Written by Michael Stocker
Spoon Feed
A novel termination of resuscitation (TOR) rule for in-hospital cardiac arrest (IHCA) often proposed TOR appropriately and rarely misidentified survivable cases, while utilizing information available at the bedside.
Rules of the floor code
Out-of-hospital cardiac arrest TOR protocols are common in the ED and prehospital environment. Whether or not you respond to “floor” codes, the boarding crisis means more of us are going to encounter IHCAs in the ED. This study proposed a series of IHCA TOR rules and prospectively tested them against three large national IHCA registries totaling 23,952 included adult IHCAs. Rules combined a series of binary variables readily available at the bedside – monitored status, witnessed status, initial rhythm of asystole, and resuscitation duration ≥ 5 or 10 minutes. The primary outcome was 30-day mortality, and a rule was considered robust if it achieved a false-positive rate of 1% (recommended TOR for a patient that survived to 30 days) and positive rate (recommended TOR) of 10%.
The best performing rule achieved a false positive rate of 0.6% with a positive rate of 11% when the following criteria were met:
- unmonitored arrest
- unwitnessed arrest
- initial rhythm of asystole
- duration of resuscitation ≥ 10 minutes
The rule did not perform well in predicting no return of spontaneous circulation; however, secondary outcomes of poor neurologic status and 1-year mortality performed similarly to the primary outcome. Self-fulfilling prophecy bias is a concern when developing any TOR rule, and generalizability to the US is limited, given the registries were from Nordic countries.
How will this change my practice?
While my current shop’s EPs rarely respond to codes outside of the ED, I have encountered several arrests of boarders in the ED and don’t see that trend going away. I favor referencing the proposed best-performing rule to inform when TOR may be justified in IHCA.
Source
Termination of Resuscitation Rules for In-Hospital Cardiac Arrest. JAMA Intern Med. 2025 Apr 1;185(4):391-397. doi: 10.1001/jamainternmed.2024.7814. PMID: 39869345
