A shortcut to answer a big question

1. When to stop CPR ??
Dr. Muhammad Tharwat
M.Sc. Emergency Medicine

2. Introduction
• When to stop CPR is a daily ethical dilemma
• The general rule is to give CPR. Withholding
is exception
• Written protocols + tailored decision based on
clinical judgment

3. Objectives
• To give a concise, updated literature &
guidelines review about termination of
resuscitation
• To help resuscitation teams take the
appropriate decision regarding stopping
resuscitation efforts

4. Overview
• When DNAR
• When to stop CPR ( prehospital )
• When to stop CPR ( in-hospital )
• When NOT to stop CPR
• Conclusion
• References

5. When DNAR
Risk of serious injury or
mortal peril to the rescuer

6. When DNAR
OR
Clinical signs of
irreversible death

7. When DNAR
OR
A valid physicians orders
for (DNAR)

8. When to stop CPR - prehospital
1. ROSC
2. Care transfer to ALS
3. Exhaustion, dangerous environment,
putting others in jeopardy
4. Termination of resuscitation Criteria

9. Termination of resuscitation
Criteria: ( AHA – 2015)
Unwitnessed Arrest

10. AND
No ROSC after THREE
CPR & AED rounds
(20 min. for ALS )

11. AND
NO AED shocks delivered

12. When to stop CPR - prehospital
If criteria is missing
continue resuscitation &
transport
• Witnessed Arrest
• ROSC
• Shock advised

13. When to stop CPR - prehospital
What are the implication of
termination of resuscitation criteria ?

14. When to stop CPR - prehospital
Neonatal or Pediatric OHCA
Local protocol
Resuscitate &Transport

15. When to stop CPR ( in-hospital )
Late preterm & term infants
• An Apgar score of 0 at 10 min. of
resuscitation is a strong predictor

16. When to stop CPR ( in-hospital )
Adults
Consider the reversible causes

17. When to stop CPR ( in-hospital )
Prognostication
Co-morbidities Poor outcome
• Advancing age
• Organ failure
• Major trauma
• Stroke
• Malignancy
• Sepsis

18. When to stop CPR ( in-hospital )
Intubated patient,
ETCO2<10 mmHg at
20 min. of CPR

19. When to stop CPR ( in-hospital )
Asystole for 20 minutes of
ALS in the absence of
reversible cause

20. When NOT to stop CPR
(More prolonged resuscitation)
1.As long as VF persists
2.Hypothermia
3.Toxicological arrest
4.Thrombolytics given
5.ECPR

21. Conclusion
• ThedecisiontostopCPR is adaily challenge&mustbetailoredfor each
individual case.
• Thegeneralrule is togiveCPR. Withholdingis exception
• Applying prehospitalterminationof resuscitationcriteria helps
reduceunnecessary transport, EDburden
• Asystoleand ETCO2<10mmHg,after20min.absenceofreversible
causes areimportantindicators toterminateCPR

22. References
1. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic
review of 67 prospective studies. Berdowski J et al. Resuscitation 2010;81 :1479–1487
2. The formula for survival in resuscitation. 0. Soreide E, Morrison L, Hillman K, et al.
Resuscitation 2013;84:1487–93
3. Out-of-hospital cardiac arrest survival improving over time: Results from the
Resuscitation Outcomes Consortium (ROC) Daya, Mohamud R. et al. Resuscitation ,
Volume 91 , 108 – 115
4. Regional Variation in Outcomes of Hospitalized Patients Having Out-of-Hospital
Cardiac Arrest Aiham Albaeni, et al, Am J Cardiol. 2017 Aug 1; 120(3): 421–427
5. Morrison LJ, Validation of a universal prehospital termination of resuscitation clinical
prediction rule for advanced and basic life support providers.
Morrison LJ, Resuscitation. 2009;80:324–328
6. Factors complicating interpretation of capnography during advanced life support
in cardiac arrest–a clinical retrospective study in 575 patients. Heradstveit BE.
Resuscitation. 2012 Jul;83(7):813-8.