CPR: how long with no revival before they stop CPR?

Factual Questions
1

For a person in an emergency room, say, if their heart stops and CPR is performed, if their heart does not restart then how long will CPR be tried before they stop and declare the person dead?

There’s probably no fixed number of minutes for this and not every situation is the same, so I’m asking for a general answer. Is it roughly 15 minutes? 30? 60?

Also, there is a machine called LUCAS to do automated chest compressions. So chest compressions can be done for a long time. When I took my CPR classes there was no such device. There may be others and I’m not asking about that.

I ask because I know of a case that I’d like to share, later.

2

In the fire service, unless the person is decapitated or otherwise so dead there is no chance, CPR continues till a doctor declares them dead (we have one member who is a doctor), or EMS takes over, or we are exhausted, or discover a DNR.

3

In the ER they will be using a defibrillator and other machines to revive a stopped heart or more likely one in defib. Manual CPR can take place between those procedures but won’t revive someone by itself. CPR is just to keep someone going until they can get to definitive care. The results of those machines in the ER will determine when it will be called

In the wilderness we’re told to go as long as you can until help arrives. But you can’t keep it up indefinitely to exhaustion and put yourself at risk. It will rarely go beyond an hour.

4

My mother died that way. I was there.

She collapsed in a public place and paramedics arrived rather quickly and started CPR for a few minutes then loaded her onto their truck while continuing CPR. They drove to the hospital (~8 minutes) with me following in her car. They were still doing compressions on her as they were unloading her when I pulled up a few minutes after they did.

They wheeled her into the ED and kept going for about 20 minutes before the attending doc in charge declared the effort fruitless and it was game over. And yes, they defibbed, injected various drugs, and all the rest in addition to the CPR. Both at the scene and in the hospital. Mom even had an implanted pacemaker which had tried on its own to restart her. As Python would have it, she was well and truly dead. As in 99.9% surely beyond the point of saving right from the git-go.

I’d say the total CPR effort was about 40 minutes and the effort inside the ED was about 20.

That was about 15 years ago in a US major metro area. So practice may have changed since, or vary by jurisdiction, but now you’ve got one fairly solid data point.

5

Much the same with the UK ambulance service. If they can get a pulse going with CPR, they work in relays and/or use Lucas until the patient gets to A&E. The only way they will give up there is if a scan shows no brain activity.

6

They do brain scans? They aren’t checking for a shockable rhythm?

7

I used to teach CPR and emergency medicine. It’s been a while. I would still do it if needed.

But …

In 2010 a review of 79 studies, involving almost 150,000 patients, found that the overall rate of survival from out-of-hospital cardiac arrest had barely changed in thirty years. It was 7.6%.

8

Just as a general note, neither defibrillators or pacemakers will “restart” a heart. The purpose of a defibrillator is to interrupt the spastic fibrillations that occur during the heart attack, allowing the heart to restart at a regular pace (generally after a shot of epinephrine). The purpose of a pacemaker is to prevent irregularities in the rhythm of the heartbeat by stimulating the autonomous response.

CPR should be performed for as long as the responder can manage; unlike what you typically see in t.v. and film where the actors bend their elbows and do a delicate little ‘push’, actually performing CPR requires compressing the entire chest 2-2.5 inches at a rate of approximately 2 times per second (100-120 beats per minute). On an adult-sized person this takes all the weight of the torso of the responder (or most of the body if the responder is smaller than the patient and has to raise their hips to get sufficient force), so you are essentially doing pushups, and even a very fit person will find it difficult to maintain continuously at this rate for more than 5-10 minutes. This will also break multiple ribs on the patient and often completely flail the chest, so the responder needs to confirm that the patient is non-responsive, not breathing, and has an erratic or no pulse before beginning.

EMTs/paramedics will typically perform compressions for the entire ambulance ride, or until directed to stop because it is obvious that the patient will not respond. ER physicians will assess, and if the patient cannot retain sufficient blood volume to facilitate perfusion, or has a trauma that indicates that resuscitation will not be successful, or is just not responding to epinephrine or other measures to stimulate the heart, they cease CPR. There isn’t a set time but I think most ER physicians will stop compressions if there is no response in about 20 or 30 minutes because of the strong likelihood of irreversible acute brain damage (unless the patient is put on a heart/lung machine or ECLS, in which case they aren’t doing compressions, of course).

Although rescue breathing used to be the standard protocol in field CPR it is now not recommended for a single rescuer, and for most organizations it is optional or not recommended even when there are multiple rescuers because there is a preponderance of evidence that it does little good and interrupts the flow of compressions pushing the-still oxygenated blood through the heart and into the brain. The typical healthy person actually has sufficient oxygen in the blood to survive for well more than five minutes without breathing with no ill effects provided that blood pressure can be maintained sufficient for oxygen to enter cells. In an EMS or hospital setting pure oxygen will be provided to force perfusion and extend a viable time for resuscitation.

Some ER doctors and cardiologists of advanced age have a medical directive for themselves that CPR not be performed in a hospital setting because of the likelihood of severe brain damage and the compromise to quality of life which they have observed in patients over their careers. There is a strong likelihood, especially in adults over 50, that a heart attack or other condition severe enough to require CPR will result in brain damage from anoxia without prompt restarting of the heart.

This is certainly true without defibrillation (and in many cases CPR may just not actually have done any good) but with AED+CPR the survival to discharge rate is significantly higher. The point about potentially doing more harm for the elderly or people with a terminal condition is still valid.

Stranger

9

I’ve seen a lot of pronouncements. I guess it depends on what your state allows paramedics to do. Early in my career I was told by a paramedic that they get in trouble if they bring dead people to the hospital.

In my state paramedics carry in everything they need to treat a cardiac arrest. They have everything an ER would use. If there is an obvious extended downtime they will pronounce right away even if CPR had started. The paramedics make a determination of death and the doctor they have romote contact with makes the official pronouncement.

If there is reason to believe the downtime was short CPR will continue. How long they go isn’t set by a time limit although time is one factor. The paramedics have protocols they follow. They are authorized to administer the same medications an ER would. If they reach the end of what they can push on their own they can get permission from a doctor to give more. If after all those procedures are followed and the patient has never shown a shockable rhythm they are pronounced dead at the scene. It’s generally about 20 minutes. That’s by far the most likely scenario if someone’s heart stops. If there is some heart activity and a shockable rhythm they will be transported.

There are other factors like age of the patient and what the underlying medical condition is. Trauma is handled differently than cardiac arrest.

10

It should be noted that field CPR is applied under the assumption of the availability of emergency medical services (EMS) and rapid transport to an emergency facility is available. CPR is taught in backcountry medicine but with the caveat that spontaneous recovery in most cases is extremely unlikely, and it is impossible to maintain compressions while carrying a patient to a trailhead even if rapid evac were available, so while the official line is to start and continue compressions until you cannot continue, realistically it is a judgment call to the rescuer as to how long to continue compressions or whether to even start them. Performing a pre-cordial thump used to be taught in some classes as a field expedient way of stopping fibrillation but I think it has been discontinued as not effective; it was never in the treatment protocol for WFA/WFR since I was certified.

Stranger

11

Unfortunately this is the case. An EMT friend once related the story when they stopped putting any effort into it because the old dead guy’s chest was collapsing from over an hour of CPR.

12

I wonder if those studies showing the success rate with an AED were for witnessed cardiac arrest. In my experience that was a rare occurrence. Usually we wouldn’t know if the downtime was a minute or 30 minutes. For an unwitnessed cardiac arrest the chance of survival is extremely small.

13

I think the studies just look at intake versus live discharge, and obviously an AED isn’t going to function on an already deceased patient or be of much use on a patient who has been in cardiac arrest for tens of minutes, so there may be some survival bias for patients upon whom an AED will function. But an AED provides at least some marginal benefit in potentially allowing spontaneous recovery of normal cardiac rhythm, and in most circumstances where an AED is available it will be in a public area where a collapse is likely to be observed.

I considered adding an AED to the medical/trauma bag I have in my truck but weighed against it because of the cost and low probability it would be useful, and in fact I’ve never had to perform CPR outside of a class setting (thankfully).

Stranger

14

A couple of friends were walking through downtown shortly after the town had installed public AEDs and done a lot of publicity about them. The witnessed an older tourist collapse. One of them started CPR and the other ran and got an AED that was a block away. The man is (AFAIK) alive today because of their quick action. We bought an AED for our house since the costs have come down so much and we’re not that close to EMS…

15

IIRC, we were taught that the method of injury factors into this. If you have a catastrophic heart attack in the wilderness, there’s almost nothing a rescuer can do. But if there was a lightning strike or drowning then CPR is a more likely to do some good. But in any case, CPR in the wilderness will rarely have a positive outcome.

16

I saw an incident at Killington Ski area where a skier who had an accident on slope was loaded on the sled, and ski patrol was skiing them down with another patroller in the sled also preforming CPR on the way down.

One question I have asked in training is at the point of exhaustion and no further compressions are practically possible, why don’t we use our feet. I didn’t get an answer, but 2 chimed in that this is informally called prison CPR by those who have worked in corrections and has been used in those situations. I don’t know if it’s a matter of not caring to put in that much effort or not putting one in a compromising position around other inmates but for batter or worse it seems to be used to some effect there.

17

For official guidance, the training is to start compressions regardless of injury unless it is clear that the patient is already dead or injured in such as way that resuscitation is impossible. Realistically, as a backcountry rescuer you have to make a call about resources and safety versus the likelihood of recovery. If I came across an unresponsive patient with no pulse miles into the backcountry with no idea of how long they were in this condition I wouldn’t bother, and if a member of my party had what appeared to have a massive coronary event I’d make an attempt at CPR but would probably discontinue if there wasn’t a prompt response. But with a lightning strike or drowning victim I’d put in all possible effort because there is a greater likelihood (although still not good) of spontaneous recovery.

I don’t understand what “use our feet” means? Are you suggesting jumping on the patient’s chest? What would you expect that to accomplish?

Stranger

18

The question “how long before they stop CPR” is affected by a large number of variables, so even if I were to say “about 20 minutes in most cases,” it wouldn’t be very meaningful.

Outside a hospital setting, as has been noted, EMS must follow certain standing orders. However these will rarely include termination of resuscitation except in very specific cases (non-survivable injuries, rigor mortis, etc.) Usually a verbal physician order will be needed.

Many agencies still transport cardiac arrest victims to the hospital, despite overwhelming evidence that this does not increase survival (with certain rare exceptions). The patient’s best chance is to be managed in the field.

What gets people back from cardiac arrest is rock-star quality CPR and early defibrillation. (With, as always, certain exceptions.)

In the hospital the duration of resuscitation will be affected by many things including the attending physician’s own experiences and philosophy (and what journal article he or she last read).

Where once CPR might be performed in shifts for hours (Been part of those!) the pendulum has swung to shorter resuscitations, and many docs will consider calling it after about 20 minutes. Some research has suggested a small additional number of patients might benefit from longer attempts, but from what I’ve been seeing, it’s unusual these days to go longer than 30 minutes.

But what’s the patient’s temperature? Those who go into arrest from severe hypothermia have survived hours of pulselessness!

What’s the EKG showing? Despite the miserable prognosis after 20 minutes of CPR, many are reluctant to quit when there’s still a shockable rhythm (V-fib or pulseless V-tach). “Let’s try one more shock!”

What caused the initial arrest? There’s a similar reluctance to stop when the cause is something “fixable.”

What’s the emotional component? Is the patient a child or young person? A member of the medical team?

What’s the family’s reaction? I’ve done many “social resuscitations,” working long after any reasonable expectation of survival, just because the family needed the extra time to feel certain everything possible had been done. Sometimes you’re just there to help the survivors.

19

Lightweight health professionals are often trained in doing CPR with their feet. It’s not ‘by the book’ but if they’re the only ones around it does give the victim a chance. A heel on the mid sternum can easily give sufficient compression even with the CPR giver weighing under 100 pounds.

CPR by foot

20

Huh…I’ve never encountered that in any training, even as a side discussion to the formal procedure. It seems that it would be difficult to maintain rhythm/rate, and assuming this is from a standing position would mean essentially balancing on one leg.

Stranger