Selected topic: Prehospital care| Volume 35, ISSUE 2, P175-179, August 2008

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Out-of-Hospital Unwitnessed Cardiopulmonary Collapse and No-Bystander CPR: A Practical Addition to Resuscitation Termination Guidelines

  • Samuel J. Stratton
    Reprint Address: Samuel J. Stratton, md, mph, Department of Emergency Medicine, University of California, Irvine Medical Center, 101 The City Drive South, Building 200, Route 128-01, Orange, CA 92868
    Department of Emergency Medicine, University of California, Irvine School of Medicine, Irvine, California

    Los Angeles County Department of Health Services, Emergency Medical Services Agency, Los Angeles, California
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  • Paula Rashi
    Los Angeles County Department of Health Services, Emergency Medical Services Agency, Los Angeles, California
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  • Los Angeles County Prehospital Care Coordinators
    Author Footnotes
    1 Los Angeles County Prehospital Care Coordinators listed at the end of article.
  • Author Footnotes
    1 Los Angeles County Prehospital Care Coordinators listed at the end of article.


      Cardiopulmonary resuscitation (CPR) provides possible survival from otherwise fatal cardiopulmonary collapse. Termination guidelines have been developed for use when resuscitation has no potential benefit for a victim. The purpose of this prospective cohort study was to determine if unwitnessed collapse combined with no-bystander cardiopulmonary resuscitation would support a decision to terminate attempted resuscitation. There were 541 patients analyzed during 6 months, with functional neurological survival the outcome of interest. There were no functional neurological survivors at hospital discharge among the 180 victims in the unwitnessed, no-bystander CPR subgroup (95% confidence interval [CI] 0.0%–2.1%). Functional neurological survival for witnessed collapse, bystander CPR was 6.0% (95% CI 2.8%–12.5%), for witnessed collapse, no-bystander CPR was 3.8% (95% CI 1.9%–7.7%), and for unwitnessed collapse, bystander CPR 1.3% (95% CI 0.2%–6.9%). With confirmation by further studies, unwitnessed collapse and lack of bystander CPR may be a practical addition to resuscitation termination guidelines.


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        • Hazinski M.F.
        • Nadkarni V.M.
        • Hickey R.W.
        • O'Connor R.
        • Becker L.B.
        • Saritsky A.
        Major changes in the 2005 AHA Guidelines for CPR and ECC.
        Circulation. 2005; 112: IV206-IV211
        • Nichol G.
        • Stiell I.G.
        • Laupacis A.
        • Pham B.
        • De Maio V.J.
        • Wells G.A.
        A cumulative meta-analysis of the effectiveness of defibrillator-capable emergency medical services for victims of out-of-hospital cardiac arrest.
        Ann Emerg Med. 1999; 34: 517-525
        • Kahn C.A.
        • Pirrallo R.G.
        • Kuhn E.M.
        Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis.
        Prehosp Emerg Care. 2001; 3: 261-269
        • Centers for Disease Control and Prevention
        Ambulance crash-related injuries among Emergency Medical Services workers—United States, 1991–2002.
        MMWR Morb Mortal Wkly Rep. 2003; 8: 154-156
        • Becker L.R.
        • Zaloshnja E.
        • Levick N.
        • Li G.
        • Miller T.R.
        Relative risk of injury and death in ambulances and other emergency vehicles.
        Accid Anal Prev. 2003; 6: 941-948
        • Bailey E.D.
        • Wydro G.C.
        • Cone D.C.
        Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest.
        Prehosp Emerg Care. 2000; 4: 190-195
        • Kuisma M.
        • Jaara K.
        Unwitnessed out-of-hospital cardiac arrest: is resuscitation worthwhile?.
        Ann Emerg Med. 1997; 30: 69-75
        • Eckstein M.
        • Stratton S.J.
        • Chan L.S.
        Cardiac arrest resuscitation evaluation in Los Angeles: CARE-LA.
        Ann Emerg Med. 2005; 45: 504-509
        • Stiell I.G.
        • Wells G.A.
        • DeMaio V.J.
        • et al.
        Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS study phase I results.
        Ann Emerg Med. 1999; 33: 44-50
        • Mitchell R.G.
        • Brady W.
        • Guly U.M.
        • Pirrallo R.G.
        • Robertson C.E.
        Comparison of two emergency response systems and their effect on survival from out of hospital cardiac arrest.
        Resuscitation. 1997; 32: 225-229
        • Westfal R.E.
        • Reisman S.
        • Doering G.
        Out-of-hospital cardiac arrests: an 8-year New York City experience.
        Am J Emerg Med. 1996; 14: 364-369
        • Haukoos J.S.
        • Lewis R.J.
        • Niemann J.T.
        Prediction rules for estimating neurologic outcome following out-of-hospital cardiac arrest.
        Resuscitation. 2004; 63: 145-155
        • US Census Bureau
        United States Census 2000 (US Department of Commerce Web site).
        • Brain Resuscitation Clinical Trial I Study Group
        A randomized clinical study of cardiopulmonary-cerebral resuscitation: design, methods, and patient characteristics.
        Am J Emerg Med. 1986; 4: 72-86
        • Jacobs I.
        • Nadkarni V.
        • Bahr J.
        • et al.
        Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation.
        Circulation. 2004; 110: 3385-3397
        • Newcombe R.G.
        • Altman D.G.
        Statistics with confidence.
        in: Altman D.G. Machin D. Bryant T.N. Gardner M.J. Calculating confidence intervals for proportions and their differences. 2nd edn. British Medical Journal, London, UK2000: 45-56
        • Lombardi G.
        • Gallagher J.
        • Gennis P.
        Outcome of out-of-hospital cardiac arrest in New York City.
        JAMA. 1994; 271: 678-683
        • Becker L.B.
        • Ostrander M.P.
        • Barrett J.
        • Kondos G.T.
        Outcome of CPR in a large metropolitan area—where are the survivors?.
        Ann Emerg Med. 1991; 20: 355-361
        • Cummins R.O.
        • Eisenberg M.S.
        • Hallstrom A.P.
        • Litwin P.E.
        Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation.
        Am J Emerg Med. 1985; 3: 114-119
        • Troiano P.
        • Masaryk J.
        • Stueven H.A.
        • Olson D.
        • Barthell E.
        • Waite E.M.
        The effect of bystander CPR on neurologic outcome in survivors of prehospital cardiac arrests.
        Resuscitation. 1989; 17: 91-98
        • Swor R.A.
        • Boji B.
        • Cynar M.
        • et al.
        Bystander vs EMS first-responder CPR: initial rhythm and outcome in witnessed nonmonitored out-of-hospital cardiac arrest.
        Acad Emerg Med. 1995; 2: 494-498
        • Herlitz J.
        • Engdahl J.
        • Svensson L.
        • Young M.
        • Angquist K.A.
        • Holmberg S.
        Can we define patients with no chance of survival after out-of-hospital cardiac arrest?.
        Heart. 2004; 10: 1114-1118
        • Bossaert L.
        • Van Hoeyweghen R.
        Bystander cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest.
        Resuscitation. 1989; 17: S55-S69
        • Spaite D.W.
        • Hanlon T.
        • Criss E.A.
        • et al.
        Prehospital cardiac arrest: the impact of witnessed collapse and bystander CPR in a metropolitan EMS system with short response times.
        Ann Emerg Med. 1990; 19: 1264-1269
        • Sayre M.R.
        • Travers A.H.
        • Daya M.
        • et al.
        • PAD Investigators
        Measuring survival rates from sudden cardiac arrest: the elusive definition.
        Resuscitation. 2004; 62: 25-34