cardiac arrest (OHCA) is a catastrophic event with known poor survival rates. Since most patients who suffer OHCA have poor outcomes and transporting these patients also has potential drawbacks, there has been growing interest in identifying which patients will benefit from initiation of CPR and subsequent hospital transport versus termination of efforts on scene. While the termination of resuscitation guidelines have been promoted since the early 2000s, continued research and development are needed for widespread use. EMS medical directors and other stakeholders will need to continue to develop best practices to benefit patients, EMS personnel, and the community at large.

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