Field Termination of Resuscitation Efforts

[helicopper 1,050]

This thread is reincarnated from another that was perceived to be questionable because it was based upon a specific incident also posted on this site. This thread is GENERIC and/or HYPOTHETICAL and should not be construed to be based upon any recent incident or events regardless of what prompted the question.

So, the question is this: When is it appropriate to terminate field resuscitation and who should make the determination to do so?

Those who posted in the other thread are invited to re-post their responses so long as they are not specific to any recent incidents or events.

Thank you!

[WAS967 97]

We recently had this discussion on a Laguardia CC facebook thread. Think of it like the spinal immobilization protocol.....if there is any doubt, work it. I'm a proponent of using the monitor to confirm asystole in three leads when doing any sort of declaration in the field (this of course being in the case of person being found down and not initiating efforts).

For the case of field termination (when CPR has been started and you are looking to STOP cpr), the decision MUST be made in consult with Medical Control and I believe ONLY ALS can terminate efforts. It makes sense that circulatory access (IV or IO) should be established and advanced/alternative airway (intubation, king, combitube, LMA) be in place and confirmed, plus rounds of meds given.

A lot of people believe that if there is ANY sort of electrical activity you should transport regardless, but IMHO even if there is electrical activity, but no mechanical activity, termination could still be considered, especially if there has been no signs of life for the better part of more than 20 minutes. Statistically the person just won't recover, and if they do, quality of life will be greatly diminished if not non-existent.

[JetPhoto 626]

A few examples of stopping CPR

Dispatched to a unconscious person with emd cpr in progress. EMT gets on the scene and see obvious signs of rigor mortise. EMT stops cpr based on his training

Dispatched to a unconscious person in the middle of the woods with an hour extrication time or you are 2 hours away from the nearest hospital is 2 hours away and closest medic is an hour.

You respond to a accident a first responder starts cpr, you arrive and find obvious open head injury

Many possibilities that can / have happened. It comes down to knowing the risk / benefit and your training. Contact medical control also, but maintain life support procedures until they give you the ok

And if a medic is on the scene let the medic make the call!

Just remember document, document, document!

[Bnechis 3,961]

Polish Paramedics.bmp

[PEMO3 523]

Dispatched to a unconscious person in the middle of the woods with an hour extrication time or you are 2 hours away from the nearest hospital is 2 hours away and closest medic is an hour.

JetPhoto, I agree with all of your thinking except the one noted. I have had my share of pre-hospital saves with just CPR and no ALS intervention. If you made it to the patient, unless the patient shows obvious signs of death or it is a multiple patient triage situation as a medical provider you owe it to the patient to attempt to resuscitate as long as they do not have obvious injuries that would dictate differently. Extrication time or travel time should not be a factor if you made patient contact. Just my 2 cents.

[Guest alsfirefighter]

I feel that the current ALS protocol is sufficient in its delineation of how to handle termination in the field. I'm with WAS. 20 minutes of resuscitation efforts with no change is a pretty good indication that the situation is not going to come to a successful conclusion. All interventions need to be completed and at least 2 rounds of medication therapy with ample time for circulation.

At no time do I feel that in our area should BLS TERMINATE efforts in the field if no ALS is available. Start CPR get the AED attached and get moving to your facility. If you bag well and get good compressions you will keep oxygen moving and let the hospital make the decision.

Field termination is a decision that a Paramedic must make with good judgement. I have had the inclination to do so but its not just what the patient is showing...you have to take the environment into factor. The family/loved ones are they not handling the situation well. Are you in the middle of the street or crowd? Is it a holiday? etc. You also have to take the emotional well being of the others involved as well.

[Mark Z 18]

I feel that the current ALS protocol is sufficient in its delineation of how to handle termination in the field. I'm with WAS. 20 minutes of resuscitation efforts with no change is a pretty good indication that the situation is not going to come to a successful conclusion. All interventions need to be completed and at least 2 rounds of medication therapy with ample time for circulation.

At no time do I feel that in our area should BLS TERMINATE efforts in the field if no ALS is available. Start CPR get the AED attached and get moving to your facility. If you bag well and get good compressions you will keep oxygen moving and let the hospital make the decision.

What about the patient that has obvious rigor or dependent lividity? I don't see a need for transport BLS in that situation, the danger inherent in lights and siren transport is high enough that doing it for no reason is silly. If ALS is not available the EMT's need to step up and be able to make those decisions, or you need more ALS resources so that EMT's won't have to make those decisions then..

Edited June 13, 2010 by Mark Z

[Guest alsfirefighter]

What about the patient that has obvious rigor or dependent lividity? I don't see a need for transport BLS in that situation, the danger inherent in lights and siren transport is high enough that doing it for no reason is silly. If ALS is not available the EMT's need to step up and be able to make those decisions, or you need more ALS resources so that EMT's won't have to make those decisions then..

LOL. What about if someone read my post again and know what terms mean what. If there is rigor or lividity those are signs of OBVIOUS DEATH..hence BLS personnel do not need to start resuscitation efforts. Therefore..if you don't start any resuscitation efforts...you cannot TERMINATE them. Clearer now for ya?

So again...no BLS should not be able to terminate resusciation efforts in the field being they are not trained to nor do their AED's more often do not show EKG rhythems. Which by the way the protocol states that an AED is only to be placed on an unresponsive patient for all you LP 12 as AED's and are putting leads on patients.

Also I for the most part do not have the ambulance crew use lights and sirens to the hospital with a cardiac arrest. There is nothing I'm not doing that they are not going to do at the ER and 9 times out of 10 they call it within several minutes of arrival. Not worth the risk or on the high priority "True Emergency" scale.

[Mark Z 18]

LOL. What about if someone read my post again and know what terms mean what. If there is rigor or lividity those are signs of OBVIOUS DEATH..hence BLS personnel do not need to start resuscitation efforts. Therefore..if you don't start any resuscitation efforts...you cannot TERMINATE them. Clearer now for ya?

So again...no BLS should not be able to terminate resusciation efforts in the field being they are not trained to nor do their AED's more often do not show EKG rhythems. Which by the way the protocol states that an AED is only to be placed on an unresponsive patient for all you LP 12 as AED's and are putting leads on patients.

Also I for the most part do not have the ambulance crew use lights and sirens to the hospital with a cardiac arrest. There is nothing I'm not doing that they are not going to do at the ER and 9 times out of 10 they call it within several minutes of arrival. Not worth the risk or on the high priority "True Emergency" scale.

OK, we agree then! You made a statement that I wanted to clarify and your clarification was not what I was afraid you might intend. Thanks for taking the time to respond to my question and I can't imagine a paramedic around here not taking a cardiac arrest what we call priority 1(lights and sirens) to the ER, there is at least one service that does all transports priority 1 regardless of the patient complaint. Thanks again.

[Guest alsfirefighter]

OK, we agree then! You made a statement that I wanted to clarify and your clarification was not what I was afraid you might intend. Thanks for taking the time to respond to my question and I can't imagine a paramedic around here not taking a cardiac arrest what we call priority 1(lights and sirens) to the ER, there is at least one service that does all transports priority 1 regardless of the patient complaint. Thanks again.

Don't see what needed to be clarified as my first post said the same exact thing.

Believe me I have BLS agencies that use lights and sirens for BLS transports and have more excuses as to why. From the driver saying "I'm not the crew chief" to "traffic." Kinda funny..I can't remember traffic being listed as a true emergency.

You save seconds using lights and sirens and the minute you add the L and S to a driver something has to give as they worry about what siren to switch to and often its braking and acceleration making it difficult to do effective CPR. And ACLS is ACLS no matter where its utiized.

Glad I clarified it for you. And trust me I always love a good conversation/debate.

[WAS967 97]

My favorite is when they say they go lights and sirens because "it's our policy when there is a patient in the back".

Uhm...okay. Guess what. Your policy is against the law.