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When to Start and Stop CPR
Mary Fran Hazinski, RN, MSN, FAAN, FAHAVanderbilt University Medical Center
Senior Science Editor, American Heart Association
Potential Conflicts of Interest
Compensated editor, AHA Emergency Cardiovascular Care (ECC) ProgramsCo-editor of 2005 International Consensus on CPR and ECC Science publicationEditor of 2005 AHA Guidelines for CPR and ECCSome therapies discussed not yet approved by the FDA (eg, therapeutic hypothermia)
Purposes
Highlight potential indications for not starting and for stopping CPR in prehospital and in-hospital settingsHighlight potential impact of new CPR Guidelines on these issuesEmphasize need for effective CPR, post-resuscitation care and process of continuous quality improvement
Key Messages
CPR is backQuality of CPR influences outcome
Ensure effective chest compressions, minimize interruptions, allow recoilCreate process of continuous quality improvement (eg, www.nrcpr.org)
Tailor your approach
Challenges
Increase intact neurologic survival Respect patient autonomy and self-determinationApply healthcare resources responsibly
AHA 2005 CPR and ECC Guidelines: Withholding CPR
Valid DNAR order or advanced directiveSigns of irreversible death (eg, rigor mortis, decapitation, decomposition or dependent lividity)Futility--No expected physiologic benefit(eg, deterioration of vital functions despite maximal therapy, pre-hospital blunt trauma arrest)EMS: Danger to the rescuer
Withholding or Discontinuing CPR: EMS Issues
Protocols needed regardingDNAR orders or advanced directivesFatal illnessFutilityExtenuating exceptions (eg, hypothermia)Pediatric patients
Few adults have advanced directives
“Compelling Reasons” Protocol to Withhold CPR--Seattle
BOTH of the following conditions present:Patient is in the end stage of a terminal conditionPatient, family or caregiver indicate -- in writing or verbally -- that the patient did not want a resuscitation
Seattle—King County EMSFeder, Matheny, Loveless, ReaAnn Int Med, 2006
“Compelling Reasons” Protocol to Withhold CPR--Seattle
Results comparing 763 patients before protocol to 841 patients
Reduced attempted resuscitation (51.1% to 42.9%) Increased CPR withheld (5.9% to 11.8%)
Seattle—King County EMSFeder, Matheny, Loveless, ReaAnn Int Med, 2006
Tested Prediction Rule for Termination of OOH CPR
Rule recommends termination of OOH resuscitation efforts if:Arrest not witnessed by EMS personnelNo shocks advised No pre-hospital ROSC
Survival unlikely (0.5%) if all 3 presentNote: Patients treated 2002-2004
Morrison et al, NEJM, 2006
Withholding or Discontinuing CPR: In-hospital Setting
Clinical Decision Aid to Discontinue In-Hospital CPR
Unlikely to survive unless arrest characterized by one of the following:Arrest witnessed orInitial cardiac rhythm non-VF/VT orROSC within first 10 minutes of chest compressions
Survival unlikely (1.1%) in absence of these descriptors Van Walraven, JAMA, 2001
Note: Patients treated 1987-1996
What is Impact of New Guidelines?
Previous indicators or “goal posts” based on poor CPR
Pediatric Resuscitation Guidelines: 2000-2005
2000If a child fails to respond to at least 2 doses of
epinephrine with a return of spontaneous circulation, the child is unlikely to survive.
2005Unfortunately there are no reliable predictors of
outcome during resuscitation to guide when to terminate resuscitative efforts.
….intact survival after unusually prolonged in-hospital resuscitation has been documented.
New Data Needed
Providers must Treat pre-arrest conditions Provide effective CPRDeliver consistent high-quality post-resuscitation care
Programs must implement processes of continuous quality improvement CPR decisions must be tailored
The The ““Bow TieBow Tie”” ConceptConcept
Cardiac Arrest
Post Resuscitation
Outcomes
Pre-Arrest Recognition and Intervention
PALS
ACLS
Neonatal Resuscitation Program
Provide Effective CPR and Defibrillation
…combined, as indicated, with advanced care.
Monitoring of CPR Quality
CompressionsCompressions
ECGECG
VentilationsVentilations
Cardiac arrest
Defibrillatorarrives
RhythmCheck
Rhythm Check
Rhythm Check
Go to A
A
Schedule rhythm checks, shock delivery around 2-minute periods of uninterrupted CPR
CPR CPR
CPRCPR
CPR
CPR
CPR
ConsiderANTIARRHYTHMIC
+CPR
GiveVASOPRESSOR
+CPR+
= ShockCPR = 5 cycles or
2 minutes of CPR += CPR whiledefibrillator chargingKey
Compression Pauses Reduce Shock Success
EffestolEffestol et al, et al, ResuscitationResuscitation, 2006, 2006
Teams Must Practice Codes
Rescue ECMO—Encouraging Results
% S
urvi
val
0
25
50
75
100
Field ROSC Hosp Admit
HospD/C
Weil and Tang ed. 1999, CPR
In-Hospital Cardiac Arrest (U Chicago)52% ROSC rate18% survival to hospital d/c
Post Cardiac Arrest Survival is PoorPost Cardiac Arrest Survival is PoorOut-of-Hospital Cardiac Arrest
30% ROSC rate10% survive 24h4% survive to hospital d/c
PostPost--ROSC Mortality is SignificantROSC Mortality is Significant
“The majority of patients who achieve ROSC are being abandoned long before it is even reasonable to predict
neurological recovery.”
Are we giving up too soon at the bedside?Are we giving up too soon at the bedside?
Withdrawal of Technologic
Support
RO
SC 24h 72h12h
63% of Post-ROSC patients made DNAR30% had technologic support withdrawn5% met clinical criteria for brain deathAverage time to death was 1.5 days
10 excludeddied beforeICU admission
58 patients admitted to ICU
18 (31%) patients survived9 CPC 16 CPC 2 2 CPC 31 CPC 4
Control period (1996-98)68 patients admitted to ED
34 (56%) patients survived31 CPC 13 CPC 2
61 patients admitted to ICU
Intervention period (2003-2005)69 patients admitted to ED
8 excludeddied beforeICU admission
15 (26%) patients withone-year survival
34 (56%) patients withone-year survival
Effect of Post-resuscitation Protocol on Survival
SundeSunde et al, Resuscitation, 2007et al, Resuscitation, 2007
26% withfavourableoutcome
p=0.00156% withfavourableoutcome
p=0.001
Concluding MessagesCPR is backQuality of CPR influences outcome
Ensure effective chest compressions, minimize interruptions, allow recoilCreate process of continuous quality improvement (eg, www.nrcpr.org)
Tailor your approachWhen to start: before the arrestWhen to stop: continue protocol-based support after ROSC
Acknowledgements
Mickey Eisenberg, Sylvia Metheny and Roger Federer: Seattle—King County Termination of ResuscitationLaurie Morrison: Toronto Validation of Termination of Resuscitation study informationTerry Vanden Hoek—Postresuscitation CareRoger White—Rochester EMS protocolKjetil Sunde—Oslo Postresuscitation Care
Thank you.