From the Guidelines
The duration of cardiopulmonary resuscitation (CPR) for asystole before declaring death is generally recommended to be at least 20-30 minutes, as stated in the 1998 European Resuscitation Council guidelines for adult advanced life support 1. This recommendation is based on the understanding that prolonged asystole with no response to interventions indicates irreversible cardiac death, and continuing beyond a reasonable timeframe offers no benefit while potentially compromising dignity. The decision to terminate resuscitation ultimately depends on multiple factors including the patient's underlying condition, comorbidities, time to CPR initiation, and response to interventions. Some situations may warrant longer resuscitation attempts, such as:
- Hypothermia
- Drug overdoses (particularly from cardiac medications)
- Pediatric cases During resuscitation, providers should focus on:
- High-quality chest compressions with minimal interruptions
- Securing the airway
- Obtaining vascular access
- Identifying potentially reversible causes (the "H's and T's" such as hypoxia, hypovolemia, hypothermia, toxins, etc.) It is essential to note that the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care also emphasize the importance of high-quality CPR and the need for brief pauses in CPR 1. However, the most recent and highest quality study relevant to the specific question of CPR duration for asystole is the 1998 European Resuscitation Council guidelines 1. Therefore, the recommendation of at least 20-30 minutes of CPR for asystole before declaring death is based on this guideline.
From the Research
Duration of Cardiopulmonary Resuscitation (CPR) for Asystole
The duration of CPR for asystole before declaring death varies depending on several factors, including the presence of reversible causes, the patient's medical history, and the duration of the resuscitation attempt.
- According to 2, unless spontaneous circulation resumes after 30 minutes of medical resuscitation, the survival chances are considered to be nil, except in cases of hypothermia or persistent ventricular fibrillation (or tachycardia).
- 3 suggests that termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical, and that patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation after a full resuscitative effort, including at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines.
- 4 identifies a subset of patients with limited chances for long-term survival, including those in electromechanical dissociation (EMD) or asystole on arrival of the mobile intensive care unit (MICU) team, without pupil reaction to light during CPR, and with inefficient cardiac massage by the MICU.
- 5 recommends that in asystole with no reversible causes, resuscitation efforts should be continued for at least 20 minutes, and that CPR should not be abandoned immediately after unsuccessful defibrillation, as transient asystole can occur after defibrillation.
- 6 reports that the majority of emergency physicians (65%) abandon the resuscitation attempt at the latest after performing advanced cardiac life support for 45 minutes if spontaneous circulation cannot be restored, and that factors such as pre-existing diseases, presumed interval between onset of arrest and application of CPR, duration of the resuscitation attempt, age of the patient, and electrocardiographic alterations are considered when deciding to terminate CPR.
Factors Influencing the Decision to Terminate CPR
Several factors influence the decision to terminate CPR, including: