CONVERSATIONS ABOUT EMS RESEARCH
GUIDELINES & RULES
Are we trying too hard for some cardiac arrests?
By Keith Wesley, MD, FACEP, FAEMS & Karen Wesley, NREMT-P
Drennan I, Case E, Verbeek P, et al. A comparison
of the Universal TOR Guideline to the absence of
prehospital ROSC and duration of resuscitation
in predicting futility from out-of-hospital cardiac
arrest. Resuscitation. 2017;111:96–102.
The authors wanted to determine how well the
Universal Termination of Resuscitation (TOR)
Guideline could predict survival from cardiac
The TOR recommends
that resuscitation be terminated in the field when all
three of the following are
true: 1) EMS didn’t witness
the arrest; 2) return of spontaneous circulation (ROSC)
didn’t occur despite resuscitation attempts; and 3) the
patient was never defibrillated. Specifically, the
authors wanted to discover
the survival rate of patients
who were transported solely
based on failing to obtain
Data were extracted from the Resuscitation Outcomes Consoritum PRIMED database, which was created to study the effect of
an impedance threshold device (ITD) and/or
immediate vs. delayed defibrillation.
Between 2007 and 2011 there were 36,543
cases of cardiac arrest. Of these, 9,467 (26%)
were transported without ROSC. Patients without ROSC for whom the TOR recommend
termination at the scene had a survival rate of
0.7% compared to 3.0% of patients for whom
the TOR recommended transport.
The authors concluded that transporting cardiac arrest patients based solely on the absence
of ROSC isn’t appropriate and encourage EMS
agencies to utilize the TOR fully to identify the
best candidates for survival.
DOC WESLEY COMMENTS:
Deciding who should be transported and who
should be terminated on scene is one of the most
difficult decisions for EMS providers. The TOR
has been validated showing that when all three
conditions are met, terminating resuscitation in
the field is appropriate.
Let’s examine one of the truly concerning
results in this study that the authors don’t address.
Although the authors were focused on the dismal
survival rate of those transported despite being
recommended for termination by the guidelines,
there were 4,040 patients for whom the TOR
recommended transport but were instead terminated on scene by EMS—84.6% of them were
defibrillated and 15.3% were witnessed arrests.
I can imagine countless scenarios where EMS
would transport a cardiac arrest victim without ROSC: Family dynamics, scene safety, poor
confidence in deciding to terminate and lack of
on-line medical control availability are a few.
I would like to know why over 4,000 patients
for whom the TOR guidelines recommended
transport were instead terminated, when these
patients are the most likely to survive. Transporting patients who ultimately die is an over-triage
that most systems are willing to accept, but failing
to transport patients for whom the TOR guidelines predict improved survival is unacceptable.
MEDIC WESLEY’S COMMENTS:
Looking at the ROC database, we’re provided
with a ton of information on many issues of
resuscitation. The study of over 36,000 patients
provides us with valuable tools for the prehospital setting of cardiac arrest patients.
As Doc stated, the TOR is a three-step
method for determining the likelihood of survival. But is it a guideline or a rule?
The medical research community puts very
little in the “can’t or won’t” category when determining who “should or can” be transported.
Sometimes the least likely
candidate for resuscitation
is the one who survives, and
the patient who meets all the
criteria for what should be a
save ends up dying.
We’re provided with scientific guidelines to assist us
in making extremely difficult
decisions in prehospital cardiac arrest patients. Sometimes something tells us we
should keep trying despite
the science-based score that
we’re provided. That’s why
it’s a guideline and not a
rule. It allows us to sleep a little better some
nights when we question whether we should
have done more.
Although science supports us with guidelines, the heart and soul of the provider is often
the rule. JEMS
Keith Wesley, MD, FACEP, FAEMS is the medical director for HealthEast Medical Transportation in St. Paul, Minn., and United EMS
in Wisconsin Rapids, Wis. He can be reached
at dr email@example.com.
Karen Wesley, NREMT-P, is a paramedic and
educator for Mayo Clinic Medical Transport
and is the medic team leader for the Eau Claire
County (Wis.) Regional SWAT team. She can
be reached at firstname.lastname@example.org.
Transporting patients who
ultimately die is an over-triage that
most systems are willing to accept,
but failing to transport patients for
whom the TOR guidelines predicts
improved survival is unacceptable.