Protocol 27 Withholding Resuscitation 12/15/2022

Cardiopulmonary Resuscitation (CPR) Guidelines

• CPR is initiated for all patients experiencing cardiopulmonary arrest, excluding those with clear signs of irreversible biological death or valid Do Not Resuscitate Orders (DNRO).
• Resuscitation efforts cannot be stopped without a valid DNRO or evident irreversible biological death.

Documentation and Caution

• Document reasons for withholding or terminating resuscitation in the Patient Care Report's Narrative Section.
• Exercise extreme caution when deciding to withhold CPR; initiate resuscitation if patient viability is uncertain.

Presumptive Signs and Symptoms of Cardiac Arrest

• Patients may show multiple signs: unwitnessed, pulseless, apneic, discolored, cool and pale, fixed and dilated pupils, trismus, and asystole.
• These signs do not justify withholding resuscitation; follow Protocol 9.A for procedures.

Guidelines for Withholding or Terminating CPR

• CPR may be withheld if there is no pulse, no spontaneous respiration, and EKG shows asystole in at least 2 leads, along with definitive signs:

  • Tissue decomposition.
  • Rigor Mortis (fixed and non-reactive pupils, muscle rigidity).
  • Livor Mortis (purple skin discoloration that does not blanch).

• Specific criteria for traumatic cardiac arrests include:

  • Obvious fatal injuries (e.g., decapitation).
  • Tissue decomposition, rigor mortis, and livor mortis as mentioned above.

Absence of Respiration and DNRO Considerations

• In multiple casualty scenarios, if no spontaneous respiration is observed after airway repositioning, CPR may be withheld.
• If CPR is started against a patient's documented wishes (DNRO), it should be discontinued.

Procedures for Death on Scene (DOA)

• Inform law enforcement for proper procedures in confirmed cases of death on the scene.
• Ensure scene stability before clearing the unit once law enforcement is on-site.

Termination of Resuscitation Efforts

• Resuscitation may be stopped if:

  • The arrest was unwitnessed.
  • EKG remains non-shockable throughout.
  • No Return of Spontaneous Circulation (ROSC) occurs after 20 minutes.
  • ET Tube is in place with an ETCO2 reading below 10 post-20 minutes.

• Document criteria used for decisions on CPR initiation or termination in the ePCR's narrative section.

• All equipment used during resuscitation efforts must stay in place after resuscitation is terminated.

Special Considerations

• Irreversible biological death may be hard to assess in cases of hypothermia, drowning, or electrocution; these patients may still benefit from resuscitation.
• Transfer deceased patients when necessary due to environmental concerns, advising law enforcement as needed.
• EMS Field Supervisors can approve the termination of efforts after 20 minutes of attempted resuscitation, even if not all criteria are met; the rationale must be documented.

Documentation for Major Trauma Cases

• In severe trauma (e.g., decapitation), EKG readings are not required; focus on detailed documentation of injuries and physical assessments in the narrative section.

Test your knowledge on the criteria and protocols for initiating and terminating cardiopulmonary resuscitation (CPR) in patients. Understand the significance of Do Not Resuscitate Orders and the documentation required during resuscitation efforts. This quiz is essential for healthcare professionals involved in emergency care.