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Thursday, 26 October 2017 21:57

Derivation of a Termination of Resuscitation Clinical Decision Rule in the UK

By Matthew House, DHC, MSc, LL.B (hons) , Michael Jackson, MBA, MSc, DipIMC(Ed), FCPara , Joanne Dinning, MSc , Peter McMeekin, PhD

Transport of cardiac arrest patients entails substantial costs and involves risk due to emergency blue-light transportation. Photos courtesy North West Ambulance Service NHS Trust
In the United Kingdom, sudden cardiac arrest accounts for close to 100,000 deaths annually.1 Despite improvements in resuscitation practices,2 outcomes from OHCA remain poor, regardless of interventions utilized.3
In a one-year period during 2014-2015, approximately 30,406 out-of-hospital cardiac arrests (OHCAs) in England were transported to hospitals by ambulance, with a survival rate of 8.6%.4
Transporting patients with nearly certain poor outcomes represents an ineffective use of ambulance resources.5,6 Termination of resuscitation (TOR) clinical decision rules (CDRs) for OHCA exist and have been validated.5,7,8
These TOR CDRs reduce the burden on both the ambulance and wider healthcare system, and improve public safety by reducing blue light transports, which present an inherent risk.
The guideline proposed after reviewing the study data compared 
favorably with pre-existing termination of resuscitation guidelines.
Several studies have identified predictors of unsuccessful prehospital resuscitation, allowing for the development of evidence-based and validated TOR CDRs.9,10
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The BLS guideline predicts that the patient will not survive to hospital discharge if the arrest isn't witnessed by the ambulance clinician, there's no return of spontaneous circulation (ROSC) before transport and no shocks have been administered.
The ALS guideline adds that the cardiac arrest must not have been witnessed by a bystander and there must have been no bystander CPR. Although these rules have been independently validated, it's been shown that they're not universal for all patient groups.11
Moreover, these studies involved systems with no pre-existing TOR guidelines. In systems where clinicians already terminate efforts on scene, the ALS guidelines have been shown potentially to increase the numbers of futile transportations.12
U.K. ambulance services are able to terminate attempts that have resulted in asystole following ALS.13 Therefore, the majority of patients transported to a hospital in the U.K. will be those who persist with pulseless electrical activity (PEA) on scene. (See Figure 1.)



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