person confirm death. EMS personnel should not be surprised by these situations. Prompt consultation with the direct medical oversight physician may be appropriate in these situations.
Physician Orders for Life‐Sustaining Treatment (POLST), is an effort to provide a standardized order sheet to indicate the specific wishes of the patient in a detailed manner. It signed by the patient and physician. A number of states have enacted legislation for this program. The specific operational details must be implemented prospectively to avoid confusion and misunderstanding at the patient’s side (see Chapter 65).
Dead on arrival
Noninitiation of resuscitation may be appropriate in certain situations when lividity, rigor mortis, decomposition, decapitation, or other signs of obvious death are present. Protocols should specify when EMS personnel should and should not initiate resuscitation. These guidelines should address special circumstances, such as hypothermia and trauma, in addition to medical arrests. Consultation with the direct medical oversight physician is prudent in unclear situations.
Protocols should also detail specific tasks that EMS personnel must carry out after noninitiation of resuscitation, including notification of police, the coroner, or the medical examiner. EMS clinicians should also receive training in notifying the next‐of‐kin or loved ones on scene that the patient is dead and in providing emotional support.
Termination of resuscitation
Traditionally, in many areas EMS crews transported all cardiac arrest victims to the hospital, continuing resuscitative efforts en route. However, there is growing awareness that cardiac arrest patients who are not responding to initial treatment will likely not receive additional benefit from transport to the hospital [91]. Therefore, EMS agencies have adopted protocols for terminating resuscitation efforts in the field.
Several studies have evaluated the prediction of futility by EMS clinicians [92–96]. The Universal Termination of Resuscitation rule developed by Verbeek and Morrison indicates termination of resuscitation in patients who meet three criteria: arrest not witnessed by EMS, no shock delivered, and no ROSC after three periods of CPR and three AED analyses [96, 97]. This applies to BLS and ALS personnel.
Other research also supports that patients who receive appropriate initial ACLS (including airway management and IV access) and who remain in asystole or PEA for greater than 20‐30 minutes of resuscitative efforts without return of pulses are unlikely to be resuscitated [94, 96]. ACLS guidelines support cessation of efforts in these patients without transport to the hospital [1, 91, 93, 95]. Consultation with the direct medical oversight physician may be appropriate in these cases [98].
Nontransport after termination of efforts applies only to patients with sustained pulselessness from suspected cardiac or general medical etiologies. This approach does not apply to patients with special situations such as drug overdoses or severe hypothermia.
The decision to terminate resuscitation or transport to the hospital involves important social and ethical matters. Although some express concern that cessation of resuscitative efforts at the scene may be poorly accepted, two studies suggest that nontransport is well accepted and often preferred if proper counseling and explanation are given to bystanders and family members [99, 100]. Nonetheless, circumstances in which transport to the hospital may be prudent include cardiac arrests occurring in public locations, unexpected death in the very young, and situations with extremely distraught or unaccepting family members. Paramedics are often uncomfortable terminating resuscitation in children [101]. Direct medical oversight physician input may prove helpful in these situations. EMS personnel should receive specific training regarding termination of resuscitation and providing notice of death to loved ones at the scene [102].
As resuscitation strategies and post arrest care continue to improve, the accepted criteria for termination of resuscitation requires continuous reevaluation. A system that looked at using ETCO2 levels to help guide decisions to terminate found no change in transport rate or survival [103]. However, newly emerging therapies, including strategies for rapid transport and initiation of eCPR, and new diagnostic modalities available in the field, such as capnography and ultrasound, will require reassessment of the decision making and criteria for termination of resuscitation in the prehospital setting.
Post cardiac arrest care
A common misconception is that the resuscitation ends after restoration of pulses. In fact, the body is in an extremely tenuous state in the immediate post arrest period. Without proper support, cardiac arrest may recur. In essence, the restoration of pulses represents the beginning of post arrest care.
The goals of post arrest care are: 1) maintain hemodynamic stability; 2) preserve the brain; and 3) correct metabolic derangements. The salient elements of post arrest care include:
Vasopressor titration.
Ventilator management.
Targeted temperature management.
Appropriate cardiac catheterization.
Sedation.
Glucose and electrolyte management.
The most important EMS consideration is vasopressor support after ROSC. Animal models of cardiac arrest predictably develop cardiovascular collapse shortly after ROSC [104]. This hemodynamic instability may result from myocardial stunning as well as the waning effect of epinephrine [105–108]. Because of the likely need for vasopressor support, it is reasonable to prepare a dopamine, norepinephrine, or epinephrine infusion immediately after achieving ROSC. Push dose vasopressors have also been used to increase systolic blood pressure in the critical care transport arena, though an increase in mortality was noted [109]. Rescuers need to anticipate cardiovascular collapse. If they wait for collapse to occur, the patient will deteriorate before rescue therapy can be initiated.
Coronary artery disease is common in this population and is independent of the primary arrest rhythm [110]. Early coronary angiography is strongly supported in guideline statements and has been associated with improved outcomes following ROSC [110, 111]. A prehospital 12‐lead ECG analysis is indicated in the patient successfully resuscitated from cardiac arrest, as this is helpful in identifying patients who should receive immediate catheterization [112]. Patients with a history consistent with acute coronary syndrome or obvious ECG changes should be transported to a percutaneous coronary intervention center.
The induction of mild hypothermia for brain preservation has demonstrated significant improvement in neurologic outcome in comatose patients following cardiac arrest [113, 114]. Hypothermia is believed to decrease cerebral metabolism, reduce free radical production, and impose direct protective effects on neural and cardiac tissue [115–119].
In the Hypothermia After Cardiac Arrest (HACA) study, comatose survivors of VF/VT cardiac arrest were randomized to a goal temperature of 32°C to 34°C for 24 hours or normal care and normothermia [113]. The investigators noted 55% of patients receiving hypothermia enjoyed a good outcome (defined as a Cerebral Performance Category 1 [Good Recovery] or 2 [Moderate Disability]) compared with 39% of normothermic patients. In a separate study, patients were randomized to a goal temperature of 33°C for 12 hours or normal care and normothermia [114]. Forty‐nine percent of the hypothermic patients enjoyed a good outcome (defined as discharge home or to acute rehabilitation), compared with 26% of the normothermic patients. However, the specific strategy used might matter. When 950 post cardiac arrest adults were randomized to temperature management at 36°C or 33°C for 24 hours, there was no outcome advantage [115]. However, both groups received precise attention to temperature management and intensive care, which may be greatly influential factors in survival. Current thinking is that, for comatose survivors of out‐of‐hospital cardiac arrest, the goal is to maintain a constant temperature between 32°C and 36°C during temperature management [1].
Early prehospital induction of hypothermia is empirically appealing and supported by