1. Home>
2. Specialties>
3. Cardiology>
4. Summary and Comment

When to Stop Resuscitation for Out-of-Hospital Cardiac Arrest

A simple prediction rule might help EMTs make a difficult decision.

Automated external defibrillators (AEDs) have improved the chances of successful resuscitation for out-of-hospital cardiac arrest. However, emergency medical technicians (EMTs) face decisions about how long to continue their efforts with AEDs, given a patient’s likelihood of survival and the dangers and costs of emergency transport.

In a Canadian study of 1240 patients (mean age, 69; 69% men) with out-of-hospital cardiac arrest who were treated by EMTs with AEDs, investigators sought to validate their previously proposed prediction rule: Termination of resuscitation should be considered if spontaneous circulation does not return before transport is initiated, if no AED shocks are given before transport is initiated, and if the arrest was not witnessed by emergency personnel.

Of the patients, 94.5% had no return of spontaneous circulation, 70.0% received no shocks, and 90.3% had arrests not witnessed by the EMTs. The median emergency response time was 8.0 minutes. The prediction rule recommended termination of resuscitation for 776 patients and emergency transport for 464 patients; 772 of the termination-recommended patients died (99.5% positive predictive value), and 37 of the transport-recommended patients survived (8.0% negative predictive value). The rule’s sensitivity was 64.4%, and its specificity was 90.2%. Although all patients were transferred to the hospital in this validation study, only 37.4% would have been transported if the rule had been applied.

Comment: This study validates a simple rule for making decisions about termination of resuscitation. However, an editorialist notes that such a rule cannot determine, for example, how long to continue resuscitation efforts before declaring "no return of spontaneous circulation." Another important caveat is that this study employed resuscitation guidelines that have been superseded by more recent ones (Journal Watch Cardiology Jan 26 2006). Nevertheless, the prediction rule may be useful for supplementary guidance in the field.

— Harlan M. Krumholz, MD, SM

Published in Journal Watch Cardiology August 30, 2006

Citation(s):

Morrison LJ et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2006 Aug 3; 355:478-87.

• Original article (Subscription may be required)
• Medline abstract (Free)

Ewy GA. Cardiac resuscitation — When is enough enough? N Engl J Med 2006 Aug 3; 355:510-2.

• Original article (Subscription may be required)
• Medline abstract (Free)