Resuscitation - When to stop

 An article in NEJM looked at the outcome in 185 patients who had 
failed pre-hospital resusitation (1). Patients who were victims of trauma
or drowning or under the age of 16 were excluded. Of these 9% (16/185) were
sucessfully resusitated in the ED and admitted to the hospital. Short
pre-hospital traetment and transport times (< 15 minutes) were associated
with improved short term outcome. Females and patients with CHF did better
statistically.  In the end, none (zero, nada, no one) survived to hospital
discharge. Incidentally with regard to the yellow cab issue, transport by
BLS vs ALS ambulance did not effect likelihood of ED resusitation.  The
authors concluded that failure of pre-hospital resusitation should prompt
termination of efforts in the ED as the yield is zero.

 An earlier article in the Annals (2) looked at 181 patients who 
had failed resusitation at the scene.  Although 10 (6%) were eventually
resusitated in the E,D only 1 (0.6%) patient survived.  This particular
patient was not intubated in the field, however, and so he did not have the
full benefit of reusitative efforts.  An accompanying editorial (3)
recommended implementing these guidelines of field pronouncement excepting
patients who failed ET intubation or line placement.  (The latter would be
taken to the ED). In it he sites a study by Kellerman who looked at 240
patients who failed pre-hospital interventions (4). Only 4 survived to
hospital discharge and of these only 2 were neurologically intact.


H. Louzon MD


(1)  Gray et. al. Unsucessful Emergency Resusitation--Are Continued 
Efforts in the Emergency Department Justified?  NEJM 1991;325:1393-8

(2) Bonnin et. al. Outcomes in Unsucessful Field Resusitation Attempts. 
Annals Emer Med  May 1989 ; 18:507-12

(3) ibid. 594-596

(4) Kellerman et. al. In-Hospital Resusitation Following Unsucessful 
Prehospital Advanced Life Support: ' Heroic Efforts or an Excersize in
Futility?'  Ann Emer Med 1988;17:589-594

(Harvey Louzon, M.D.)