The safety of a field termination-of-resuscitation protocol

A 1999 National Association of EMS Physicians position paper recommends that termination of resuscitation (TOR) be considered if the adult nontraumatic out-of-hospital cardiac arrest (OOHCA) patient receives cardiopulmonary resuscitation, definitive airway management, intravenous access, and at least 20 minutes of resuscitative efforts, yet remains in asystole or pulseless electrical activity with no return of spontaneous circulation (ROSC) in the field.

To test the safety of this protocol, with survival to discharge as the primary endpoint. The study hypothesis was that the protocol is 100% specific: no patient who would be eligible for TOR survived to discharge.

Utstein template data were collected prospectively for all OOHCA patients received at two academic emergency departments between August 1999 and January 2003, and retrospective OOHCA data were collected at one of the hospitals covering the interval October 1993 to June 2002. Each case was examined to determine whether the patient would have been eligible for TOR, and whether he or she survived.

Three hundred sixty-six prospective and 135 retrospective cases were included. Twelve patients survived to discharge, but none were eligible for TOR, as all had ROSC in the field (specificity 100%, sensitivity 58%). Of the 63 patients who survived to admission, four were eligible for TOR (specificity 94%, sensitivity 64%). None of these four survived to discharge, and not regained consciousness prior to death.

The proposed protocol appears to be safe, with 100% specificity for lack of survival to discharge in this sample. A small number of patients eligible for TOR did survive to admission, but none survived to discharge.