resuscitaion in ohca
DESCRIPTION
By Kanok Ongskul,MDTRANSCRIPT
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Resuscitation in OHCA:When to START
andWhen to STOP
Review by : Kanok Ongskul , MD2nd yr emergency medicine resident
Rajavithi hospital
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Goals of Resuscitation
Preserve life
Restore health
Relieve suffering
Limit disability
Respect the individual’s decisions, rights, and privacy
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Ethical Issues
HCP should consider the ethical, legal, and cultural factors assoc. w/ resuscitation.
Guided by science, the preferences of the individual or surrogates, and local policy and legal requirements
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Healthcare Advance Directive
A legal binding document
Tells the thoughts, wishes, or preferences for healthcare decisions during periods of incapacity
Verbal or Written (more trustworthy)
May be based on conversations, written directives, living wills, or durable power of attorney for health care
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Do Not Attempt Resuscitation (DNAR) order
Described more recently as a DNACPR decision, or “Allow Natural Death” (AND)
Given by a licensed physician or alternative authority
Must be signed and dated to be valid
Most preceded by a documented discussion with the patient, family, or surrogate decision maker
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Withholding & Withdrawing CPRin OHCA
Reduce unnecessary transport
Reduce associated road hazards
Reduces inadvertent paramedic exposure to potential biohazards
Reduce cost of ED pronouncement
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Criteria for Not Starting CPR (OHCA)
Begin CPR without seeking consent except… (where withholding CPR might be appropriate)
1. Situations would place the rescuer at risk of serious injury or mortal peril
2. Obvious signs of irreversible death (eg, rigor mortis, dependent lividity, decapitation, transection, or decomposition)
3. A valid, signed, and dated DNAR order or an advance directive indicating that resuscitation is not desired
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DNAR Orders in OHCA
Can take many forms (eg, written bedside orders, identification cards/bracelets)
In some EMS systems this includes verbal DNAR requests from family members (pts w/ a terminal illness, who were under the care of a physician)
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Advance Directives in OHCA
Do not have to include a DNAR order
DNAR order is valid w/o an advance directive.
Initiate CPR if doubt …the validity of a DNAR orderthe victim may have had a change of mindwhether the pt intended the advance directive to be applied under that condition
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Termination of Resuscitation (TOR)in OHCA
Neonatal / Pediatric: NO validated clinical decision rules
AdultBLSALSCombined BLS and ALS
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When to STOP BLSROSC
Care is transferred to ALS
The rescuer is unable to continue because ofExhaustionDangerous environmental hazardsIt places others in jeopardy
Reliable and valid criteriaIrreversible death / Obvious death“BLS termination of resuscitation rule” (prospectively validated)
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BLS Termination of Resuscitation Rule for Adult OHCA
1. Arrest not witnessed by EMS provider or first responder
2. No ROSC after 3 full rounds of CPR and AED analyses
3. No AED shocks delivered
If ALL criteria are met >>> consider TOR
Morrison LJ, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2006;355: 478-487.
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BLS termination-of-resuscitation rule for adult OHCA
Use the rule to develop protocols in areas where ALS is not available or may be significantly delayed (Class I, LOE A).
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When to STOP ALS
NAEMSP: Resuscitation could be terminated in pts not respond to at least 20 min of ALS.
“ALS termination of resuscitation rule”
(retrospectively externally validated)
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ALS Termination of Resuscitation Rule for Adult OHCA
Arrest not witnessed (by anyone)
No bystander CPR provided
No ROSC after complete ALS care in the field
No shocks delivered
If ALL criteria are met >> consider TOR
Morrison LJ, et al. Derivation and evaluation of a termination of resuscitation clinical prediction rule for advanced life support
providers. Resuscitation. 2007;74: 266.275.
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It is reasonable to employ this rule in all ALS services (Class IIa, LOE B).
ALS termination-of-resuscitation rule for adult OHCA
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TOR in a Combined BLS and ALSOut-of-Hospital System
Use of a universal rule can avoid confusion
The BLS rule is reasonable to use in these services (Class IIa, LOE B).
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Implementation of the Rules
Applied BEFORE ambulance transport
Contact online medical control when the criteria are met
EMS providers should receive training in sensitive communication with the family
Support for the rules should be sought from collaborating agencies such as hospital EDs, the medical coroner’s office, online medical directors, and the police.
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When to Start/Stop CPR ?
Consider the therapeutic efficacy of CPR, potential risks, and pt’s preferences
All rules should be validated prospectively before implementation
Grey areas where subjective opinions are required in pts with HF & severe respiratory compromise, asphyxia, major trauma, head injury and neurological disease.
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General Rule
In generalResuscitation should be continued as long as VF persistsOngoing asystole > 20 min in the absence of a reversible cause, and with ongoing ALS TOR
Reports of exceptional cases that do not support the general rule
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The quality of CPR is compromised during transport, and survival is linked to optimizing scene care rather than rushing to hospital.
In OHCA of cardiac origin, if recovery is going to occur, ROSC usually takes place on site.
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Organ Procurement
Continuing futile resuscitation attempts with the sole purpose of harvesting organs is debatable
If considering prolonging CPR and other resuscitative measures to enable organ donation to take place mechanical chest compressions may be valuable.
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Traumatic Cardiopulmonary Arrest
(TCPA)
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J Am Coll Surg 2003;196:475—81.
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Blunt Trauma
Resuscitation efforts may be withheld if
1. Apneic2. Pulseless3. No organized ECG activity
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Penetrating Trauma
Resuscitation efforts may be withheld If1. Apneic2. Pulseless3. No other signs of life, such as
Pupillary reflexesSpontaneous movementOrganized ECG activity
If any of these signs are present>> resuscitation and
transport
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Penetrating or Blunt Trauma
Resuscitation should be withheld if
1. Injuries obviously incompatible with life, such as decapitation or hemicorporectomy
2. Evidence of a significance time lapse since pulselessness, including dependent lividity, rigor mortis, and decomposition
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Nontraumatic Cause of Arrest ?
Mechanism of injury not correlate with clinical condition
>> Standard Resuscitation
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Termination of Resuscitation (TOR)
should be considered if
1. EMS-witnessed arrest + 15 min of unsuccessful CPR
2. Transport time > 15 min after the arrest
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Special Consideration
Drowning
Lightning Strike
Significant Hypothermia
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These recommendations specifically DO NOT address
1. Pediatric pts
2. Pts in whom a medical cause (i.e. MI) is the likely inciting event
3. Pts w/ complicating factors, such as severe hypothermia
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Guidelines and protocols must be individualized for each EMS system.
Consider the factors such asaverage transport timethe scope of practice of the various EMS providersdefinitive care capabilities
Airway management and IV line placement during transport when possible
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EMS providers should be thoroughly familiar with the guidelines and protocols.
All termination protocols should be developed and implemented under the guidance of the medical director.
On-line medical control may be necessary.
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Policies and protocols for TOR must include notification of the law enforcement agencies and medical examiner or coroner.
Families of the deceased should have access to resources, including clergy, social workers, and other counseling personnel, as needed.
EMS providers should have access to resources for debriefing and counseling as needed.
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…Still Controversy
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Retrospective cohort study in Seattle
184 TCPA pts transported to a Level I trauma center by EMS between January 1, 1994 and April 1, 2001
If the NAEMSP/ACSCOT guidelines applied, 13 of the 14 survivors would not have been resuscitated
J Trauma. 2005;5:951-958.
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Retrospective review of a statewide major trauma registry between 2001 to 2004 in Australia
89 pts received CPR in the field and transport
4 survivors: 2 penetrating inj. with 1 demonstrating signs of life2 blunt inj. probably experiencing cardiac arrest secondary to electrocution and hypoxia (In 1 casea a total prehospital time of 54 min)
Injury, Int. J. Care Injured (2006) 37, 448—454
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Retrospective review of trauma pts receiving out-of-hospital CPR between 1994-2004 in UK
Helicopter EMS include an experienced physician
909 pts 68 (7.5%) survive to hospital discharge
13 (19%) of 68 would not have been resuscitated if NAEMS/ACS-COT guidelines adherence
Ann Emerg Med. 2006;48:240-244.
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The NAEMS/ACS-COT guidelines require careful consideration when applied in the field.
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