Most resuscitation attempts are unsuccessful — we need to know when to stop.
- The decision to stop CPR should be tailored according to the specifics of the individual case and is based on clinical judgement
- The decision is best made by the Team Leader in consultation with other team members
- Always maintain initial resuscitation efforts until adequate information is available to make the call to discontinue
However, selected patients potentially have good outcomes with prolonged, aggressive resuscitation (see ‘when not to stop’)
KEY DETERMINANTS OF SURVIVAL
- Survival from cardiac arrest is highly dependent on time to defibrillation and return of spontaneous circulation (ROSC) unless a primary reversible cause is present
- Survival to discharge from out-of-hospital arrest (OOHA) is minimal if the initial rhythm on arrival in ED is asystole or agonal — if asystole -> always check leads, gain settings and connections — Asystole for 20 minutes is generally considered non-survivable
- Advanced age is not an independent predictor of survival
KEY QUESTIONS AND CONSIDERATIONS
- was arrest observed?
- what was the initial rhythm?
- cardiac vs non-cardiac cause? (better survival in cardiac group in OOHA)
- time to CPR?
- time to defibrillation?
- time to ROSC?
A more detailed approach involves consideration of:
- Factors related to circumstances of arrest
- Prehospital measures and response
- In hospital measures and response
CIRCUMSTANCES OF ARREST
- Premorbid medical state, e.g. cancer, advanced dementia, etc
- Advanced directive?
- Time of arrest (or when ambulance service notified / Code Blue called)?
- Time until resus commenced?
- Time to first shock?
- Time to ROSC (if occurred prehospital)?
- Effective bystander CPR?
- Rhythm on ambulance arrival?
PREHOSPITAL MEASURES AND RESPONSE
- Number of shocks?
- ROSC? Rhythm changes? (Progressing from initial non-shockable rhythms to a shockable rhythm is associated with improved outcome after out-of-hospital cardiac arrest)
- Any other measures, ACLS drugs?
- Time since arrest
IN HOSPITAL MEASURES AND RESPONSE
- Any reversal factors requiring treatment? (i.e. 4Hs and 4Ts)
- Number of shocks?
- Drugs given according to ACLS guidelines
- ROSC? Rhythm changes?
- ETCO2 readings > 10 mmHg? (Persistently low PETCO2 values (<10 mm Hg) during CPR in intubated patients after 20 mins has essentially zero survival)
- Bedside echo findings – any cardiac activity? (in a systematic review by Blyth et al, 2011 as many as 15.7% (lower 95% CI on sensitivity) of patients experienced ROSC despite a lack of cardiac activity on ultrasound)
- Any other measures?
- Time since arrest?
WHEN TO CEASE CPR
A general approach is to stop CPR after 20 minutes if there is no ROSC or viable cardiac rhythm re-established, and no reversible factors present that would potentially alter outcome.
Reasons to cease CPR generally include:
- resuscitation guidelines require 2 min of CPR post defibrillation prior to checking for ROSC; may be identified by an upsurge in ETCO2
- pre-existing chronic illness preventing meaningful recovery
- ie. nursing home resident with dementia, disseminated cancer
- acute illness preventing recovery
- ie. 100% burns, non-survivable injuries, catastrophic TBI with no brain stem reflexes
- no response to ACLS after 20min of efficient resuscitation in absence of ROSC, a shockable rhythm or reversible causes
In the prehospital setting a validated rule has been described by Morrison et al (2006):
- Stop CPR if:
- no return of spontaneous circulation
- no shocks are administered, and
- the arrest is not witnessed by emergency medical-services personnel
- Otherwise, the rule recommends transportation to the hospital, in accordance with routine practice
Other special situations:
- in a newly born baby with no detectable heart rate that remains undetectable for 10 minutes, it is appropriate to consider stopping resuscitation
- traumatic arrest (perform emergency thoracotomy if appropriate; closed-chest CPR is ineffective)
- when rescuers are exhausted (in the prehospital setting)
- If the patient is irrefutably dead! (e.g. rigor mortis, decomposition, hemisection, decapitation)
Remember – stop CPR after the second “ouch.” — tweeted by Joe Lex at SMACC
WHEN NOT TO STOP
More prolonged resuscitation is generally required in these settings:
- continue in young people who have persistent VF until reversible factors have been fixed (see also Electrical storm) or therapeutic options exhausted
- hypothermia (“not dead until warm and dead”)
- asthma (need to correct dynamic hyperinflation)
- toxicological arrest (full neurological recovery after >4 hours CPR is possible; asystole may be a direct drug effect that will recover in time)
- thrombolytics given during CPR (should continue up to 2 hours post-administration)
- pregnancy prior to resuscitative caesarean section
At The Alfred ICU about 50% of patients who meet the criteria below have excellent neurological outcomes when treated with a combination of mechanical CPR, intra-arrest cooling, ECPR and early cardiac catheterisation (CHEER trial):
- no ROSC at 30 minutes
- bystander CPR with initial rhythm VF/VT
- age <65 years
- no known significant comorbidities
References and Links
- Larkin GL. Termination of resuscitation: the art of clinical decision making. Curr Opin Crit Care. 2002 Jun;8(3):224-9.. PMID: 12386501.
- Morrison LJ, Visentin LM, Kiss A, Theriault R, Eby D, Vermeulen M, Sherbino J, Verbeek PR; TOR Investigators. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med. 2006 Aug 3;355(5):478-87. PMID: 16885551. [Free Full Text]
- Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation. 86:88-94. 2015. [pubmed]
FOAM and web resources
- EMLON — Longer resuscitation “saves”
- INTENSIVE — Steve Bernard on ECMO-CPR (2014)
- RAGE Podcast — When should resuscitation stop? (2014)
- SMACC — When to stop resuscitation (2015)
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.