Termination of Resuscitation in the Prehospital Setting

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Stanley Shields
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1 Resuscitation Outcomes Consortium Termination of Resuscitation in the Prehospital Setting Mr. Ian R Drennan ACP BScHK PhD(c) Rescu, Li Ka Shing Knowledge Institute, St. Michael s Hospital Institute of Medical Science, Faculty of Medicine, University of Toronto

2 None Conflicts Of Interest

3 ROC Funding Partners

4 Epidemiology

5 Universal Termination of Resuscitation Guideline Arrest not witnessed by emergency medical services personnel No return of spontaneous circulation (prior to transport) No AED shock was delivered (prior to transport) If ALL criteria are present, consider termination of resuscitation If ANY criteria are missing, continue resuscitation and transport 100% specificity and 100% PPV for futility Predicted reduction in transport rate to 46% Medical futility defined as <1% chance of survival

6 Universal Termination of Resuscitation Guideline A number of other studies have re-examined the Universal TOR Guideline in a variety of prehospital settings: Sasson (2008) JAMA Ruygrok (2009) Annals of Emergency Medicine Richman (2008) Academic Emergency Medicine Kajino (2013) Resuscitation Morrison (2006) New England Journal of Medicine Morrison (2009) Resuscitation Drennan (2013) Resuscitation

7 Background Implementation of the Universal TOR Guideline is slow and inconsistent Many EMS services continue to use non-validated methods to terminate resuscitation in the field Absence of return of spontaneous circulation (ROSC) Pre-specified duration of resuscitation (e.g. 20 minutes)

8 Hypothesis The Universal TOR Guideline is more accurate than using the absence of prehospital ROSC alone to predict futility from OHCA

9 Study Objectives Primary Objective: 1. To compare survival rates in patients transported to hospital without a ROSC who met Universal TOR Guidelines for termination of resuscitation to patients that met the single criterion of no prehospital ROSC Secondary Objectives: 1. Determine factors associated with patient survival for those transported without a ROSC 2. Examine the relationship between the duration of CPR and survival

10 Study Design Retrospective, Observational Cohort Study Resuscitation Outcomes Consortium (ROC)-Epistry Cardiac Arrest and ROC-PRIMED databases

11 Study Design Time period: January 1, 2006 to December 31, 2011 Inclusion criteria: Age > 18 Non-traumatic OHCA of presumed cardiac etiology treated by EMS Exclusions: Obvious cause etiology Patients with a valid Do Not Resuscitate order

12 Study Outcomes Primary Outcome: Survival to hospital discharge Secondary Outcome: Functional survival at hospital discharge (mrs<3)

13 Patient Flow Diagram Adult OHCA of presumed cardiac etiology treated by EMS N = 55,204 Transported to Hospital n = 32,324 No Prehospital ROSC n = 15,313 Not Transported to Hospital n = 22,880 Prehospital ROSC n = 17,011 Met TOR for Termination of Resuscitation n = 7,129 Met TOR for Transport to Hospital n = 8,184

14 Results Survival in patients transported without a prehospital ROSC All Included Patients Met TOR for termination (no shocks AND not EMS witnessed) Met TOR for transport (Shock delivered OR EMS witnessed) P Value Survival (95% CI) 1.3 (1.0 to 1.6) 3.4 (3.0 to 3.8) <0.001 Functional Survival (95% CI) 0.4 (0.1 to 0.6) 2.2 (1.7 to 2.7) <0.001 Subgroup Analysis (PRIMED/Post PRIMED) Survival (95% CI) 0.7 (0.4 to 1.1) 2.9 (2.3 to 3.5) <0.001 Functional Survival (95% CI) 0.4 (0.1 to 0.6) 2.2 (1.7 to 2.7) <0.001 Futility is <1% Survival

15 Results Multivariable Logistic Regression Model for survival to hospital discharge (n = 15,313) Odds Ratio (95% CI) Age 0.98 (0.96, 0.99) Male 1.02 (0.53, 1.95) Shock delivered 3.17 (1.68, 5.96) EMS response time 0.92 (0.84, 1.01) Public location 2.53 (1.46, 4.37) Witnessed by EMS 2.86 (1.19, 6.88) Witnessed by bystander 1.42 (0.75, 2.68) Bystander CPR 1.96 (1.07, 3.59) *Also adjusted for site (not shown)

16 Results Time to ROSC and survival to hospital discharge 90 th 99th mrs <3 mrs 4-5

17 Limitations Retrospective, observational design Cannot determine causality Data quality oversight Site variation in transport practices

18 Conclusion Universal TOR Guideline remains a strong predictor of futility from OHCA Absence of ROSC as the sole criterion for prehospital termination of resuscitation can miss potential survivors EMS Services should focus on high-quality resuscitation on scene and implement validated criteria for determination of futility

19 Significance Provides evidence that the use of absence of prehospital ROSC alone is cavalier and misses potential survivors Demystifies duration of CPR as unreliable as potential survivors were identified as requiring transport to hospital earlier employing the 3 components of the Universal TOR Guideline Evaluates the outcome of functional survival between commonly used methods to terminate resuscitation in the prehospital setting

20 Acknowledgments Co-Authors Dr. Laurie J. Morrison Thank you to the prehospital Dr. P Richard Verbeek providers participating in the Erin Case ROC Clinical Trial Network Robert H. Schmicker Dr. Joshua C. Reynolds Dr. Zachary D. Goldberger Jamie Jasti Heather Herren Paul R. Leslie Mark Charleston Dr. Ahamed Idris Dr. Yan Xiong Resuscitation Outcomes Consortium (ROC) Investigators

21 Extra Slides

22 3 Results Time of ROSC min (95% CI) ROSC Occurred After EMS Witnessed OR Shock Delivered Percentile 75th mrs (12.0,13.2) (95%) mrs (14.2,16.2) (79%) All survivors 13.3 (12.8,14.0) (89%) 90th mrs (18.4,20.3) (96%) mrs (19.1,23.0) (86%) All Survivors 20.0 (19.0,20.7) (93%) 99th mrs (35.2,40.9) (100%) mrs (33.4, ) 5 5 (100%) All Survivors 37.0 (35.1,40.4) (100%)

23 Slide 22 3 delete - combine info with slide before Nicole Ilavsky, 5/6/2015

CPR Quality During OHCA Transport

CPR Quality During OHCA Transport Sheldon Cheskes, MD CCFP(EM) FCFP Medical Director, Sunnybrook Centre for Prehospital Medicine Associate Professor, Division of Emergency Medicine, University of Toronto