When can resuscitation efforts be stopped in a cardiac arrest?

When to Stop Resuscitation in Cardiac Arrest

Resuscitation efforts should be terminated when there is a high degree of certainty that the patient will not respond to further advanced life support, considering factors such as duration of CPR, witnessed status, initial rhythm, and patient characteristics. 1

Adult Out-of-Hospital Cardiac Arrest

BLS Termination Rule

Consider terminating BLS resuscitative efforts when ALL of the following criteria are met 1:

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

This rule has been validated in rural and urban EMS services and can reduce unnecessary hospital transports by 37% without compromising patient care 1.

ALS Termination Rule

Consider terminating ALS resuscitative efforts 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 in multiple regions across the US, Canada, and Europe 1.

In-Hospital Cardiac Arrest

The decision to terminate resuscitative efforts in the hospital setting should consider 1:

• Witnessed versus unwitnessed arrest
• Time to CPR initiation
• Initial arrest rhythm
• Time to defibrillation
• Comorbid diseases
• Pre-arrest state
• Whether ROSC occurred at any point during resuscitation

Prognostic Indicators

• End-tidal CO2 (ETCO2) < 10 mmHg after 20 minutes of CPR may be considered as part of a multimodal approach to decide when to end resuscitation efforts (but should not be used in isolation) 1
• High serum values of neuron-specific enolase (NSE) at 48-72 hours after cardiac arrest may support the prognosis of poor neurologic outcome 1

Pediatric Cardiac Arrest

Neonatal Resuscitation

• Consider stopping resuscitation if heart rate remains undetectable for 10 minutes 1
• Decision to continue beyond 10 minutes should consider: presumed etiology, gestational age, presence of complications, and parents' previously expressed feelings about acceptable risk 1

Infant and Child Resuscitation

No validated clinical decision rules exist for terminating pediatric resuscitation, but consider 1:

• Duration of CPR
• Witnessed status
• Number of epinephrine doses administered
• Etiology of arrest
• Initial and subsequent rhythms
• Age of patient

Prolonged efforts are typically warranted for 1:

• Infants and children with recurring or refractory VF/VT
• Those who demonstrate some ROSC
• Cases involving drug toxicity
• Primary hypothermia
• When extracorporeal CPR (ECPR) is being considered

Special Considerations

Traumatic Cardiac Arrest

For pediatric traumatic out-of-hospital cardiac arrest 1:

• Withholding resuscitation is reasonable in cases of obvious death (decapitation, dependent lividity, rigor mortis)
• If arrest has exceeded 30 minutes and the nearest facility is more than 30 minutes away, involving parents in decision-making should be considered

Duration of Resuscitation

• Most patients with favorable outcomes achieve ROSC within the first 37 minutes of resuscitation 2
• Patients with favorable characteristics (initial shockable rhythm, witnessed arrest, bystander CPR) may benefit from prolonged resuscitation up to 40-47 minutes 2
• If CPR continues for more than 30 minutes with no ROSC, survival is extremely rare 3

Rare Phenomenon

Be aware of the Lazarus phenomenon (spontaneous return of circulation after cessation of CPR), which has been documented in rare cases 4, 5. This underscores the importance of careful observation after termination of resuscitation efforts.

Family Considerations

• Consider offering select family members the opportunity to be present during resuscitation (Class IIa, LOE C for adults; Class I, LOE B for pediatric patients) 1
• Family presence during resuscitation has been reported to help with adjustment to the death of a loved one 1
• Provide emotional support to family members regardless of resuscitation outcome 1

Organ Donation Considerations

• All patients who are resuscitated from cardiac arrest but subsequently progress to death or brain death should be evaluated for organ donation (Class I, LOE B-NR) 1
• Patients who do not achieve ROSC may be considered candidates for kidney or liver donation in settings where such programs exist (Class IIb, LOE B-NR) 1