Monday, August 14, 2006

Stop CPR and no trip to the hospital

Few people survive a cardiac arrest. Over 300,000 individuals in the US die of cardiac arrest each year; “sudden” cardiac arrests of cardiac origin (rhythm or perfusion) are the least likely to be resusitatable.

A recent study in the New England Journal of Medicine (not a NEJM link, that is subscription only) tested a three criteria decision-making “tool” to see if it was reasonable for rescue personnel to stop CPR “in the field” based on futility of actions. This may seem ‘cold”, but the large numbers of individuals taken to ERs by rescue personnel in whom resuscitation is unlikely to be successful ties up rescue personnel and equipment and ER personnel and capacity that might be better used for others more likely to benefit. These “cost” (not just monetary costs) vs. benefit decisions must be looked at and “tough” decisions made.

The criteria included were: arrest not while rescue personnel were present, a rhythm not correctable by defibrillation or counter-shock, and pulselessness during resuscitative interventions (adding paramedic arrival time greater than 8 minutes in a 2-tiered EMS response system and arrest without any witnesses made the “tool” even more predictive of failure)

According to the study the application of this decision-making tool would decrease by about two-thirds the number of people in cardiac arrest taken to hospitals, those with incredibly low likelihood of survival/resusitatibility (0.5% in their study group).

It is time we looked at whether this is a reasonable advancement in pre-hospital care and whether this is in the interest of the greater good, without abandoning “hope” for those without much chance of survival.

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