Resuscitaion in ohca


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By Kanok Ongskul,MD

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Resuscitaion in ohca

  1. 1. Resuscitation in OHCA: When to START and When to STOP <ul><li>Review by : Kanok Ongskul , MD </li></ul><ul><li>2nd yr emergency medicine resident </li></ul><ul><li>Rajavithi hospital </li></ul>
  2. 2. Goals of Resuscitation <ul><li>Preserve life </li></ul><ul><li>Restore health </li></ul><ul><li>Relieve suffering </li></ul><ul><li>Limit disability </li></ul><ul><li>Respect the individual’s decisions, rights, and privacy </li></ul>
  3. 3. Ethical Issues <ul><li>HCP should consider the ethical, legal, and cultural factors assoc. w/ resuscitation. </li></ul><ul><li>Guided by science, the preferences of the individual or surrogates, and local policy and legal requirements </li></ul>
  4. 4. Healthcare Advance Directive <ul><li>A legal binding document </li></ul><ul><li>Tells the thoughts, wishes, or preferences for healthcare decisions during periods of incapacity </li></ul><ul><li>Verbal or Written (more trustworthy) </li></ul><ul><li>May be based on conversations, written directives, living wills, or durable power of attorney for health care </li></ul>
  5. 5. Do Not Attempt Resuscitation (DNAR) order <ul><li>Described more recently as a DNACPR decision, or “Allow Natural Death” (AND) </li></ul><ul><li>Given by a licensed physician or alternative authority </li></ul><ul><li>Must be signed and dated to be valid </li></ul><ul><li>Most preceded by a documented discussion with the patient, family, or surrogate decision maker </li></ul>
  6. 6. พรบ . สุขภาพแห่งชาติ พ . ศ . ๒๕๕๐ <ul><li>หมวดที่ ๑ สิทธิและหน้าที่ด้านสุขภาพ มาตรา ๑๒   “ บุคคลมีสิทธิทำหนังสือแสดงเจตนาไม่ประสงค์จะรับบริการสาธารณสุขที่เป็นไปเพียงเพื่อยืดการตายในวาระสุดท้ายของชีวิตตน หรือเพื่อยุติการทรมานจากการเจ็บป่วยได้ การดำเนินการตามหนังสือแสดงเจตนาตามวรรคหนึ่ง ให้เป็นไปตามหลักเกณฑ์และวิธีการที่กำหนดในกฎกระทรวง เมื่อผู้ประกอบวิชาชีพด้านสาธารณสุขได้ปฏิบัติตามเจตนาของบุคคลตามวรรคหนึ่งแล้ว มิให้ถือว่าการกระทำนั้นเป็นความผิดและให้พ้นจากความรับผิดทั้งปวง ” </li></ul>
  7. 8. Withholding & Withdrawing CPR in OHCA <ul><li>Reduce unnecessary transport </li></ul><ul><li>Reduce associated road hazards </li></ul><ul><li>Reduces inadvertent paramedic exposure to potential biohazards </li></ul><ul><li>Reduce cost of ED pronouncement </li></ul>
  8. 9. Criteria for Not Starting CPR (OHCA) <ul><li>Begin CPR without seeking consent except… (where withholding CPR might be appropriate) </li></ul><ul><li>Situations would place the rescuer at risk of serious injury or mortal peril </li></ul><ul><li>Obvious signs of irreversible death (eg, rigor mortis, dependent lividity, decapitation, transection, or decomposition) </li></ul><ul><li>A valid, signed, and dated DNAR order or an advance directive indicating that resuscitation is not desired </li></ul>
  9. 10. DNAR Orders in OHCA <ul><li>Can take many forms (eg, written bedside orders, identification cards/bracelets) </li></ul><ul><li>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) </li></ul>
  10. 11. Advance Directives in OHCA <ul><li>Do not have to include a DNAR order </li></ul><ul><li>DNAR order is valid w/o an advance directive. </li></ul><ul><li>Initiate CPR if doubt … </li></ul><ul><ul><li>the validity of a DNAR order </li></ul></ul><ul><ul><li>the victim may have had a change of mind </li></ul></ul><ul><ul><li>whether the pt intended the advance directive to be applied under that condition </li></ul></ul>
  11. 12. Termination of Resuscitation (TOR) in OHCA <ul><li>Neonatal / Pediatric: </li></ul><ul><ul><li>NO validated clinical decision rules </li></ul></ul><ul><li>Adult </li></ul><ul><ul><li>BLS </li></ul></ul><ul><ul><li>ALS </li></ul></ul><ul><ul><li>Combined BLS and ALS </li></ul></ul>
  12. 13. When to STOP BLS <ul><li>ROSC </li></ul><ul><li>Care is transferred to ALS </li></ul><ul><li>The rescuer is unable to continue because of </li></ul><ul><ul><li>Exhaustion </li></ul></ul><ul><ul><li>Dangerous environmental hazards </li></ul></ul><ul><ul><li>It places others in jeopardy </li></ul></ul><ul><li>Reliable and valid criteria </li></ul><ul><ul><li>Irreversible death / Obvious death </li></ul></ul><ul><ul><li>“ BLS termination of resuscitation rule” </li></ul></ul><ul><ul><li> (prospectively validated) </li></ul></ul>
  13. 14. BLS Termination of Resuscitation Rule for Adult OHCA <ul><li>Arrest not witnessed by EMS provider or first responder </li></ul><ul><li>No ROSC after 3 full rounds of CPR and AED analyses </li></ul><ul><li>No AED shocks delivered </li></ul><ul><li>If ALL criteria are met >>> consider TOR </li></ul>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.
  14. 15. <ul><li>BLS termination-of-resuscitation rule for adult OHCA </li></ul>Use the rule to develop protocols in areas where ALS is not available or may be significantly delayed (Class I, LOE A).
  15. 16. When to STOP ALS <ul><li>NAEMSP: Resuscitation could be terminated in pts not respond to at least 20 min of ALS. </li></ul><ul><li>“ ALS termination of resuscitation rule” </li></ul><ul><li> (retrospectively externally validated) </li></ul>
  16. 17. ALS Termination of Resuscitation Rule for Adult OHCA <ul><li>Arrest not witnessed (by anyone) </li></ul><ul><li>No bystander CPR provided </li></ul><ul><li>No ROSC after complete ALS care in the field </li></ul><ul><li>No shocks delivered </li></ul><ul><li>If ALL criteria are met >> consider TOR </li></ul>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.
  17. 18. It is reasonable to employ this rule in all ALS services (Class IIa, LOE B). <ul><li>ALS termination-of-resuscitation rule for adult OHCA </li></ul>
  18. 19. TOR in a Combined BLS and ALS Out-of-Hospital System <ul><li>Use of a universal rule can avoid confusion </li></ul><ul><li>The BLS rule is reasonable to use in these services (Class IIa, LOE B). </li></ul>
  19. 20. Implementation of the Rules <ul><li>Applied BEFORE ambulance transport </li></ul><ul><li>Contact online medical control when the criteria are met </li></ul><ul><li>EMS providers should receive training in sensitive communication with the family </li></ul><ul><li>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. </li></ul>
  20. 22. When to Start/Stop CPR ? <ul><li>Consider the therapeutic efficacy of CPR, potential risks, and pt’s preferences </li></ul><ul><li>All rules should be validated prospectively before implementation </li></ul><ul><li>Grey areas where subjective opinions are required in pts with HF & severe respiratory compromise, asphyxia, major trauma, head injury and neurological disease. </li></ul>
  21. 23. General Rule <ul><li>In general </li></ul><ul><ul><li>Resuscitation should be continued as long as VF persists </li></ul></ul><ul><ul><li>Ongoing asystole > 20 min in the absence of a reversible cause, and with ongoing ALS  TOR </li></ul></ul><ul><li>Reports of exceptional cases that do not support the general rule </li></ul>
  22. 24. <ul><li>The quality of CPR is compromised during transport, and survival is linked to optimizing scene care rather than rushing to hospital. </li></ul><ul><li>In OHCA of cardiac origin, if recovery is going to occur, ROSC usually takes place on site. </li></ul>
  23. 25. Organ Procurement <ul><li>Continuing futile resuscitation attempts with the sole purpose of harvesting organs is debatable </li></ul><ul><li>If considering prolonging CPR and other resuscitative measures to enable organ donation to take place mechanical chest compressions may be valuable. </li></ul>
  24. 26. Traumatic Cardiopulmonary Arrest (TCPA)
  25. 27. <ul><li>J Am Coll Surg 2003;196:475—81. </li></ul>
  26. 28. Blunt Trauma <ul><li>Resuscitation efforts may be withheld if </li></ul><ul><ul><li>Apneic </li></ul></ul><ul><ul><li>Pulseless </li></ul></ul><ul><ul><li>No organized ECG activity </li></ul></ul>
  27. 29. Penetrating Trauma <ul><li>Resuscitation efforts may be withheld If </li></ul><ul><ul><li>Apneic </li></ul></ul><ul><ul><li>Pulseless </li></ul></ul><ul><ul><li>No other signs of life, such as </li></ul></ul><ul><ul><ul><li>Pupillary reflexes </li></ul></ul></ul><ul><ul><ul><li>Spontaneous movement </li></ul></ul></ul><ul><ul><ul><li>Organized ECG activity </li></ul></ul></ul><ul><li>If any of these signs are present </li></ul><ul><li>>> resuscitation and transport </li></ul>
  28. 30. Penetrating or Blunt Trauma <ul><li>Resuscitation should be withheld if </li></ul><ul><li>Injuries obviously incompatible with life , such as decapitation or hemicorporectomy </li></ul><ul><li>Evidence of a significance time lapse since pulselessness, including dependent lividity, rigor mortis, and decomposition </li></ul>
  29. 31. Nontraumatic Cause of Arrest ? <ul><li>Mechanism of injury not correlate with clinical condition </li></ul><ul><li>>> Standard Resuscitation </li></ul>
  30. 32. Termination of Resuscitation (TOR) <ul><li>should be considered if </li></ul><ul><ul><li>EMS-witnessed arrest + 15 min of unsuccessful CPR </li></ul></ul><ul><ul><li>Transport time > 15 min after the arrest </li></ul></ul>
  31. 33. Special Consideration <ul><li>Drowning </li></ul><ul><li>Lightning Strike </li></ul><ul><li>Significant Hypothermia </li></ul>
  32. 34. <ul><li>These recommendations specifically DO NOT address </li></ul><ul><li>Pediatric pts </li></ul><ul><li>Pts in whom a medical cause (i.e. MI) is the likely inciting event </li></ul><ul><li>Pts w/ complicating factors, such as severe hypothermia </li></ul>
  33. 35. <ul><li>Guidelines and protocols must be individualized for each EMS system. </li></ul><ul><li>Consider the factors such as </li></ul><ul><ul><li>average transport time </li></ul></ul><ul><ul><li>the scope of practice of the various EMS providers </li></ul></ul><ul><ul><li>definitive care capabilities </li></ul></ul><ul><li>Airway management and IV line placement during transport when possible </li></ul>
  34. 36. <ul><li>EMS providers should be thoroughly familiar with the guidelines and protocols. </li></ul><ul><li>All termination protocols should be developed and implemented under the guidance of the medical director. </li></ul><ul><li>On-line medical control may be necessary. </li></ul>
  35. 37. <ul><li>Policies and protocols for TOR must include notification of the law enforcement agencies and medical examiner or coroner. </li></ul><ul><li>Families of the deceased should have access to resources, including clergy, social workers, and other counseling personnel, as needed. </li></ul><ul><li>EMS providers should have access to resources for debriefing and counseling as needed. </li></ul>
  36. 38. … Still Controversy
  37. 39. <ul><li>Retrospective cohort study in Seattle </li></ul><ul><li>184 TCPA pts transported to a Level I trauma center by EMS between January 1, 1994 and April 1, 2001 </li></ul><ul><li>If the NAEMSP/ACSCOT guidelines applied, 13 of the 14 survivors would not have been resuscitated </li></ul>J Trauma. 2005;5:951-958 .
  38. 40. <ul><li>Retrospective review of a statewide major trauma registry between 2001 to 2004 in Australia </li></ul><ul><li>89 pts received CPR in the field and transport </li></ul><ul><li>4 survivors: </li></ul><ul><ul><li>2 penetrating inj. with 1 demonstrating signs of life </li></ul></ul><ul><ul><li>2 blunt inj. probably experiencing cardiac arrest secondary to electrocution and hypoxia (In 1 casea a total prehospital time of 54 min) </li></ul></ul>Injury, Int. J. Care Injured (2006) 37, 448—454
  39. 41. <ul><li>Retrospective review of trauma pts receiving out-of-hospital CPR between 1994-2004 in UK </li></ul><ul><li>Helicopter EMS include an experienced physician </li></ul><ul><li>909 pts  68 (7.5%) survive to hospital discharge </li></ul><ul><li>13 (19%) of 68 would not have been resuscitated if NAEMS/ACS-COT guidelines adherence </li></ul>Ann Emerg Med. 2006;48:240-244.
  40. 42. <ul><li>The NAEMS/ACS-COT guidelines require careful consideration when applied in the field. </li></ul>
  41. 43. THANK YOU