When to Start and Stop CPR

Mary Fran Hazinski, RN, MSN, FAAN, FAHA

Vanderbilt University Medical Center
Senior Science Editor, American Heart
Association
Potential Conflicts of Interest
„ Compensated editor, AHA Emergency
Cardiovascular Care (ECC) Programs
„ Co-editor of 2005 International Consensus on
CPR and ECC Science publication
„ Editor of 2005 AHA Guidelines for CPR and
ECC
„ Some 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 settings
„ Highlight potential impact of new CPR
Guidelines on these issues
„ Emphasize need for effective CPR, post-
resuscitation care and process of
continuous quality improvement
Key Messages
„ CPR is back
„ Quality of CPR influences outcome
„ Ensure effective chest compressions,
minimize interruptions, allow recoil
„ Create process of continuous quality
improvement (eg, www.nrcpr.org)
„ Tailor your approach
Challenges
„ Increase intact neurologic survival
„ Respect patient autonomy and self-
determination
„ Apply healthcare resources responsibly
AHA 2005 CPR and ECC
Guidelines: Withholding CPR
„ Valid DNAR order or advanced directive
„ Signs 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 regarding
„ DNAR orders or advanced directives
„ Fatal illness
„ Futility
„ Extenuating 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

condition
„ Patient, family or caregiver indicate -- in

writing or verbally -- that the patient did

not want a resuscitation
Seattle—King County EMS
Feder, Matheny, Loveless, Rea
Ann 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 EMS

Feder, Matheny, Loveless, Rea
Ann Int Med, 2006
Tested Prediction Rule for
Termination of OOH CPR
Rule recommends termination of OOH
resuscitation efforts if:
„ Arrest not witnessed by EMS personnel

„ No shocks advised

„ No pre-hospital ROSC

Survival unlikely (0.5%) if all 3 present

Note: 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 or

„ Initial cardiac rhythm non-VF/VT or

„ ROSC 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
2000
If a child fails to respond to at least 2 doses of
epinephrine with a return of spontaneous
circulation, the child is unlikely to survive.
2005
Unfortunately 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 CPR
„ Deliver consistent high-quality post-
resuscitation care
„ Programs must implement processes of
continuous quality improvement
„ CPR decisions must be tailored
 The “Bow Tie” Concept

ACLS

Pre-Arrest Recognition Cardiac Post Resuscitation

and Intervention Arrest
Outcomes

PALS
Neonatal Resuscitation
Program
Provide Effective CPR and
Defibrillation

…combined, as indicated, with advanced care.

 Monitoring of CPR Quality
„

ECG

Ventilations

Compressions
 Schedule rhythm checks, shock delivery around
2-minute periods of uninterrupted CPR
Defibrillator
arrives Give Consider
VASOPRESSOR ANTIARRHYTHMIC

Cardiac
arrest

A
Go to
CPR + CPR
CPR + CPR CPR + CPR A

Rhythm Rhythm Rhythm

Check CPR Check Check
CPR CPR
= 5 cycles or = CPR while
2 minutes of CPR + defibrillator
Key charging CPR= Shock
Compression Pauses Reduce
Shock Success

Effestol et al, Resuscitation, 2006

Teams Must Practice Codes
Rescue ECMO—Encouraging
Results
Post
Post-Cardiac Arrest Survival
ROSC Mortality is Poor
is Significant
„ Out-of-Hospital Cardiac Arrest
„ 30% ROSC rate
„ 10% survive 24h
„ 4% survive to hospital d/c
100
„ In-Hospital Cardiac Arrest (U Chicago)
75
52% ROSC rate
% Survival
„

„ 18% survival50
to hospital d/c
25

Field ROSC Hosp Hosp

Admit D/C
Weil and Tang ed. 1999, CPR
Are we giving up too soon at the bedside?
„ 63% of Post-ROSC patients made DNAR
30%
„“The had technologic
majority support
of patients who withdrawn
achieve ROSC are being
abandoned long before it is even reasonable to predict
„ 5% met clinical criteria for brain death
neurological recovery.”
„ Average time to death was 1.5 days
ROSC

12h 24h 72h

Withdrawal of
Technologic
Support
Effect of Post-resuscitation Protocol on Survival
Control period (1996-98) Intervention period (2003-2005)
68 patients admitted to ED 69 patients admitted to ED

10 excluded 8 excluded
died before died before
ICU admission ICU admission

58 patients admitted to ICU 61 patients admitted to ICU

18 (31%) patients survived 34 (56%) patients survived

9 CPC 1 26% with 31 CPC 1 56% with
6 CPC 2 3 CPC 2 p=0.001
favourable favourable
2 CPC 3 outcome outcome
1 CPC 4

15 (26%) patients with 34 (56%) patients with

one-year survival one-year survival p=0.001

Sunde et al, Resuscitation, 2007

Concluding Messages
„ CPR is back
„ Quality of CPR influences outcome
„ Ensure effective chest compressions, minimize
interruptions, allow recoil
„ Create process of continuous quality improvement
(eg, www.nrcpr.org)
„ Tailor your approach
„ When to start: before the arrest
„ When to stop: continue protocol-based
support after ROSC
Acknowledgements
„ Mickey Eisenberg, Sylvia Metheny and Roger
Federer: Seattle—King County Termination of
Resuscitation
„ Laurie Morrison: Toronto Validation of
Termination of Resuscitation study
information
„ Terry Vanden Hoek—Postresuscitation Care
„ Roger White—Rochester EMS protocol
„ Kjetil Sunde—Oslo Postresuscitation Care
Thank you.