When to Start and Stop CPR

Mary Fran Hazinski, RN, MSN, FAAN, FAHAVanderbilt University Medical Center

Senior Science Editor, American Heart Association

Potential Conflicts of Interest

Compensated editor, AHA Emergency Cardiovascular Care (ECC) ProgramsCo-editor of 2005 International Consensus on CPR and ECC Science publicationEditor of 2005 AHA Guidelines for CPR and ECCSome therapies discussed not yet approved by the FDA (eg, therapeutic hypothermia)

Purposes

Highlight potential indications for not starting and for stopping CPR in prehospital and in-hospital settingsHighlight potential impact of new CPR Guidelines on these issuesEmphasize need for effective CPR, post-resuscitation care and process of continuous quality improvement

Key Messages

CPR is backQuality of CPR influences outcome

Ensure effective chest compressions, minimize interruptions, allow recoilCreate process of continuous quality improvement (eg, www.nrcpr.org)

Tailor your approach

Challenges

Increase intact neurologic survival Respect patient autonomy and self-determinationApply healthcare resources responsibly

AHA 2005 CPR and ECC Guidelines: Withholding CPR

Valid DNAR order or advanced directiveSigns of irreversible death (eg, rigor mortis, decapitation, decomposition or dependent lividity)Futility--No expected physiologic benefit(eg, deterioration of vital functions despite maximal therapy, pre-hospital blunt trauma arrest)EMS: Danger to the rescuer

Withholding or Discontinuing CPR: EMS Issues

Protocols needed regardingDNAR orders or advanced directivesFatal illnessFutilityExtenuating exceptions (eg, hypothermia)Pediatric patients

Few adults have advanced directives

“Compelling Reasons” Protocol to Withhold CPR--Seattle

BOTH of the following conditions present:Patient is in the end stage of a terminal conditionPatient, family or caregiver indicate -- in writing or verbally -- that the patient did not want a resuscitation

Seattle—King County EMSFeder, Matheny, Loveless, ReaAnn Int Med, 2006

“Compelling Reasons” Protocol to Withhold CPR--Seattle

Results comparing 763 patients before protocol to 841 patients

Reduced attempted resuscitation (51.1% to 42.9%) Increased CPR withheld (5.9% to 11.8%)

Seattle—King County EMSFeder, Matheny, Loveless, ReaAnn Int Med, 2006

Tested Prediction Rule for Termination of OOH CPR

Rule recommends termination of OOH resuscitation efforts if:Arrest not witnessed by EMS personnelNo shocks advised No pre-hospital ROSC

Survival unlikely (0.5%) if all 3 presentNote: Patients treated 2002-2004

Morrison et al, NEJM, 2006

Withholding or Discontinuing CPR: In-hospital Setting

Clinical Decision Aid to Discontinue In-Hospital CPR

Unlikely to survive unless arrest characterized by one of the following:Arrest witnessed orInitial cardiac rhythm non-VF/VT orROSC within first 10 minutes of chest compressions

Survival unlikely (1.1%) in absence of these descriptors Van Walraven, JAMA, 2001

Note: Patients treated 1987-1996

What is Impact of New Guidelines?

Previous indicators or “goal posts” based on poor CPR

Pediatric Resuscitation Guidelines: 2000-2005

2000If a child fails to respond to at least 2 doses of

epinephrine with a return of spontaneous circulation, the child is unlikely to survive.

2005Unfortunately there are no reliable predictors of

outcome during resuscitation to guide when to terminate resuscitative efforts.

….intact survival after unusually prolonged in-hospital resuscitation has been documented.

New Data Needed

Providers must Treat pre-arrest conditions Provide effective CPRDeliver consistent high-quality post-resuscitation care

Programs must implement processes of continuous quality improvement CPR decisions must be tailored

The The ““Bow TieBow Tie”” ConceptConcept

Cardiac Arrest

Post Resuscitation

Outcomes

Pre-Arrest Recognition and Intervention

PALS

ACLS

Neonatal Resuscitation Program

Provide Effective CPR and Defibrillation

…combined, as indicated, with advanced care.

Monitoring of CPR Quality

CompressionsCompressions

ECGECG

VentilationsVentilations

Cardiac arrest

Defibrillatorarrives

RhythmCheck

Rhythm Check

Rhythm Check

Go to A

A

Schedule rhythm checks, shock delivery around 2-minute periods of uninterrupted CPR

CPR CPR

CPRCPR

CPR

CPR

CPR

ConsiderANTIARRHYTHMIC

+CPR

GiveVASOPRESSOR

+CPR+

= ShockCPR = 5 cycles or

2 minutes of CPR += CPR whiledefibrillator chargingKey

Compression Pauses Reduce Shock Success

EffestolEffestol et al, et al, ResuscitationResuscitation, 2006, 2006

Teams Must Practice Codes

Rescue ECMO—Encouraging Results

% S

urvi

val

0

25

50

75

100

Field ROSC Hosp Admit

HospD/C

Weil and Tang ed. 1999, CPR

In-Hospital Cardiac Arrest (U Chicago)52% ROSC rate18% survival to hospital d/c

Post Cardiac Arrest Survival is PoorPost Cardiac Arrest Survival is PoorOut-of-Hospital Cardiac Arrest

30% ROSC rate10% survive 24h4% survive to hospital d/c

PostPost--ROSC Mortality is SignificantROSC Mortality is Significant

“The majority of patients who achieve ROSC are being abandoned long before it is even reasonable to predict

neurological recovery.”

Are we giving up too soon at the bedside?Are we giving up too soon at the bedside?

Withdrawal of Technologic

Support

RO

SC 24h 72h12h

63% of Post-ROSC patients made DNAR30% had technologic support withdrawn5% met clinical criteria for brain deathAverage time to death was 1.5 days

10 excludeddied beforeICU admission

58 patients admitted to ICU

18 (31%) patients survived9 CPC 16 CPC 2 2 CPC 31 CPC 4

Control period (1996-98)68 patients admitted to ED

34 (56%) patients survived31 CPC 13 CPC 2

61 patients admitted to ICU

Intervention period (2003-2005)69 patients admitted to ED

8 excludeddied beforeICU admission

15 (26%) patients withone-year survival

34 (56%) patients withone-year survival

Effect of Post-resuscitation Protocol on Survival

SundeSunde et al, Resuscitation, 2007et al, Resuscitation, 2007

26% withfavourableoutcome

p=0.00156% withfavourableoutcome

p=0.001

Concluding MessagesCPR is backQuality of CPR influences outcome

Ensure effective chest compressions, minimize interruptions, allow recoilCreate process of continuous quality improvement (eg, www.nrcpr.org)

Tailor your approachWhen to start: before the arrestWhen to stop: continue protocol-based support after ROSC

Acknowledgements

Mickey Eisenberg, Sylvia Metheny and Roger Federer: Seattle—King County Termination of ResuscitationLaurie Morrison: Toronto Validation of Termination of Resuscitation study informationTerry Vanden Hoek—Postresuscitation CareRoger White—Rochester EMS protocolKjetil Sunde—Oslo Postresuscitation Care

Thank you.