Q: When should you begin and abandon CPR in the backcountry?

Q: It is my understanding that once you begin CPR you can not stop until the patient’s pulse and breathing resumes or paramedics arrive on the scene. Otherwise, it would be considered an abandonment of care. Is this true and are you familiar with any legal issues of administering CPR in the backcountry?

A: I cannot give you a simple answer to this one.  My opinion is based on my interpretation of published data and personal experience.

Here is what the American Heart Association published last month as part of their 2010 CPR Guidelines:

When not to start:

  • Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril
  • Obvious clinical signs of irreversible death (eg, rigor mortis, dependent lividity, decapitation, transection, or decomposition)
  • A valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated DNAR order

Terminating Resuscitative Efforts in a BLS Out-of-Hospital System

Rescuers who start BLS should continue resuscitation until one of the following occurs:

  • Restoration of effective, spontaneous circulation
  • Care is transferred to a team providing advanced life support
  • The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy
  • Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation (TOR) are met.

Unfortunately, the criteria for TOR referenced generally depend on tools or capabilities that most of us don’t have in the field (e.g., automatic external defibrillator).

There is literature supporting the notion that if spontaneous circulation is not restored within 30 min of initiating resuscitative efforts (some would say 20), the chance of survival is nil.  The outcome is even more grim without an AED and when good quality CPR is not started promptly and sustained without interruption.  Trauma arrests have the worse prognosis of all.  Unfortunately, the AHA, et al have yet to explicitly offer a specific guideline that uses time as a criteria under any circumstances.  Their reluctance and/or lack of interest is understandable because their focus is on situations where a call to and timely response from advanced-level EMS is the norm.

So is it abandonment to stop?  That is a legal concept that one can only speculate about.  It would be unlikely if one made a decision to stop based on the AHA criteria listed above.  In remote, low resource settings (e.g., no likelihood of an AED or advanced capabilities), the physical toll even if one could maintain good quality CPR indefinitely would be substantial making prolonged resuscitation efforts potentially risky for the rescuer(s).  Low benefit and significant risk.  What do you think?

We and others have advocated stopping CPR in non-hypothermic arrests after reasonable efforts have been made, usually after 20 to 30 minutes of continuous CPR.  There are many urban-based EMS systems that use the same time-based benchmark.  Unfortunately, stories of rescuers continuing CPR for time periods up to 2 hours are still reported.  I suspect some do so out of fear they will be accused of abandonment and/or hope their efforts will make a difference.  Not surprisingly, the results are the same; no survival.

Bottom line: The legal system is the final arbiter of what abandonment is and when it has occurred.  CPR, even good CPR, cannot sustain a person’s viability indefinitely.  From published reports and studies, 30 minutes seems to be a reasonable time frame.  Regardless of time, do not put yourselves or others at risk.



2 Responses to “Q: When should you begin and abandon CPR in the backcountry?”

  1. Ben Dowdy

    I found it very interesting that FDNY EMS instituted a 20 minute CPR policy during the snowstorm in late December of last year that taxed their resources so severely. Here’s a link to the story:

    I think it’s a nice example of two things; that a wilderness context is often closer than we might choose to believe, and that abnormal situations call for reasonable applications of normal procedures and protocols.

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