Predicting the Outcome of Unsuccessful Prehospital Advanced Cardiac Life Support

Objective. —To determine if failure to achieve return of spontaneous circulation following prehospital advanced cardiac life support (ACLS) warrants termination of efforts at the scene. Design. —Retrospective case series. Setting. —Memphis, Tenn, a city of 610337 people that is served by a fire department—based emergency medical service system. All city ambulances provide ACLS. Patients. —Adult victims of out-of-hospital cardiac arrest due to heart disease. Intervention. —All patients received prehospital ACLS according to the 1986 American Heart Association guidelines. Following prehospital ACLS, all patients were transported to the nearest hospital emergency department whether or not a pulse was restored in the field. Main Outcome Measures. —Survival to hospital admission, survival to hospital discharge, and neurological status at discharge. Results. —Over the 39-month study interval, the Memphis Fire Department treated 1068 victims of out-of-hospital cardiac arrest. Three hundred ten of these (29%) had return of spontaneous circulation prior to transport for some period. The remaining 758 patients (71%) never regained a pulse and were transported with ongoing cardiopulmonary resuscitation. Patients who had return of spontaneous circulation prior to transport were more likely to be admitted (69% vs 7.0%) and far more likely to be discharged alive (26.5% vs 0.4%) than patients who failed to respond to prehospital ACLS. Three patients who survived to hospital discharge despite failure to achieve return of spontaneous circulation prior to emergency medical service transport sustained their cardiac arrest after paramedic arrival. All three were discharged with moderate to severe cerebral disability. Conclusion. —Rapid transport of adults who fail to respond to an adequate trial of prehospital ACLS does not result in meaningful rates of survival. In such cases, on-line emergency medical service physicians should authorize paramedics to cease efforts in the field. ( JAMA . 1993;270:1433-1436)