Key Feature 6: In patients requiring resuscitation, assess their circumstances (ex: asystole, long code times, poor pre-code prognosis, living wills) to help you decide when to stop. (Avoid inappropriate resuscitation.)
Skill: Clinical Reasoning
Phase: Diagnosis, Treatment
The first time I witnessed CPR in action was during my Emergency Medicine rotation in medical school. I came to one of the trauma bays and found a code taking place. The victim was a man who was found outside in the freezing cold. He looked like he had been beaten up by the wounds on his face, and no one knew who he was, his medical identification number listed as a string of 9's. Next thing I knew, there was a pulse and rhythm check, and I was standing up on the stool next to the victim's body next in life to give the proceeding round of chest compressions. The code had already been going on for quite awhile, although I wasn't sure for exactly how long and the adrenaline of the situation certainly distorted my sense of timing. I wondered how much of a chance there would be of bringing this man back to life after what felt like an already lengthy resuscitation effort. As I hovered over the victim's body, the emergency physician leading the code asserted, "I've got a femoral pulse," stunning the air and signalling the need to transition from the algorithm for cardiac arrest to the one for post-cardiac arrest care.
In patients who are receiving basic or advanced cardiac life support, at what point to you stop the resuscitation if there is no return of circulation? The ACLS manual provides the following information for guidance:
On terminating in-hospital resuscitative efforts
"If healthcare providers cannot rapidly identify an underlying cause and the patient does not respond to the BLS and ACLS interventions, termination of all resuscitative efforts should be considered. The decision to terminate resuscitative efforts rests with the treating physician in the hospital and is based on consideration of many factors, including:
The final decision to stop resuscitative efforts can never be as simple as an isolated time interval. If ROSC of any duration occurs, it may be appropriate to consider extending the resuscitative effort.
Experts have developed clinical rules to assist in decisions to terminate resuscitative efforts for in-hospital and out-of-hospital arrests. You should familiarise yourself with the established policy or protocols for your hospital or EMS system.
Continue out-of-hospital resuscitative efforts until one of the following occurs:
When I was on that ED rotation witnessing the code unfold, I hadn't yet taken my ACLS training, and I didn't know that hypothermia is a reversible condition that warrants a prolonged resuscitation effort. There is at least of smidgeon of truth then, it would seem, to those sci-fi movies in which a person lives longer by going into a "deep freeze." In hindsight, my sense of how long the code was going for was probably less distorted than I previously thought, and indeed it was probably a longer resuscitative effort than is usual before terminating efforts given that he was probably hypothermic. The team successfully brought this man back to life after he essentially thawed, and although his quality of life after resuscitation was unclear at the time, my hope was that he would live long and prosper.