When to Stop Resuscitation?

Dan StevensEmergency Medicine

When to Stop?

When to Stop?

When to Start?

When to Stop CPR

1. When the patient doesn’t want it• Advance directive

2. No chance of meaningful outcome• ???????

3. There is nothing else that can be done• ???????

No Chance of a Meaningful Outcome

• Asystole• Pupils are unreactive– Reactive pupils is a good sign– Unreactive is a bad sign (but can still have good

functional neurological outcome)– Lack of pupillary response at 72 hours is a very bad

sign• Cardiac standstill on Ultrasound• Low CO2– NEJM – An end tidal CO2 < 1.3 kPa after 20 minutes of

resuscitation no one achieved ROSC

Chance of a Meaningful Outcome

• Pre-morbid state• Time to CPR• Quality of CPR• Signs of life– Good colour– Occassional movements– Reactive pupils

• Special circumstances– Drowning / hypothermia

There is Nothing Else That Can be Done

Resuscitation By Specialists• Best resuscitation care

– Minimal / no pause CPR – good quality (LUCUS)– Best Airway management– Capnography– Thrombolysis– Upping energy, changing position of pads

• 4 pads better than 2?– ECHO– Other drugs

• Vasopressin, esmolol, steroids– ECLS (extracorporeal life support) – Cath Lab (PCI) during arrest– The Traumatic arrest

Summary

• Discuss with patients / family about DNAR• The Decision on when to stop resuscitation

should be taken on a case by case basis

When to StopSTOP CPR CONTINUE CPR

Low ETCO2 at 20 minutes of resuscitation Hypothermia

Ventricular standstill on ultrasound Fit and well

Poor Pre-morbid state At scene good quality CPR

Prolonged period without CPR Reversible cause

No reversible cause VF / VT persists

Asystole

Resources• http://intensivecarenetwork.com/reid-when-should-resuscitation-s

top/• http://edecmo.org/• http://intensivecarenetwork.com/scott-weingart-cutting-edge-intra

-arrest-care/• http://intensivecarenetwork.com/reid-cliff-resuscitation-dogmalysi

s/• http://emcrit.org/podcasts/traumatic-arrest/• http://blog.ercast.org/trauma-arrest/• http://emcrit.org/wp-content/hypoarts/rittenberger

%20prognosis.pdf• http://stemlynsblog.org/als-airway-breathing-c02/• http://www.nejm.org/doi/pdf/10.1056/NEJM199707313370503