4.5. TERMINATION OF RESUSCITATION MEASURES

Related Names

Related Names

Purpose of assistance

1. In the absence of an effect on resuscitation in cardiac arrest at the pre-hospital stage, it is quite acceptable to stop resuscitation.
2. In sudden cardiac arrest for the purpose of resuscitation at the prehospital stage, there is a restoration of the activity of the heart until irreversible neurological lesions have occurred. In most cases, subject to appropriate training, doctors are able to carry out resuscitation actions that do not differ from those at an early hospital stage and, as a rule, in most cases there are no additional advantages of resuscitation in emergency departments.
3. The effectiveness of CPR during preparation for transportation and directly during transportation is significantly less than CPR at the scene. Also, EMF specialists risk injury if CPR is performed in a moving car. In addition, continued resuscitation in infertile cases puts other motorists and pedestrians at risk, increases the time when EMF crews are not available for another call, prevents emergency departments from helping other patients, and incurs extra hospital costs. Finally, the return of spontaneous circulation depends on targeted, timely resuscitation. A patient in cardiac arrest should be treated as soon as possible, including qualitative, continuous CPR and timely defibrillation as indicated.
4. In a situation where resuscitation actions are no longer effective, the main goal of EMF specialists is the care of family members. Families need to be informed about what is being done, and transporting all cardiac arrest patients to the hospital is not supported by evidence and inconvenience to the family, requiring a trip to the hospital where they must begin to experience grief in unfamiliar surroundings.

Patient description

Patient with cardiac arrest.

Inclusion criteria

1. Any cardiac arrest patient who received on-site resuscitation but did not respond to treatment.
2. When resuscitation began and the patient was found to have a “DO NOT RESUSCITATE” statement or other medical order (e.g. form of RLPRP/MRPRP).

Consider continuing to resuscitate cardiac arrest patients associated with medical conditions that may have a better outcome despite prolonged resuscitation, including hypothermia (although under certain circumstances the direct medical supervisor may issue an order to stop resuscitation for such conditions).

Patient care

Resuscitation measures may be suspended in case of the following conditions:

1. Non-traumatic cardiac arrest.

1.1. The patient is at least 18 years old.

1.2. Cardiac arrest at the time of arrival of the EMF team:

a) no pulse;
b) no breathing;
c) no signs of cardiac activity (for example, asystole or pulse-free electrical activity (BEA) with a rhythm below 60 beats/min, no cardiac tones).

1.3. Resuscitation actions are performed depending on the available rhythm:

a) resuscitation can be stopped in the case of asystole or a slow wide complex of electrical activity without a pulse, if spontaneous circulation is not restored after 20 minutes (in the absence of hypothermia and the release rate SO2 below 20 mm Hg);
b) narrow BEA complex with a rhythm above 40 beats/min or resistant and recurrent ventricular fibrillation/ventricular tachycardia:

• • • • consider resuscitation for up to 60 minutes (the time begins from the moment the EMF team leaves);
      • completion of resuscitation actions can be stopped within 60 minutes due to the following factors (the list is not limited only to those given below): SO2 content below 20 mm Hg, age, presence of concomitant diseases, distance to the nearest EMF department, availability of resources in the nearest hospital. Termination of resuscitation ahead of schedule should be performed after consultation with the medical director.

1.4. Absence of signs of restoration of spontaneous circulation and neurological function (lack of pupil response and reaction to pain, absence of spontaneous movements).

1.5. No signs or suspicion of hypothermia.

1.6. All EMF team members agree that interruption of resuscitation is the right decision.

1.7. Contact your medical supervisor before stopping resuscitation.

2. Traumatic cardiac arrest.

2.1. The patient is at least 18 years old.

2.2. Stopping resuscitation efforts is possible in the event of any blunt trauma to the patient, as a result of which (after a detailed examination) respiratory arrest, lack of pulse, as well as asystole on an ECG or heart monitoring were detected before the brigade arrived at the scene.

2.3. In a situation of penetrating trauma and lack of pulse and breathing, EMF workers should quickly conduct an examination to identify other signs of life, such as pupil reaction, spontaneous movements, reaction to pain, electrical activity on the ECG:

a) resuscitation can be interrupted with the permission of medical management in the absence of the above signs of life;
b) if resuscitation is not stopped, transportation is shown.

2.4. Patients with cardiac arrest in whom the mechanism of injury does not correlate with their clinical condition, which indicates a non-traumatic cause of cardiac arrest, and therefore the patient needs to perform resuscitation measures for standard life support.

2.5. All members of the EMF team agree that stopping resuscitation is the right decision.

2.6. Contact your medical supervisor before stopping resuscitation.

Condition assessment

1. Pulse.
2. Breath.
3. Neurological condition (see Appendix 3; purposeful movements, pupil reaction).
4. Cardiac activity (including ECG, cardiac auscultation and/or ultrasound).
5. Quantitative capnography

Treatment and intervention

1. Focus on long-term and high-quality CPR.
2. Focus on family members and/or passersby. Explain the reasons for the interruption of resuscitation.
3. Provide support for family members, friends, clergy, faith leaders, or chaplains.
4. If patients are younger than 18 years of age, a consultation with a medical supervisor is recommended.

Patient safety

All patients with ventricular fibrillation or ventricular tachycardia need to be fully resuscitated at the scene.

Useful information for training

Key considerations and relevant evaluation results

1. Recent studies have shown that in order to save more than 99% of patients who can be saved in cardiac arrest (especially ventricular fibrillation or ventricular tachycardia), resuscitation should be carried out for about 40 minutes. However, this does not mean that every case of resuscitation should be carried out during this period (for example, with asystole).

2. In remote locations, EMF workers should actively communicate with medical supervisors; however, resuscitation activities may be stopped under the following conditions and without first consulting medical management under the following conditions:

a) no pulse, despite CPR for more than 30 minutes (this does not apply to the situation of existing hypothermia);
b) transportation to the EMF compartment takes more than 30 minutes (this does not apply to the situation of existing hypothermia);
c) EMF workers are physically tired and physically impossible to perform resuscitation.

3. It is necessary to take into account logistical factors – possible traffic jams in public places, the wishes of family members, the safety of others and the team.

4. Survival and neurological functionality are unlikely unless the EMF team has resumed spontaneous circulation. Resuscitation while driving is dangerous for the EMF team, pedestrians and other road users.

5. The quantitative capnography index is below 10 mm Hg. or a decrease of more than 25% despite resuscitation measures indicates a negative prognosis and is the reason for stopping resuscitation.

Key elements of documentation

1. All subclauses 1.1. – 2.6. items 1, 2 in traumatic and non-traumatic cardiac arrest, patient care should be clearly documented in the medical report in addition to the assessment of data confirming the decision to interrupt resuscitation.
2. If resuscitation continued under special conditions or despite non-compliance with the criteria in this guideline, an explanation/reason for continuing resuscitation should be included in the documentation.

EMF delivery efficiency criteria

1. CPR start time.
2. Time of application of AED (if any).
3. Quality assessment of CPR.
4. Duration of resuscitation procedures.
5. Evaluation of biometric indicators/quality of CPR performance.
6. Feasibility of interruption of resuscitation.
7. Evaluation of each episode of transporting a cardiac arrest patient from the scene.