In resuscitation decisions, providers walk a narrow line
When to terminate resuscitation is an issue that continues to stir public debate and raise ethical and philosophical questions for providers. To help guide resuscitation decisions, Mayo Clinic uses two guidelines. One identifies adults with prehospital traumatic cardiac arrest who can't be saved; the other is an algorithm for quickly assessing and treating the subset of patients in extremis or cardiac arrest after significant blunt trauma injury.
The algorithms were developed by Brian D. Kim, M.D., a trauma surgeon at Mayo Clinic's campus in Rochester, Minnesota.
"The algorithms were a response to a few cases of people who had arrested in the field and who then came in for resuscitation. Between multiple providers in the ED and EMS personnel and my own surgical partners, there are many ways of performing a blunt trauma arrest resuscitation, and the algorithms were an attempt to codify that," he says.
The Traumatic Blunt Agonal/Arrest Algorithm is used for blunt trauma patients who demonstrate class IV shock or have arrested as a result of a blunt mechanism. It aims to:
- Rapidly assess patients for signs of life
- Identify patients for whom withholding or terminating resuscitation is appropriate
- Rapidly identify and control life-threatening injuries
- Safely introduce life-sustaining measures
Although the algorithm uses the same Advanced Trauma Life Support survey used for other seriously injured patients, the survey is overlaid with actionable items, including rapid airway assessment (with the heightened awareness that a surgical airway may be necessary), bilateral needle thoracostomy or tube thoracostomy placement, and rapid delivery of blood cells via large-bore peripheral or central access (with possible initiation of massive blood transfusion protocol).
"We are always assessing the patient for signs of life," Dr. Kim says. "As with other trauma evaluations, we use ultrasound to assess sites of potential hemorrhage, but in the blunt agonal algorithm, we will use the ultrasound as a rapid echocardiogram to see if there is cardiac activity — agonal trauma patients may be pulseless and still have cardiac kinetic activity."
Other signs, such as spontaneous patient movement and Glasgow Coma Scale score, also are assessed. If signs of life are noted, the resuscitative effort continues. If signs of life are absent, resuscitation is withheld or terminated, contingent on how long signs of life have absent.
Resuscitation is withheld in patients who have suffered prehospital traumatic cardiac arrest and in whom spontaneous circulation has not returned after more than 15 minutes of CPR. In addition, resuscitation is terminated in patients who have had CPR performed for less than 15 minutes without return of spontaneous circulation and any of the following:
- No cardiac motion by FAST
- Asystole, no organized cardiac rhythm, wide complex idioventricular rhythm or narrow complex sinus bradycardia with a rate less than 40 beats per minute
- Injuries that are obviously incompatible with life, such as decapitation
"We want to make sure the patient comes first in every respect," Dr. Kim says. "We don't want to deviate from accepted practice and standard of care, but we also like to think we are thinking individuals who can move forward with clinical discretion. Clearly, we don't want to prolong efforts when resuscitation is futile. Likewise, we don't want to miss an opportunity to save a life; that's why we do what we do in this field. There must be caution on both sides of this sometimes narrow line."
Moving between established medical guidelines and individual discretion is challenging in the best circumstances. For providers in small or rural hospitals, it can be even more daunting, Dr. Kim says.
"I have the privilege of having a lot of support and assistance — multiple providers and a whole system at my fingertips — and I can only try to understand what it might be like for providers who don't have those resources when patients arrive who must be stabilized in anticipation of transfer to definitive care. At the same time, we are all responsible for understanding what constitutes appropriate therapy and the limits of therapy and what is impossible. But I would also advocate for erring on the side of caution, and we're always here as a resource for other centers to assist in caring for the most injured."
At the same time, caution can turn into something else — the heroic, glamorized, Hollywood version of trauma resuscitation that can sometimes seep into real practice.
"We can lose sight of the North Star and even the best of us need guidelines to keep us on the rail," Dr. Kim says. "We often review the guidelines as a team if we have enough time and notification before a patient comes in to make sure we're all together. And we try to have a debriefing at the end, no matter what the outcome, to make sure that everyone is comfortable with what has happened. I also make sure there are no disagreements prior to pronunciation of death or termination of resuscitation so that everyone's concerns are addressed in the moment, not after the fact."
For more information
Withholding or Termination of Resuscitation in Adult Patients with Prehospital Traumatic Cardiac Arrest
Traumatic Blunt Agonal/Arrest Algorithm