Should patients with out-of-hospital cardiac arrest and suspected myocardial infarction or pulmonary embolism be transported to the hospital while being resuscitated? Should Advanced Life Support interventions be prolonged in such cases?
Bernd W. Böttiger: This is a difficult question and very much depends on the system where you are working. I am coming from a country where we have physicians in the out-of-hospital setting, in the emergency medical service (EMS) system. All over the country it is the right of a patient to have a physician if he or she is in severe circumstances. In these cases, a physician in the out-of-hospital setting can decide to stop cardiopulmonary resuscitation (CPR) after, I do not know, 30 to 45 minutes, depending on the whole case because a physician can make this decision.
In my country we are transporting patients during ongoing CPR to a hospital if we think that in the hospital there will be some therapies available that we do not have available in the out-of-hospital setting. For example, we will bring a patient to the hospital if he or she is hypothermic because we need to have a normothermic patient – [otherwise] we cannot stop therapy. We say, “No one is dead until he or she is normothermic.” In that case we will transport during ongoing CPR.
Same may apply to severe poisoning, where you have some therapies in the hospital available to treat that entity. Same may apply in cases of highly suspected pulmonary embolism, because in the hospital you can treat a patient with thrombolytic agents, or with extracorporeal circulation, or something like this. In pulmonary embolism it is also important not to stop CPR too early. In our European Resuscitation Council guidelines we recommend at least 90 minutes of CPR if a patient were not stabilized before in suspected pulmonary embolism because if you use thrombolytic agents during CPR in this kind of patients, you may be successful even after 1, 2, or maybe 3 hours.
In acute myocardial infarction it can also be useful to transport a patient to the hospital because in the catheterization laboratory you may be able to reopen the coronary artery and in that case he or she has a chance to survive. But in the end we do not have strong recommendations right now on this because we do not have any randomized controlled studies, so it is always an individual decision. This is for countries with physicians in the out-of-hospital setting.
For countries with paramedics and no physicians in the out-of-hospital setting the whole story is much more complicated. As far as I know, they are transporting more patients to the hospital during ongoing CPR because in some cases they are not allowed to decide to stop it in the out-of-hospital setting.