When to terminate cardiopulmonary resuscitation (CPR) in cardiac arrest scenarios?

Guidelines for Terminating Cardiopulmonary Resuscitation

Termination of resuscitative efforts should follow standardized protocols based on specific clinical criteria, with different rules for out-of-hospital versus in-hospital cardiac arrests to reduce variability in decision-making and prevent futile resuscitation attempts.

Out-of-Hospital Cardiac Arrest (OHCA) Termination Rules

BLS Termination Rule (Class I, LOE A)

For BLS providers when ALS is not available or significantly delayed, terminate resuscitation when ALL of the following criteria are met 1:

• Arrest was not witnessed by EMS provider
• No return of spontaneous circulation (ROSC) after 3 full rounds of CPR and AED analysis
• No AED shocks were delivered

Implementation of this rule can reduce unnecessary hospital transport by approximately 60% 1, 2.

ALS Termination Rule (Class IIa, LOE B)

For ALS providers, consider termination when ALL of the following criteria are met 1:

• Arrest was not witnessed
• No bystander CPR was provided
• No ROSC after full ALS care in the field
• No AED shocks were delivered

This rule has been validated across multiple regions in the US, Canada, and Europe 1.

Combined BLS/ALS Systems

In tiered systems with both BLS and ALS providers, using the BLS rule is reasonable to avoid confusion at the scene (Class IIa, LOE B) 1.

In-Hospital Cardiac Arrest (IHCA) Termination Guidelines

For in-hospital arrests, the decision to terminate rests with the treating physician based on multiple factors 1:

• Witnessed vs. unwitnessed arrest
• Time to CPR
• Initial arrest rhythm
• Time to defibrillation
• Comorbid diseases
• Pre-arrest state
• Whether ROSC occurred at any point

A recent validated rule for IHCA suggests considering termination when all four criteria are present 3:

• Unwitnessed arrest
• Unmonitored patient
• Initial rhythm of asystole
• Resuscitation duration ≥10 minutes

Special Populations and Circumstances

Pediatric Patients

• No validated clinical decision rules exist for pediatric resuscitation termination 1
• For neonates with no detectable heart rate, consider stopping resuscitation if heart rate remains undetectable for 10 minutes (Class IIb, LOE C) 1
• For pediatric traumatic arrest, consider termination after 30 minutes of unsuccessful resuscitative efforts 1

Traumatic Arrest

For pediatric victims of penetrating or blunt trauma, consider termination when 1:

• Injuries obviously incompatible with life (decapitation, hemicorporectomy)
• Evidence of significant time lapse (lividity, rigor mortis, decomposition)
• At least 30 minutes of unsuccessful resuscitative efforts in witnessed arrests

Special Circumstances for Extended Resuscitation

Consider prolonged resuscitation efforts for 1, 4:

• Patients with recurring or refractory VF/VT
• Patients who demonstrate some ROSC during efforts
• Drug toxicity
• Primary hypothermia
• Drowning with hypothermia
• Lightning strike/electrical injuries

Prognostic Indicators During Resuscitation

• End-tidal CO2 (ETCO2) <10 mmHg after 20 minutes of CPR may be considered as one component in deciding when to end resuscitation (Class IIb, LOE C-LD) 1
• High serum values of NSE at 48-72 hours after cardiac arrest may support prognosis of poor neurologic outcome (Class IIb, LOE B-NR) 1

Ethical Considerations

• Withholding resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent (Class IIb, LOE C) 1
• Offering select family members the opportunity to be present during resuscitation is reasonable and desirable (Class IIa, LOE C for adults; Class I, LOE B for pediatric patients) 1
• "Slow codes" or token efforts are inappropriate and compromise ethical integrity 1

Common Pitfalls to Avoid

1. Modifying validated termination rules - The reliability and validity of termination rules are uncertain if modified (Class IIb, LOE A) 1

2. Failing to consider reversible causes - Always rule out reversible causes before termination, especially in special circumstances like hypothermia, drug overdose, or electrolyte abnormalities 4

3. Inadequate observation time - A "hands-off" period of 5-20 minutes may be required before declaring death, depending on local protocols 4

4. Misinterpreting spinal reflexes - These can be mistaken for signs of life 4

5. Premature termination - All survivors in one study achieved ROSC within 25 minutes of paramedic arrival 5

By following these evidence-based guidelines for termination of resuscitation, healthcare providers can make appropriate decisions that respect patient dignity while avoiding futile resuscitation attempts.