To the Hospital or Not? Debating How to Handle Out-of-Hospital Cardiac Arrest

September 23, 2014

SAN ANTONIO, TX and BRISTOL, UK — Should patients who experience an out-of-hospital cardiac arrest be taken to the hospital?

It might seem intuitive, says one expert, since "these patients are critically ill and the hospital seems the obvious place to go." But for Dr Jonathan Benger (University of the West of England, Bristol, UK), the strategy of taking these sick patients to the hospital made sense when the hospital was the only place that had defibrillators.

"However, this is no longer the case, and hospitals have nothing to offer almost all such patients beyond the care that is provided by a well-trained and equipped ambulance service," writes Benger. "Preparing patients for transport, moving them, and driving them to the hospital leads to pauses in CPR and suboptimal chest compressions, even with the most skilled and committed staff."

Dr Bruce Adams (University of Texas Health Sciences Center, San Antonio), who advocates for taking arrested patients to the emergency room, argues that clinical-decision rules over the past 10 years have sought to clarify when further CPR and hospital transport is futile. "The fear that CPR creates long-term neurovegetative survivors is not borne out by the data. For the most part, patients that are destined to die do so fairly soon," he states.

For those who do die, 5% of all organs harvested are from legally brain-dead patients who receive CPR. Reducing ambulance transport could have the unintended consequence of diminishing organ donation, he suggests.

Benger and Adams, both experts in emergency-care medicine, argue their positions in a "Head-to-Head" article published September 23, 2014 in the BMJ[1].

Clinical-Decision Rules, Such As BLS-TOR

The American Heart Association 2013 update on heart disease and stroke statistics notes that fewer than 10% of individuals who have a cardiac arrest outside the hospital survive. Adams says that those who see the glass as 90% empty are typically physicians who see one arresting patient after another, patients who "come in dead and stay dead." The optimists are looking to return more survivors to productive lives.

For Benger, the ambulance paramedics are the best option in managing out-of-hospital cardiac arrest and provide the best chance at achieving spontaneous circulation. Given that time is critical, the ambulance staff should use these early minutes to provide CPR, achieve early defibrillation, and give the best possible care at the scene. Transportation should take place only once spontaneous circulation has returned or the patient has no chance of survival.

For the survivors, they can be transported to a specialized cardiac-arrest center capable of performing coronary angiography, computed tomography, and critical care with temperature control. "If spontaneous circulation does not return, then the patient's death should be accepted and made as dignified as possible," writes Benger.

While clinical-decision rules can help guide resuscitation and hospital transport, the most studied of which is the Basic Life Support Termination of Resuscitation (BLS-TOR) rule, Adams says that validation studies have "almost always found a handful of survivors who would have been declared dead."

Moreover, these clinical-decision rules have been shown to be fallible, especially when applied to different patient populations, even across different US cities. Some paramedics who have participated in studying these clinical-decision rules have expressed discomfort in applying them, notes Adams.

If money is the issue, Adams states that hospital transport for patients with out-of-hospital cardiac arrests has an almost negligible impact on costs to the healthcare system. Had transport been avoided for every patient who died in a US emergency room, the total savings to the Medicare program would have been just $58 million. If the goal is reducing injury and accidents, 2178 ambulance transports would need to be stopped to prevent a single injury. Adams says that with a "false-positive rate of just 1%, that effort would result in more than 20 unnecessary deaths."

The authors report no conflicts of interest.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.