Hick J L, Mahoney B D, Lappe M
Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.
Ann Emerg Med. 1998 Jul;32(1):19-25. doi: 10.1016/s0196-0644(98)70094-0.
Prior research has established the futility of continued resuscitation efforts for patients in cardiac arrest who fail to respond to out-of-hospital advanced cardiac life support. Determination of both medical and nonmedical factors resulting in the transport of patients in continuing cardiac arrest to the hospital may encourage the development of new systems or strategies to increase the appropriateness of these transports.
The attending paramedic completed a prospective survey after unsuccessful resuscitation efforts in our urban, hospital-based, two-tier emergency medical services (EMS) system. All nontraumatic adult arrests were included unless they were clearly noncardiac in nature.
Paramedics responded to 259 cardiac arrests between September 12, 1996, and April 31, 1997. Seventy-nine patients were pronounced dead without resuscitation efforts. Of the remaining 180 patients, 44 had return of spontaneous circulation and were transported to the hospital, 68 were pronounced dead in the field, and 68 were transported to the hospital in continuing cardiac arrest. The 68 patients transported while in cardiac arrest are the focus of this study. Rare problems with field termination were identified. Reasons for transport of the 68 patients in continuing cardiac arrest included arrest in ambulance or going to ambulance (n = 6), arrest in a public place (n = 17), environmental factors (n = 6), road hazard to paramedics (n = 1), possible reversible cause (n = 4), persistent ventricular dysrhythmia (n = 5), no intravenous access (n = 5), airway difficulties (n = 5), family unable to accept field termination (n = 3), cultural or language barrier (n = 1), EMS physician ordered transport (n = 1), and obesity (n = 1). A protocol allowing pronouncement of death in the ambulance and transport of the body to a designated area could have prevented lights-and-siren transport to the emergency department in 24 of the 68 cases.
Factors other than medical ones often influence the decision to transport patients in continuing cardiac arrest. In our urban system, physician, medical examiner, and paramedic education and protocols were needed to aid decision-making in this situation.
先前的研究已证实，对于院外心脏骤停且对高级心脏生命支持无反应的患者，继续进行复苏努力是徒劳的。确定导致持续性心脏骤停患者被转运至医院的医学和非医学因素，可能会促使开发新的系统或策略，以提高此类转运的合理性。
在我们基于医院的城市两级紧急医疗服务（EMS）系统中，急救医护人员在复苏努力失败后完成了一项前瞻性调查。纳入所有非创伤性成人心脏骤停病例，除非其本质上明显不是心脏原因导致的。
1996年9月12日至1997年4月31日期间，急救医护人员共应对了259例心脏骤停病例。79例患者未经复苏努力即被宣告死亡。其余180例患者中，44例恢复自主循环并被转运至医院，68例在现场被宣告死亡，68例在持续性心脏骤停状态下被转运至医院。本研究聚焦于这68例在心脏骤停状态下被转运的患者。发现现场终止复苏的情况很少见。68例持续性心脏骤停患者被转运的原因包括在救护车内或前往救护车途中发生心脏骤停（n = 6）、在公共场所发生心脏骤停（n = 17）、环境因素（n = 6）、对急救医护人员存在道路危险（n = 1）、可能存在可逆病因（n = 4）、持续性室性心律失常（n = 5）、无静脉通路（n = 5）、气道困难（n = 5）、家属无法接受现场终止复苏（n = 3）、文化或语言障碍（n = 1）、EMS医生下令转运（n = 1）以及肥胖（n = 1）。一项允许在救护车内宣告死亡并将尸体转运至指定区域的方案，本可避免68例中的24例在亮起警灯并鸣笛的情况下被转运至急诊科。
除医学因素外，其他因素往往会影响对持续性心脏骤停患者进行转运的决策。在我们的城市系统中，需要对医生、法医和急救医护人员进行教育并制定相关方案，以协助在此种情况下做出决策。
