Survival after failed out-of-hospital resuscitation. Are further therapeutic efforts in the emergency department futile?

BACKGROUND

Because of extremely poor outcomes, the practice of continuing cardiopulmonary resuscitation in hospital emergency departments after unsuccessful out-of-hospital cardiopulmonary resuscitation has been strongly questioned. Before revising our institutional guidelines according to previous pessimistic reports we wished to review our own experience with this practice.

METHODS

The case histories of 141 consecutive victims of witnessed cardiac arrest brought to the emergency department with ongoing cardiopulmonary resuscitation were reviewed. The emergency medical system was two-tiered and was based on the emergency department of a single university hospital. The first tier, staffed with emergency medical technicians, provided only basic cardiac life support. The second, physician-staffed tier provided advanced cardiac life support and was allowed to terminate resuscitation in the field. Rates of successful resuscitation, survival to discharge and after 1 year, and the cerebral performance of resuscitated and surviving patients were determined.

RESULTS

Ninety-one patients (65%) died in the emergency department; 50 (35%) were resuscitated and admitted. Thirty-two patients (23%) died in the hospital, 18 (13%; 95% confidence interval, 8% to 20%) survived to discharge. Sixteen survivors showed no or only mild neurologic impairment at discharge. Seventeen patients were alive 1 year later. Bystander resuscitation, short intervals to initiation of resuscitation, and ventricular fibrillation at emergency department entry were significantly associated with survival.

CONCLUSIONS

Institutional guidelines for the decision whether to continue resuscitation after failed out-of-hospital efforts should be based on an analysis of the characteristics and results of the local emergency medical system. Continuing efforts in the hospital may not be inevitably futile.