Prehospital Cardiac Arrest Therapy To the Editor." The article by Bonnin et al, "Outcomes in Unsuccessful Field Resuscitation A t t e m p t s " [May 1989;18:507-512[ states as a conclusion that "any adult nontraumatic cardiac arrest victim who does not respond to prehospital ACLS efforts should be pronounced dead at the scene." This conclusion, justified simply by the data presented, fails to take into account several arguments against such a policy. The neurologic and cardiac outcome of patients resuscitated in the emergency department after failed prehospital ACLS is not uniformly poor. There is a certain rate of intact neurologic survival in these patients, albeit low. A policy such as that suggested in this article will result in avoidable cardiovascular death. 0.6% of 181 patients does not seem to be significant. However, 0.6% of the 350,000 prehospital cardiovascular deaths that occur per year in the United States sheds a different light on the numbers involved. If we indeed have only 30 minutes in which to restore cardiovascular function, then perhaps we should look to change what we do in those 30 minutes in patients who are failing prehospital ACLS protocol. We have found (unpublished data) that 84% of prehospital cardiac arrests that survive to intact neurologic hospital discharge were resuscitated in the field after an airway, defibrillation, and 1 mg epinephrine. Patients who progress further along the ACLS protocol have a progressively decreased likelihood of survival. Perhaps we should transport immediately after the intubation, defibrillation, and 1 mg epinephrine have failed. At the hospital, such insufficiently tested therapeutic modalities as emergency partial cardiac bypass and open cardiac massage could be performed. Improving neurologic outcome through cerebral resuscitation is a science just emerging that may in the future play a significant role in shaping our attitude and approach to cardiac resuscitation. The point is that if what we are currently doing for refractory prehospital cardiac arrest is not working, it is time for new approaches. The history of medicine is replete with examples of disease processes that had equally dismal outcomes, only to be systematically and effectively solved.
Doug Brunette, MD Steve Sterner, MD Emergency Department Hennepin County Medical Center Minneapolis, Minnesota
In Reply: We appreciate the c o m m e n t s of Drs Brunette and Sterner and agree that there is a need for new approaches to the patient in preliospital cardiac arrest. The literature documents the futility of prolonged resuscitative effortsl, 2 as currently practiced. Changes in resuscitative protocols, such as higb-dose epinephrine, open-chest massage, or cardiac bypass, may yield better survival rates. Brunette and Sterner state, however, that the outcome from failed prehospital cardiac arrest resuscitation is not uniformly poor. That statement is supported neither by our data nor our review of the literature. We documented that no patient who received all ACLS protocol resuscitative efforts survived to hospital discharge. We cannot extrapolate our data to say that no patient will ever survive after failed prehospital efforts. We suggest that the risks of transport to our paramedics (and the public) outweigh the benefits of transporting a patient who has failed a complete effort. When prehospital resources are scarce, this futile effort may further compromise patient care to the community at large. Our conclusion from these data is that physicians must realize and accept the limitations of current cardiac arrest therapy in the prehospital setting. We owe our patients our best efforts, but we must also be able to accept when our efforts are futile.
Marni J Bonnin, MD Baylor College of Medicine City of Houston EMS Houston, Texas Robert A Swor, DO, FACEP Department of Emergency Medicine William Beaumont Hospital Royal Oak, Michigan
1. Smith JP, BodaiBI: Guidelines for discontinuingprehospital CPR in the emergency department - A review. Ann Emerg Med 1985;14:1093-1098. 2. Warner LL, HoffmanJR, BaraffLJ: Prognostic significance of field response in out-of-hospitalventricular fibrillation. Chest 1985;87:22-28.
Studies on Prehospital Pharmacologic Therapy To the Editor: In their article, "Pharmacologic Intervention in Prehospital Care: A Critical Appraisal" [February 1989;18: 192-196], Shuster and Chong "review the evidence concerning the effectiveness of prehospital pharmacologic in184/340
tervention." Fourteen studies regarding prehospital pharmacological intervention and one emergency department study are reviewed. The authors concluded "there is no evidence that any medication given by the prehospital
Annals of Emergency Medicine
19:3 March 1990