What is the best course of management for a patient who was found pulseless at home, had unsuccessful cardiopulmonary resuscitation (CPR) and was then brought to the emergency room (ER) without any further intervention during transport?

Management of Failed Out-of-Hospital Cardiac Arrest Arriving to the Emergency Department

Do not attempt resuscitation in the ER if the patient had failed CPR at home and arrived pulseless with no intervention during transport—this patient meets criteria for termination of resuscitation efforts. 1

Immediate Assessment Upon ER Arrival

When the patient arrives to the emergency department, immediately perform the following within 10 seconds: 1

• Check for pulse and breathing simultaneously (look for no breathing or only gasping while palpating for a pulse) 1
• Verify the patient remains pulseless with no signs of life 1
• Confirm the timeline: document the exact duration from initial collapse to ER arrival and the total "no-flow" time (time without any CPR) 2, 3

Decision to Initiate or Withhold Resuscitation

The critical question is whether to restart resuscitation efforts in the ER. This decision depends on several factors:

Factors Favoring Termination of Resuscitation:

• Prolonged downtime without CPR during transport significantly reduces survival probability and increases risk of severe neurological injury even if return of spontaneous circulation (ROSC) is achieved 4, 5
• Failed resuscitation attempts at home indicate the arrest has already progressed beyond the window where standard interventions are effective 1
• Absence of shockable rhythm (if rhythm can be quickly assessed) suggests lower likelihood of successful resuscitation 1, 2
• Extended total arrest time (typically >20-30 minutes without ROSC) is associated with extremely poor neurological outcomes 5

If Resuscitation is Attempted (Rare Circumstances):

Only consider restarting CPR if there are exceptional circumstances such as: 2, 3

• Hypothermic cardiac arrest (patient was in cold environment)
• Suspected reversible cause that was not addressed (e.g., tension pneumothorax, massive pulmonary embolism, hyperkalemia)
• Very young patient with witnessed arrest and short total downtime
• Reliable witness reports suggesting the arrest occurred during transport rather than at home

If Resuscitation is Initiated in the ER:

Follow the American Heart Association Adult Cardiac Arrest Algorithm: 1, 2

Immediate Actions:

• Begin high-quality chest compressions immediately at 100-120 compressions/minute with depth of 5-6 cm, allowing complete chest recoil 2, 3, 6
• Apply defibrillator pads and check rhythm within seconds of starting compressions 1, 2
• Establish IV/IO access without interrupting compressions 1, 2
• Secure airway with bag-mask ventilation initially, then advanced airway as appropriate 2

Rhythm-Specific Management:

For shockable rhythms (VF/pVT): 1, 2

• Deliver one shock immediately (biphasic 120-200 joules or monophasic 360 joules)
• Resume CPR immediately for 2 minutes before rechecking rhythm
• Administer epinephrine 1 mg IV/IO every 3-5 minutes
• Consider amiodarone 300 mg IV/IO bolus (or lidocaine as alternative) for refractory VF/pVT 1, 7

For non-shockable rhythms (PEA/asystole): 1, 2

• Continue high-quality CPR
• Administer epinephrine 1 mg IV/IO every 3-5 minutes
• Search for and treat reversible causes (H's and T's)
• Recheck rhythm every 2 minutes

Duration of Resuscitation Attempt:

• If no ROSC after 20 minutes of high-quality ACLS in the ER, strongly consider termination of efforts 5
• Maintain systolic blood pressure >60 mmHg during CPR (if arterial line placed) to ensure adequate cerebral perfusion 5
• Document all interventions including compression quality, medications administered, and rhythm changes 8

Critical Pitfalls to Avoid:

• Do not perform prolonged, futile resuscitation when the patient has already had failed CPR at home plus significant no-flow time—this only delays family notification and consumes resources 2, 3
• Do not provide inadequate chest compressions if resuscitation is attempted—compressions must be at least 5 cm deep at 100-120/minute with complete recoil 2, 3, 6
• Do not delay epinephrine administration beyond the first rhythm check if resuscitation is initiated 1, 2
• Do not continue resuscitation indefinitely without considering the total arrest time and likelihood of meaningful neurological recovery 4, 5

Post-Resuscitation Care (If ROSC Achieved):

In the unlikely event ROSC is achieved: 2, 4

• Initiate targeted temperature management (therapeutic hypothermia) for comatose survivors
• Obtain 12-lead ECG and consider emergent cardiac catheterization if STEMI present
• Avoid hyperoxia—titrate oxygen to SpO2 92-98% 9, 4
• Control blood glucose and treat seizures if they occur 4
• Transfer to ICU for post-cardiac arrest care and prognostication after at least 72 hours 4

Family Communication:

• Inform family immediately about the poor prognosis given the circumstances 2
• Explain the timeline and why resuscitation efforts were not continued or were terminated 3
• Offer support services and allow family presence if culturally appropriate 2