This preprint is under consideration at Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
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Original research
Cessation of Resuscitation in Pulseless Electrical Activity Out of Hospital Cardiac Arrest: A Mixed Methods Study of Senior Paramedic Decision Making
Alison Coppola
South Western Ambulance Service NHS Foundation Trust
Corresponding Author
ORCiD: https://orcid.org/0000-0003-0135-3783
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Background
Pulseless electrical activity, a non-shockable cardiac arrest, is treated using advanced life support resuscitation. Typically, survival rates are poor and there is a paucity of evidenced-based guidelines for paramedics on when to cease resuscitation. This led to one UK Ambulance Service developing a local guideline to support senior paramedics when making cessation decisions. This study aimed to describe the patient characteristics, clinical features and system factors of pulseless electrical activity and explore the experiences of senior paramedics making autonomous cessation decisions.
Design and Methods
An explanatory sequential mixed method design conducted in a single UK Ambulance Service. Data was retrieved for all adult Out of Hospital Cardiac Arrest patients from 1st December 2015 to 31st December 2018. Cases subject to a coronial or police investigation were excluded. Senior paramedics ceased resuscitation for 50 PEA patients, a consecutive sample, which was reviewed in detail using descriptive statistics. Independent t-test and Chi Square examined associations between variables known to prognosticate survival. Interviews were conducted with six senior paramedics who remotely supported on-scene paramedics and findings were analysed using content framework analysis.
Results
Patient characteristics: Mean age 78 years, male (n=30, 60%), co-morbidities (n=40, 80%), witnessed collapse (n=37, 74%), bystander BLS (n=30, 60%). Clinical features: defibrillation (n=22, 44%), ROSC (n=8, 16%), heart rate< 50 (n=46, 92%), mean ETCO2 2.3kPa. System factors: Advanced life support duration 59mins. A significant association between witnessed cardiac arrest and bystander basic life support was found (95% p=.00). Themes arising from interviews were defining resuscitation futility, the impact of ceasing resuscitation, conflicting views and clinical decision tools.
Conclusion
Senior paramedics interpreted and applied a multifactorial approach to ceasing resuscitation for patients with PEA. Patient characteristics, clinical features and system factors were balanced using clinical judgement, found to be vital to the decision-making process. This finding questions the appropriateness of paramedics making cessation decisions based on clinical features alone. As prognostic factors for survival were present, further investigation to identify the difference between an unsuccessful or futile resuscitation is required.
Keywords
Paramedic, pulseless electrical activity, resuscitation
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CURRENT STATUS: Under Review
Version 1
Posted 23 Sep, 2020
No community comments so far
Reviewer #3 agreed
On 08 Jan, 2021
Reviewer #2 agreed
On 04 Jan, 2021
Review #1 received
Received 19 Nov, 2020
Reviewer #1 agreed
On 08 Nov, 2020
Reviewers invited
Invitations sent on 07 Nov, 2020
First submitted
On 16 Sep, 2020
Editor assigned
On 16 Sep, 2020
Submission checks complete
On 15 Sep, 2020
Editor invited
On 15 Sep, 2020
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Subject Areas
Critical Care & Emergency Medicine
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This preprint is under consideration at Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Original research
Cessation of Resuscitation in Pulseless Electrical Activity Out of Hospital Cardiac Arrest: A Mixed Methods Study of Senior Paramedic Decision Making
Alison Coppola
South Western Ambulance Service NHS Foundation Trust
Corresponding Author
ORCiD: https://orcid.org/0000-0003-0135-3783
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Under Review
Version 1
Posted 23 Sep, 2020
No community comments so far
Reviewer #3 agreed
On 08 Jan, 2021
Reviewer #2 agreed
On 04 Jan, 2021
Review #1 received
Received 19 Nov, 2020
Reviewer #1 agreed
On 08 Nov, 2020
Reviewers invited
Invitations sent on 07 Nov, 2020
First submitted
On 16 Sep, 2020
Editor assigned
On 16 Sep, 2020
Submission checks complete
On 15 Sep, 2020
Editor invited
On 15 Sep, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
Subject Areas
Critical Care & Emergency Medicine
License:
This work is licensed under a CC BY 4.0 License. Read Full License
Background
Pulseless electrical activity, a non-shockable cardiac arrest, is treated using advanced life support resuscitation. Typically, survival rates are poor and there is a paucity of evidenced-based guidelines for paramedics on when to cease resuscitation. This led to one UK Ambulance Service developing a local guideline to support senior paramedics when making cessation decisions. This study aimed to describe the patient characteristics, clinical features and system factors of pulseless electrical activity and explore the experiences of senior paramedics making autonomous cessation decisions.
Design and Methods
An explanatory sequential mixed method design conducted in a single UK Ambulance Service. Data was retrieved for all adult Out of Hospital Cardiac Arrest patients from 1st December 2015 to 31st December 2018. Cases subject to a coronial or police investigation were excluded. Senior paramedics ceased resuscitation for 50 PEA patients, a consecutive sample, which was reviewed in detail using descriptive statistics. Independent t-test and Chi Square examined associations between variables known to prognosticate survival. Interviews were conducted with six senior paramedics who remotely supported on-scene paramedics and findings were analysed using content framework analysis.
Results
Patient characteristics: Mean age 78 years, male (n=30, 60%), co-morbidities (n=40, 80%), witnessed collapse (n=37, 74%), bystander BLS (n=30, 60%). Clinical features: defibrillation (n=22, 44%), ROSC (n=8, 16%), heart rate< 50 (n=46, 92%), mean ETCO2 2.3kPa. System factors: Advanced life support duration 59mins. A significant association between witnessed cardiac arrest and bystander basic life support was found (95% p=.00). Themes arising from interviews were defining resuscitation futility, the impact of ceasing resuscitation, conflicting views and clinical decision tools.
Conclusion
Senior paramedics interpreted and applied a multifactorial approach to ceasing resuscitation for patients with PEA. Patient characteristics, clinical features and system factors were balanced using clinical judgement, found to be vital to the decision-making process. This finding questions the appropriateness of paramedics making cessation decisions based on clinical features alone. As prognostic factors for survival were present, further investigation to identify the difference between an unsuccessful or futile resuscitation is required.