What is the best course of action for a pulseless patient with pallor, no chest rise, and no heartbeat, who was found unresponsive at home, had unsuccessful cardiopulmonary resuscitation (CPR) and was brought to the emergency room (ER) 30 minutes later with no intervening medical care?

Termination of Resuscitation in Failed Out-of-Hospital Cardiac Arrest

In this clinical scenario, resuscitation should not be initiated in the emergency department. The patient has already experienced failed CPR at home, followed by 30 minutes of no intervention during transport, resulting in prolonged "no-flow" time that makes survival with meaningful neurological recovery virtually impossible. 1

Clinical Assessment Upon Arrival

When the patient arrives at the ER, immediately perform the following assessment:

• Verify pulselessness by checking for a pulse within 10 seconds while simultaneously assessing for breathing or only gasping 2, 3
• Confirm pallor, absence of chest rise, and no heartbeat as described in this case 2
• Document the timeline: time of initial collapse, duration of failed home resuscitation, and total "no-flow" time (30 minutes in this case) 1
• Look for signs of obvious death: pallor, dependent lividity, rigor mortis, or other indicators that resuscitation would be futile 1

Decision to Withhold Resuscitation

The American Heart Association recommends that resuscitation efforts be terminated (or not initiated) in patients who had failed CPR at home and arrived pulseless with no intervention during transport, as the likelihood of survival with good neurological outcome is extremely low. 1

Key Factors Supporting Non-Initiation:

• Failed home resuscitation attempt indicates the arrest was likely prolonged before any intervention 1
• 30 minutes of no intervention during transport represents critical "no-flow" time where no perfusion occurred 1
• Pallor and absence of vital signs suggest prolonged circulatory arrest 2, 3
• Research demonstrates that field/ER arrests have survival rates of only 1.2%, and this is further diminished when there is prolonged no-flow time 4

Critical Pitfall to Avoid

Do not initiate prolonged, futile resuscitation when the patient has already had failed CPR at home plus significant no-flow time. This only delays family notification, consumes valuable resources, and provides false hope without meaningful chance of neurological recovery. 1 The American Heart Association specifically warns against continuing resuscitation indefinitely without considering the total arrest time and likelihood of meaningful neurological recovery. 1

Family Communication

Immediately inform the family about the circumstances and decision:

• Explain the timeline clearly: the patient was found pulseless, CPR was attempted at home without success, and 30 minutes elapsed without intervention before ER arrival 1
• State directly that resuscitation will not be attempted (or was terminated if briefly initiated) because the prolonged arrest time makes survival with meaningful brain function impossible 1
• Offer support services and allow family presence if culturally appropriate 1
• Document the decision thoroughly including the rationale based on prolonged no-flow time and failed prehospital resuscitation 1

Exception: When to Consider Brief Resuscitation Attempt

The only scenario where brief resuscitation might be considered is if there is uncertainty about the timeline or if the patient was hypothermic (which provides neuroprotection). 5 However, in this case with confirmed 30-minute no-flow time and pallor, resuscitation is not indicated.