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Clinical Articles, Lead Article

Should cardiac arrest patients go to hospital, or leave it to the paramedics?

It’s time to stop taking patients in cardiac arrest to hospital and let ambulance crews deliver the best possible care at the scene, according to a senior UK doctor writing in the British Medical Journal recently.1 A senior US doctor responds, warning that avoiding ambulance transport could result in unacceptable deaths.

Immediate cardiopulmonary resuscitation (CPR) offers the best chance of survival and ambulance services throughout the developed world tend to take patients in cardiac arrest to hospital, with CPR ongoing. This seems intuitive, writes Professor Jonathan Benger (University Hospitals Bristol NHS Foundation Trust), but he says “hospitals have nothing to offer almost all such patients beyond the care that is provided by a well trained and equipped ambulance service.” Furthermore, taking such patients to hospital may be actively harmful, he warns.

He believes this has to stop. “Ambulance staff must be empowered to use their skills to optimise CPR, achieve early defibrillation, and deliver the best possible care at the scene, with no thought of transport until spontaneous circulation has returned or until it becomes clear that the patient has no chance of survival,” he writes.

Screen shot 2014-09-26 at 10.27.13

Professor Tom Quinn (Academic Co-Chair, SPACeR Critical Care Clinical Academic Group)

Once spontaneous circulation has returned, the patient should be stabilised and transported to a “heart attack” centre for ongoing care. And if spontaneous circulation does not return then the patient’s death “should be accepted and made as dignified as possible.”

Professor Benger acknowledges that, in rare circumstances, transport to hospital is justified, but says this should be delivered by a specialist team. “For the vast majority of patients, however, it is time to call a halt to transport in cardiac arrest and to concentrate on providing the best possible resuscitation skills at scene, empowering and supporting ambulance staff. More must also be done to educate staff and the public about best possible care and what to expect when cardiac arrest occurs outside hospital,” he concludes.

Dr Bruce Adams, Chair of emergency medicine at the University of Texas Health Sciences Center, says rules for deciding when to stop resuscitation are fallible and can result in unacceptable deaths. He points out that the quality of CPR and survival outcomes “vary strikingly with geography, further complicating the application of guidelines on when to stop resuscitation.”

Dr Adams argues that the costs of CPR survival are overstated: “Avoiding ambulance transport of every patient with a cardiac arrest who died in the emergency room would save the US Medicare programme only $58m, which is less than 0.1% of its total annual losses from fraud alone,” he explains.

The rate of ambulance crashes with full lights and sirens is 46 per 100,000 patient journeys, he says. “We would need to halt 2,178 ambulance transports to prevent a single injury, but that effort would result in more than 20 unnecessary deaths.”

Furthermore, the fear that CPR creates long-term neurovegetative survivors is not borne out by the data, he adds. “For the most part, patients that are destined to die do so fairly soon.”

Meanwhile, an estimated 5% of all organs harvested are from legally brain dead patients who received CPR, “so reducing ambulance transport of patients in cardiac arrest could diminish organ donations.”

Finally, Dr Adams points to emerging advances in CPR research, saying “these promising hospital based resuscitative strategies may change our definition of who is and who is not salvageable.”

Speaking to BJC Arrhythmia Watch, Professor Tom Quinn (Academic Co-Chair, SPACeR Critical Care Clinical Academic Group) said: “I agree with Jonathan Benger. We need to take a realistic, pragmatic approach to this highly charged issue. NHS paramedics are trained in delivering high quality resuscitation and the national guidelines, produced by the Joint Royal Colleges Ambulance Liaison Committee and published by the Association of Ambulance Chief Executives, allow paramedics to terminate a resuscitation attempt in clearly defined circumstances, where a patient remains asystolic for >20 minutes despite full advanced life support measures.”

“Patients with particular conditions such as hypothermia or with drug overdose would merit continuing resuscitation effort, and the guidelines allow for this. But overall there is little to be gained in transporting patients to hospital with ongoing CPR, which we know is ineffective and such journeys can be hazardous to all concerned, including other road users,” Professor Quinn added.

References

1. Adams BD, Benger J. Should we take patients to hospital in cardiac arrest? BMJ 2014;349:g5659. http://dx.doi.org/10.1136/bmj.g5659

Published on: September 26, 2014

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  • Atrial Fibrillation Association
 

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