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Termination of resuscitation for traumatic cardiac arrest
Termination of Resuscitation for Traumatic Cardiac Arrest What guidelines have been established for terminating the resuscitation of a t r a u m a p a t i e n t i n c a r d i a c a r r e s t ? Are there differences for a prehospital arrest, s u c h as a 2 8 - y e a r - o l d m a n w h o is u n r e sponsive and pulseless after a motor vehicle crash and the emergency medical services have a 20-minute transport time, versus a patient w h o h a s b e e n p u l s e l e s s a f t e r a g u n s h o t w o u n d to t h e c h e s t a n d is s e e n i n t h e e m e r g e n c y d e p a r t m e n t after having had cardiopulmonary resuscitation (CPR) f o r 10 m i n u t e s ? These scenarios represent the types of difficult decisions health care providers must m a k e w h e n caring for trauma patients in the prehospital and emergency department settings. Medical personnel seek the best care for their patients but must also m a k e appropriate triage decisions and use available resources adequately. In the United States reimbursement and resources have b e c o m e limited and made health care providers fiscally responsible for the patient care choices they make. Clinical decisions should be based on outcome data.
CLINICALTRIALS Multiple investigators 1-8 have found that normothermic trauma patients w h o have prolonged cardiopulmonary arrest (i.e., longer than 30 minutes) and w h o do not show signs of a temporary return Maggie Morris is a flight nurse at the University of Kentucky MedicaD Center, Lexington, Ky., and an instructor with Wilderness Medical Associates, Bryant Pond, Maine. For reprints write Maggie Morris, MSN, RN, ACNP, CFRN, CCRN, CEN, WEMT, University of Kentucky Medical Center, 800 Rose St., Room HA-038B, Emergency Department, Lexington, KY 40536-0084. Int J Trauma Nurs 1997;3:127-9. Copyright © 1997 by the Emergency Nurses Association. 1075-4210/97 $5.00 + 0
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of a spontaneous pulse do not experience a normal recovery. Further research has s h o w n that for patients w h o are pulseless for 10 to 15 minutes in association with no measurable end-tidal carbon dio x i d e f u r t h e r r e s u s c i t a t i o n efforts s h o u l d b e considered futile. 9,1° Adding basic or advanced life support to the care of these patients does not change the outcome. The Emergency Cardiac Care Committee of the American Heart Association has stated: Resuscitation may be discontinued in the prehospital setting when the patient is nonresuscitable after an adequate trial of advanced cardiac life support (ACLS) . . . . Ambulance medical directors remain ultimately responsible for determination of death, and pronouncement of death in the field should have the concurrence of on-line medical control . . . . Return of spontaneous circulation for even a brief period is a positive prognostic sign and warrants consideration of transport to a hospital. Transport may also be warranted in special circumstances such as profound hypothermia. 1 Although the studies supporting this r e c o m m e n dation focused on patients with medical causes of cardiac arrest, other studies on trauma-related cardiac arrest patients have demonstrated similar findings. In 1990 the National Association of Emergency Medical Services Physicians Committee on Rural Affairs d e v e l o p e d guidelines for the delayed or prolonged transport of patients in cardiopulmonary arrest. 3 The guidelines state that a n y normothermic patient w h o sustains c a r d i o p u l m o n a r y arrest for longer than 30 minutes, without a temporary return of a spontaneous pulse, should have chest compressions, ventilatory support, and advanced life support measures discontinued? These guidelines do not differentiate b e t w e e n medical and traumatic causes of cardiopulmonary arrest.
TRAUMATIC CARDIAC ARREST The outcomes of trauma patients in cardiopulmonary arrest have b e e n studied. One study conducted over a 5-year period 6 looked at resuscitation outcomes for 106 patients w h o sustained either blunt or penetrating mechanisms of injury and received prehospital CPR. Six patients had penetrating chest
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Table 1. Guidelines for the termination of prehospital resuscitation of traumatic cardiac arrest
Table 2. Guidelines for termination of e m e r g e n c y department resuscitation of traumatic cardiac arrest
1. For patients (>14 years old) who have sustained blunt trauma, pulseless at the scene, ground EMS should initiate advanced airway, CPR, and ALS interventions. After >5 minutes of CPR without return of pulse, transport to nearest facility or establish on-line medical control for orders to discontinue resuscitative efforts. Contact appropriate local authorities (police or coroner). 2. For patients (>14 years old) who have sustained penetrating trauma to abdomen, head, neck, or groin and are pulseless at scene, ground EMS should initiate advanced airway, CPR, and ALS. After >5 minutes of CPR without return of pulse, transport to nearest facility or establish on-line medical control for orders to discontinue resuscitative efforts. Contact appropriate local authorities (police or coroner). 3. For patients (>14 years old) who have sustained penetrating trauma to chest and are pulseless at scene, ground EMS should initiate advanced airway, CPR, and ALS. After >15 minutes of CPR without return of pulse, transport to nearest facility or establish on-line medical control for orders to discontinue resuscitative efforts. Contact appropriate local authorities (police or coroner). Note: If a patient may be hypothermic or shows any sign of life (i.e., intermittent pulse or respirations), immediate transport to closest facility or trauma center is warranted (follow local protocol). If ground ALS is unavailable, requesting air medical assistance is appropriate.
Patient should be pronounced DOA when any of following criteria are met for patients >14 years old who are pulseless on arrival: • Blunt trauma: prehospital CPR >15 minutes • Penetrating trauma to abdomen, head, neck, or groin: prehospital CPR >5 minutes • Penetrating trauma to chest: CPR >15 minutes Trauma alert activation should NOT occur initially for patients meeting these prehospital criteria. Emergency department faculty will evaluate patient immediately and determine the following: • Airway management is adequate. • Patient does not have a pulse. If pulse or any signs of life are detected, a Trauma Alert should be activated immediately. • Patient is normothermic (core body temperature >90 ° F (37 ° C) After all above criteria have been assessed, patient will be pronounced DOA and no further resuscitative activity should ensue. Emergency department faculty should ensure entire completion of Trauma Admission Form. The following should be entered for diagnosis: "Patient pronounced DOA." Any injuries, such as femur fracture or penetrating head injury, that are recognized during gross physical examination should be listed. One copy of the Trauma Admission Form will be forwarded to Trauma Coordinator for entry into trauma registry, and original will become part of patient's permanent medical record.
EMS, Emergency medical services; ALS, advanced life support.
DOA, Dead on arrival. Adapted from University of Kentucky Hospital, Termination of Resuscitation Based on Prehospital Criterion, 1996.
trauma and had m o r e than 15 minutes of CPR. No patient w h o required CPR for longer than 5 minutes survived. Forty-one of the 106 patients were transported by helicopter. The costs associated with inhospital resuscitation efforts (minus flight costs) of these 106 patients w h o sustained traumatic cardiac arrest averaged $3454 per patient c o m p a r e d with $200 per patient for those p r o n o u n c e d dead on arrival in the emergency department. 4 To date, few studies have b e e n published that report the costs of prehospital resuscitation for patients w h o do not survive. One 10-year study of 328 trauma patients of all ages w h o required CPR found a survival rate of 0.0% and an approximate cost of
$854,720 (United States) for flight and emergency department resuscitative efforts. 11 CLINICAL CONSIDERATIONS The termination of resuscitation is a difficult decision but is appropriate w h e n multiple factors are considered. The financial burden generated by futile resuscitative efforts is shared b y hospitals, insurance companies, g o v e r n m e n t agencies, and families. The costs of resources include personnel from e m e r g e n c y medical services, air medical transport, e m e r g e n c y department, intensive care, and surgery; blood products; and b e d space dedicated to these patients. Indirect costs are n u m e r o u s but include
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increased exposure for the medical staff to c o m m u nicable diseases, such as h u m a n immunodeficiency virus, hepatitis, and tuberculosis.
PROTOCOLS FOR TERMINATION OF RESUSCITATION Many institutions and transport services have created policies or protocols for the trauma patient w h o is in cardiopulmonary arrest. Some protocols start at the scene, whereas others wait until the patient has b e e n admitted to the e m e r g e n c y department. Patients are evaluated for specific criteria, transport time, or availability of advanced life support services to determine if CPR is initiated. The patient can be p r o n o u n c e d dead either at the scene b y the paramedic or b y on-line communication with medical control or at the time of admission to an emergency department. Table 1 provides an example of a protocol used in the prehospital setting of a traumatic cardiac arrest, and Table 2 is used at the time of admission to the hospital. Protocols for termination of CPR for traumatic arrest should be able to assist health care providers in making decisions regarding appropriate care. Creating protocols for the care of the patient in cardiopulmonary arrest in the prehospital and emergency department settings m a y assist the staff in making the most appropriate resuscitation decisions. Multicenter evaluations of the protocols should be conducted to demonstrate the impact on health care costs, allocation of resources, and risk of exposure to health care workers. Termination of resuscitation does not m e a n termination of care to family m e m bers. 'The prehospital and emergency department staff m a y have more time and energy to devote to
OCTOBER-DECEMBER 1997
the surviving family m e m b e r s during their initial stages of grief.
Maggie Morris
REFERENCES 1. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Guidelines for cardiopulmonary resuscitation and emergency care. JAMA 1992;270:2171-285. 2. Gray WA, Capone RJ, Most AS. Unsuccessful emergency medical resuscitation: are continued efforts in the emergency department justified? N Engl J Med 1991 ;325:1393-8. 3. Goth P, editor. The National Association of EMS Physicians: model clinical guidelines. Pittsburgh (PA): National Association of EMS Physicians, 1990. 4. Pasquale MD, Rhodes M, Cipolle MD, HanleyT, Wasser T. Defining "dead on arrival" impact on a level 1 trauma center. J Trauma 1996;41:726-30. 5. Copass MK, Oreskovich MR, Bladergroen MR, et al. Prehospital cardiopulmonary resuscitation of the critically injured patient. Am J Surg 1984;148:20-6. 6. Rosemurgy AS, Norris PA, Olson SM, Hurst JM, Albrink MH. Prehospital traumatic cardiac arrest: the cost of futility. J Trauma 1993;35:468-73. 7. Fulton RL, Voigt WJ, Hilakos AS. Confusion surrounding the treatment of traumatic cardiac arrest. J Am Coil Surg 1995;181:209-14. 8. Hazinski MF, Chaine AA, Holcomb GW III, Morris JA Jr. et al. Outcome of cardiovascular collapse in pediatric blunt trauma. Ann Emerg Med 1994;23:1229-35. 9. Garnett AN, Ornato JP, Gonzalez ER, Johnson BE. Endtidal carbon dioxide monitoring during cardiopulmonary resuscitation. JAMA 1987;257:512-6. 10. Ornato JP, Shipley JB, Racht EM, Slovis CM, Wrenn KD, Pepe PE, et al. Multicenter study of a portable, hand-size, colorimetric end-tidal carbon dioxide detection device. Ann Emerg Med 1992;21:518-23. 11. Falcone RE, Herron H, Johnson R, Childress S, Lacey P, Scheiverer G. Air medical transport for the trauma patient requiring cardiopulmonary resuscitation: a 10-year experience. Air Med J 1995;14:4:197-205.
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CLINICALTRIALS Multiple investigators 1-8 have found that normothermic trauma patients w h o have prolonged cardiopulmonary arrest (i.e., longer than 30 minutes) and w h o do not show signs of a temporary return Maggie Morris is a flight nurse at the University of Kentucky MedicaD Center, Lexington, Ky., and an instructor with Wilderness Medical Associates, Bryant Pond, Maine. For reprints write Maggie Morris, MSN, RN, ACNP, CFRN, CCRN, CEN, WEMT, University of Kentucky Medical Center, 800 Rose St., Room HA-038B, Emergency Department, Lexington, KY 40536-0084. Int J Trauma Nurs 1997;3:127-9. Copyright © 1997 by the Emergency Nurses Association. 1075-4210/97 $5.00 + 0
6511185069
OCTOBER-DECEMBER 1997
of a spontaneous pulse do not experience a normal recovery. Further research has s h o w n that for patients w h o are pulseless for 10 to 15 minutes in association with no measurable end-tidal carbon dio x i d e f u r t h e r r e s u s c i t a t i o n efforts s h o u l d b e considered futile. 9,1° Adding basic or advanced life support to the care of these patients does not change the outcome. The Emergency Cardiac Care Committee of the American Heart Association has stated: Resuscitation may be discontinued in the prehospital setting when the patient is nonresuscitable after an adequate trial of advanced cardiac life support (ACLS) . . . . Ambulance medical directors remain ultimately responsible for determination of death, and pronouncement of death in the field should have the concurrence of on-line medical control . . . . Return of spontaneous circulation for even a brief period is a positive prognostic sign and warrants consideration of transport to a hospital. Transport may also be warranted in special circumstances such as profound hypothermia. 1 Although the studies supporting this r e c o m m e n dation focused on patients with medical causes of cardiac arrest, other studies on trauma-related cardiac arrest patients have demonstrated similar findings. In 1990 the National Association of Emergency Medical Services Physicians Committee on Rural Affairs d e v e l o p e d guidelines for the delayed or prolonged transport of patients in cardiopulmonary arrest. 3 The guidelines state that a n y normothermic patient w h o sustains c a r d i o p u l m o n a r y arrest for longer than 30 minutes, without a temporary return of a spontaneous pulse, should have chest compressions, ventilatory support, and advanced life support measures discontinued? These guidelines do not differentiate b e t w e e n medical and traumatic causes of cardiopulmonary arrest.
TRAUMATIC CARDIAC ARREST The outcomes of trauma patients in cardiopulmonary arrest have b e e n studied. One study conducted over a 5-year period 6 looked at resuscitation outcomes for 106 patients w h o sustained either blunt or penetrating mechanisms of injury and received prehospital CPR. Six patients had penetrating chest
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Table 1. Guidelines for the termination of prehospital resuscitation of traumatic cardiac arrest
Table 2. Guidelines for termination of e m e r g e n c y department resuscitation of traumatic cardiac arrest
1. For patients (>14 years old) who have sustained blunt trauma, pulseless at the scene, ground EMS should initiate advanced airway, CPR, and ALS interventions. After >5 minutes of CPR without return of pulse, transport to nearest facility or establish on-line medical control for orders to discontinue resuscitative efforts. Contact appropriate local authorities (police or coroner). 2. For patients (>14 years old) who have sustained penetrating trauma to abdomen, head, neck, or groin and are pulseless at scene, ground EMS should initiate advanced airway, CPR, and ALS. After >5 minutes of CPR without return of pulse, transport to nearest facility or establish on-line medical control for orders to discontinue resuscitative efforts. Contact appropriate local authorities (police or coroner). 3. For patients (>14 years old) who have sustained penetrating trauma to chest and are pulseless at scene, ground EMS should initiate advanced airway, CPR, and ALS. After >15 minutes of CPR without return of pulse, transport to nearest facility or establish on-line medical control for orders to discontinue resuscitative efforts. Contact appropriate local authorities (police or coroner). Note: If a patient may be hypothermic or shows any sign of life (i.e., intermittent pulse or respirations), immediate transport to closest facility or trauma center is warranted (follow local protocol). If ground ALS is unavailable, requesting air medical assistance is appropriate.
Patient should be pronounced DOA when any of following criteria are met for patients >14 years old who are pulseless on arrival: • Blunt trauma: prehospital CPR >15 minutes • Penetrating trauma to abdomen, head, neck, or groin: prehospital CPR >5 minutes • Penetrating trauma to chest: CPR >15 minutes Trauma alert activation should NOT occur initially for patients meeting these prehospital criteria. Emergency department faculty will evaluate patient immediately and determine the following: • Airway management is adequate. • Patient does not have a pulse. If pulse or any signs of life are detected, a Trauma Alert should be activated immediately. • Patient is normothermic (core body temperature >90 ° F (37 ° C) After all above criteria have been assessed, patient will be pronounced DOA and no further resuscitative activity should ensue. Emergency department faculty should ensure entire completion of Trauma Admission Form. The following should be entered for diagnosis: "Patient pronounced DOA." Any injuries, such as femur fracture or penetrating head injury, that are recognized during gross physical examination should be listed. One copy of the Trauma Admission Form will be forwarded to Trauma Coordinator for entry into trauma registry, and original will become part of patient's permanent medical record.
EMS, Emergency medical services; ALS, advanced life support.
DOA, Dead on arrival. Adapted from University of Kentucky Hospital, Termination of Resuscitation Based on Prehospital Criterion, 1996.
trauma and had m o r e than 15 minutes of CPR. No patient w h o required CPR for longer than 5 minutes survived. Forty-one of the 106 patients were transported by helicopter. The costs associated with inhospital resuscitation efforts (minus flight costs) of these 106 patients w h o sustained traumatic cardiac arrest averaged $3454 per patient c o m p a r e d with $200 per patient for those p r o n o u n c e d dead on arrival in the emergency department. 4 To date, few studies have b e e n published that report the costs of prehospital resuscitation for patients w h o do not survive. One 10-year study of 328 trauma patients of all ages w h o required CPR found a survival rate of 0.0% and an approximate cost of
$854,720 (United States) for flight and emergency department resuscitative efforts. 11 CLINICAL CONSIDERATIONS The termination of resuscitation is a difficult decision but is appropriate w h e n multiple factors are considered. The financial burden generated by futile resuscitative efforts is shared b y hospitals, insurance companies, g o v e r n m e n t agencies, and families. The costs of resources include personnel from e m e r g e n c y medical services, air medical transport, e m e r g e n c y department, intensive care, and surgery; blood products; and b e d space dedicated to these patients. Indirect costs are n u m e r o u s but include
128 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions
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increased exposure for the medical staff to c o m m u nicable diseases, such as h u m a n immunodeficiency virus, hepatitis, and tuberculosis.
PROTOCOLS FOR TERMINATION OF RESUSCITATION Many institutions and transport services have created policies or protocols for the trauma patient w h o is in cardiopulmonary arrest. Some protocols start at the scene, whereas others wait until the patient has b e e n admitted to the e m e r g e n c y department. Patients are evaluated for specific criteria, transport time, or availability of advanced life support services to determine if CPR is initiated. The patient can be p r o n o u n c e d dead either at the scene b y the paramedic or b y on-line communication with medical control or at the time of admission to an emergency department. Table 1 provides an example of a protocol used in the prehospital setting of a traumatic cardiac arrest, and Table 2 is used at the time of admission to the hospital. Protocols for termination of CPR for traumatic arrest should be able to assist health care providers in making decisions regarding appropriate care. Creating protocols for the care of the patient in cardiopulmonary arrest in the prehospital and emergency department settings m a y assist the staff in making the most appropriate resuscitation decisions. Multicenter evaluations of the protocols should be conducted to demonstrate the impact on health care costs, allocation of resources, and risk of exposure to health care workers. Termination of resuscitation does not m e a n termination of care to family m e m bers. 'The prehospital and emergency department staff m a y have more time and energy to devote to
OCTOBER-DECEMBER 1997
the surviving family m e m b e r s during their initial stages of grief.
Maggie Morris
REFERENCES 1. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Guidelines for cardiopulmonary resuscitation and emergency care. JAMA 1992;270:2171-285. 2. Gray WA, Capone RJ, Most AS. Unsuccessful emergency medical resuscitation: are continued efforts in the emergency department justified? N Engl J Med 1991 ;325:1393-8. 3. Goth P, editor. The National Association of EMS Physicians: model clinical guidelines. Pittsburgh (PA): National Association of EMS Physicians, 1990. 4. Pasquale MD, Rhodes M, Cipolle MD, HanleyT, Wasser T. Defining "dead on arrival" impact on a level 1 trauma center. J Trauma 1996;41:726-30. 5. Copass MK, Oreskovich MR, Bladergroen MR, et al. Prehospital cardiopulmonary resuscitation of the critically injured patient. Am J Surg 1984;148:20-6. 6. Rosemurgy AS, Norris PA, Olson SM, Hurst JM, Albrink MH. Prehospital traumatic cardiac arrest: the cost of futility. J Trauma 1993;35:468-73. 7. Fulton RL, Voigt WJ, Hilakos AS. Confusion surrounding the treatment of traumatic cardiac arrest. J Am Coil Surg 1995;181:209-14. 8. Hazinski MF, Chaine AA, Holcomb GW III, Morris JA Jr. et al. Outcome of cardiovascular collapse in pediatric blunt trauma. Ann Emerg Med 1994;23:1229-35. 9. Garnett AN, Ornato JP, Gonzalez ER, Johnson BE. Endtidal carbon dioxide monitoring during cardiopulmonary resuscitation. JAMA 1987;257:512-6. 10. Ornato JP, Shipley JB, Racht EM, Slovis CM, Wrenn KD, Pepe PE, et al. Multicenter study of a portable, hand-size, colorimetric end-tidal carbon dioxide detection device. Ann Emerg Med 1992;21:518-23. 11. Falcone RE, Herron H, Johnson R, Childress S, Lacey P, Scheiverer G. Air medical transport for the trauma patient requiring cardiopulmonary resuscitation: a 10-year experience. Air Med J 1995;14:4:197-205.
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