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Withholding and termination of resuscitation of adult cardiopulmonary arrest secondary to trauma: Resource document to the joint NAEMSP-ACSCOT position statements

Millin, Michael G. MD, MPH; Galvagno, Samuel M. DO, PhD; Khandker, Samiur R. MD; Malki, Alisa BA; Bulger, Eileen M. MDStandards and Clinical Practice Committee of the National Association of EMS Physicians (NAEMSP) and the Subcommittee on Emergency Services–Prehospital of the American College of Surgeons’ Committee on Trauma (ACSCOT)

Journal of Trauma and Acute Care Surgery: September 2013 - Volume 75 - Issue 3 - p 459–467
doi: 10.1097/TA.0b013e31829cfaea
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ABSTRACT In the setting of traumatic cardiopulmonary arrest, protocols that direct emergency medical service (EMS) providers to withhold or terminate resuscitation, when clinically indicated, have the potential to decrease unnecessary use of warning lights and sirens and save valuable public health resources. Protocols to withhold resuscitation should be based on the determination that there are no obvious signs of life, the injuries are obviously incompatible with life, there is evidence of prolonged arrest, and there is a lack of organized electrocardiographic activity. Termination of resuscitation is indicated when there are no signs of life and no return of spontaneous circulation despite appropriate field EMS treatment that includes minimally interrupted cardiopulmonary resuscitation. Further research is needed to determine the appropriate duration of cardiopulmonary resuscitation before termination of resuscitation and the proper role of direct medical oversight in termination of resuscitation protocols. This article is the resource document to the position statements, jointly endorsed by the National Association of EMS Physicians and the American College of Surgeons’ Committee on Trauma, on withholding and termination of resuscitation in traumatic cardiopulmonary arrest.

From the Department of Emergency Medicine (M.G.M.), and Post-Baccalaureate Pre-Med Program (A.M.), Johns Hopkins University School of Medicine; and Department of Anesthesiology and Program in Trauma (S.M.G.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; Emergency Medicine Associates (S.R.K.), Germantown, Maryland; and Department of Surgery (E.M.B.), University of Washington, Seattle, Washington.

Submitted: March 24, 2013, Revised: May 17, 2013, Accepted: May 17, 2013.

Address for reprints: Michael G. Millin, MD, MPH, Department of Emergency Medicine, Johns Hopkins University School of Medicine, 5801 Smith Ave, Davis Bldg, Suite 3220, Baltimore, MD 21209; email: millin@jhmi.edu.

In 2003, the National Association of EMS Physicians (NAEMSP) and the American College of Surgeons’ Committee on Trauma (ACSCOT) published a joint position article for withholding or termination of resuscitation (TOR) of patients in cardiopulmonary arrest caused by trauma1 (Table 1). This resource document supports two new positions (Tables 2 and 3) jointly endorsed by NAEMSP and ACSCOT on withholding resuscitation and TOR in traumatic cardiopulmonary arrest.2,3 It should be noted that while the previous position considered the concepts of “withholding” and “termination” collectively, the new positions refer to these concepts separately. Furthermore, while there have been no changes to the withholding position, resulting in a reaffirmation of this position, evolution of the science has resulted in revisions to the TOR position.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

TABLE 3

TABLE 3

Although the unbundling of these two positions may seem to be mere semantics, there are scientific and regulatory reasons to separate these two positions. The withholding position includes notation regarding a lack of “…organized electrocadiographic activity.” The determination that a patient does not have electrocardiographic activity requires checking for a pulse and placing a monitor on the patient. In some emergency medical service (EMS) systems, it may be possible to perform this action and then withhold resuscitation. However, in some systems, this activity may be considered a part of patient assessment, which defines the initiation of patient care and thus defines that resuscitation has already begun. Therefore, in these systems, it may be more appropriate to use a TOR protocol than a withholding protocol except in cases when the patient is clearly dead such as decapitation or hemicorporectomy.

Regardless, the purpose of this article is to present the scientific evidence supporting these two new positions. Of note, these positions pertain to the care of the trauma patient before and are not meant to guide care after arrival at an acute care facility. Comprehensive discussion on the utility of certain ED procedures, therefore, is not relevant to this article. The science discussed in this article is purely focused on the patient that has no identified signs of life and has limited chances of survival, regardless of the care provided to the patient after arrival to an acute care facility, such that the risks of resuscitation and transport outweigh any potential benefit.

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PATIENTS AND METHODS

The development of the updated TOR protocol and this resource document began with a structured review of the literature regarding the topic of resuscitation in traumatic cardiopulmonary arrest, focusing on articles that pertain to the constituents that determine the outcome of the arrest.

We began with a review of the literature that was used to support the 2003 position article. We then initiated PubMed and EMBASE searches of the English-language literature using the key words: cardiopulmonary arrest in trauma, termination of resuscitation, timing of arrest, rhythm analysis, vital sign assessment, and emergency department thoracotomy. All articles deemed to be relevant to the topic were reviewed, and a draft position, based on the supporting literature review, was formulated. This position was then sent for review and further refinement by the board of directors of NAEMSP and the EMS subcommittee of the ACSCOT. Thus, the levels of the evidence of these positions are a combination of an analysis of the best available evidence and the consensus of these two professional associations. This resource document, with included tables, discusses all the articles reviewed in the development of these positions relevant to out-of-hospital termination or resuscitation of traumatic cardiopulmonary arrest and outlines the key findings of this literature.

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Contextual Factors Influencing Resuscitation Decisions

Ambulance Crashes While Running Lights and Sirens

In 2011, NAEMSP published a position statement on TOR for nontraumatic cardiopulmonary arrest.4 The accompanying resource document by Millin et al.5 reviewed the literature on the science of ambulance crashes while running warning lights and sirens.

Most importantly, it is clear that running emergency vehicles with warning lights and sirens increases the risk of ambulance crashes, injury to EMS providers, and injury to a member of the public who is not involved in the incident.6–15 Furthermore, the literature on resuscitation demonstrates that the quality of cardiopulmonary resuscitation (CPR) significantly deteriorates when chest compressions are performed in a moving ambulance.16,17 As such, a TOR protocol reduces the risk of ambulance crashes and increases chances of successful resuscitation by focusing on high-quality, minimally interrupted chest compressions before transport to an acute care facility.18–20 However, it should be noted that there is complexity in this issue with traumatic cardiopulmonary arrest in that definitive treatment to correct major internal blood loss may be best achieved at a trauma center and the quality of chest compressions may be less relevant.

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Cost

Another consideration in the development of TOR protocols is the cost of resuscitation for a patient in cardiopulmonary arrest. Perhaps more important than the high cost of resuscitation per individual patient21,22 is the effect on the EMS system of transporting a patient that has minimal to no chances of survival because this diverts resources from living patients that have other time critical diseases such as acute myocardial infarction, stroke, and multiorgan trauma with intact pulses.23–25

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Mortality From Traumatic Arrest

Ultimately, the decision to terminate resuscitative efforts is influenced by the risk-to-benefit ratio of the resuscitation and the expectancy that the patient will survive with a favorable outcome. In general, survival rates from traumatic cardiopulmonary average approximately 2%.21,26–38 To illustrate the wide range of findings, overall point estimates for survival and 95% confidence intervals (CIs) are listed in Table 4.

TABLE 4

TABLE 4

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Conditions for TOR

Signs of Life and Initial Electrocardiographic Rhythm

Within the context of withholding and termination of resuscitation protocols, any patient that has spontaneous respirations, pulse or measurable blood pressure, or spontaneous movement should be resuscitated and transported to the closest appropriate acute emergency facility. In addition, pulseless patients with organized electrical activity identified by electrocardiogram (ECG) also warrant at least the initiation of resuscitation.

With regard to electrocardiographic rhythms, the majority of available evidence suggests that an initial rhythm of asystole is associated with a very low probability of survival for both blunt and penetrating traumatic cardiopulmonary arrest. In 1985, Aprahamian et al.27 published a study of 95 trauma patients who were in cardiopulmonary arrest on paramedic arrival. Of the 51 patients (54%) who were in asystole at the time of paramedic arrival, there were no survivors to hospital discharge. A study by Esposito et al.29 in 2004 showed similar results with no survivors in the group of patients in asystole at the time of hospital arrival. Stratton et al.31 showed that all 4 (0.8%) of 497 survivors of arrest from penetrating trauma who had a functionally intact outcome had either pulseless electrical activity (PEA) with a sinus-based rhythm at a normal rate or PEA with sinus tachycardia; no patients with asystole survived.

Seamon et al.39 showed that for survivors of penetrating trauma who had ED thoracotomy (EDT), sinus tachycardia was an independent predictor of survival (odds ratio [OR], 5.17; 95% CI, 1.04–25.60, p = 0.044). These results were reaffirmed in a 2008 follow-up study of EDT penetrating trauma patients.40 Survivors in this study more often had signs of life in the field, sinus tachycardia (nonsurvivors, 10.2% vs. survivors, 43.5%; p < 0.001) and normal sinus rhythm (nonsurvivors, 4.5% vs. survivors, 17.4%, p = 0.037). Three of the 23 survivors (1.8% of the study population) in this study had asystole recorded as the initial cardiac rhythm.40 In a 2004 study by Powell et al.,41 6 of 26 patients that had prehospital CPR had asystole at the time of EDT. Of the five survivors, one had a severe neurologic deficit, three had mild deficits, and two had no neurologic deficits. All survivors in asystole had pericardial tamponade.

More recently, Tarmey et al.37 studied 52 patients in a military setting with traumatic cardiopulmonary arrest. All 29 patients with asystole died, and 3 of the 4 survivors had a sinus-based rhythm with a rate of greater than 40.

In addition to asystole, PEA with a rate less than 40 per minute has also been shown to be correlated with extremely low odds of survival in traumatic cardiopulmonary arrest. In one study, the mean (SD) duration of CPR for five patients who had an initial rate less than 40 per minute and were admitted to the intensive care unit was 19.8 (4.2) minutes, but none of these patients survived.32 No patient with an initial rate less than 40 per minute survived, and no patients with an initial rhythm of asystole survived. Similarly, in Pickens et al.,34 stepwise regression of all clinical assessment covariates found an ECG rate of more than 40 per minute to be a strong independent predictor of survival (OR, 6.7; 95% CI, 1.7–27, p = 0.008).

Further examining the effect of heart rate on survival, Siram et al.42 attempted to devise a prediction score to determine outcomes for EDT and found a rate greater than 100 per minute to be associated with a 60% survival rate; no survival data were described for bradycardic or normocardic patient in this study.

Therefore, analysis of the existing literature demonstrates that patients in an asystolic rhythm have extremely low odds of survival (<1%). Furthermore, the literature suggests that patients in narrow complex PEA with a normal or tachycardic rhythm are more likely to survive and patients in PEA with a wide complex bradycardic rhythm are less likely to survive. An overview of the studies that examine the relationship between asystolic arrest and survival is presented in Table 5. Survival from asystolic arrest in these studies averages at less than 1%.

TABLE 5

TABLE 5

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EDT and Resuscitation Duration

Although discussion of the merits of EDT is beyond the scope of this article, there is some relevance in that it is important to identify patients in the out-of-hospital environment in traumatic cardiopulmonary arrest that might benefit from this procedure. The ACSCOT recommends that EDT is best applied to patients with penetrating cardiac injuries who arrive to the ED after a short transport time with witnessed signs of life.43 The injury that is likely to be the most amenable to EDT is pericardial tamponade—an injury easily diagnosed with a bedside ultrasound examination.44–46 The ACSCOT not only recommends EDT for other penetrating injuries but also states that these patients have a very low survival rate. The ACSCOT recommends EDT for blunt trauma patients only when the arrest was witnessed by the ED staff.43

The recommendations from the ACSCOT differ from the Western Trauma Association (WTA), which recommend EDT for patients with no signs of life and less than 10 minutes of CPR for blunt traumatic arrest and less than 15 minutes of CPR for arrest secondary to penetrating trauma.47 As referenced in the WTA practice guideline, Cothren et al.48 summarized the available literature on survival following EDT in adults. Consistent with the ACSCOT recommendations, survival rates for patients arriving to the ED with no signs of life were highest for isolated cardiac injuries with 4 (3%) of 126 patients from the reported studies surviving. Rhee et al.49 also present a review of the literature showing a survival rate of 1.2% for all patients who arrive with no signs of life in the field. As discussed later, two other references in the WTA practice guideline further present data on the effect of resuscitation time on overall survival rates.41,50

Specifically examining the effect of CPR time on the rate of successful resuscitation, the 2003 NAEMSP/ACSCOT guideline on TOR in traumatic cardiopulmonary arrest endorsed 15 minutes of CPR before TOR. The authors of the 2003 guideline felt that at the time, the collective data supported the assertion that any patient with traumatic cardiopulmonary arrest and more than 15 minutes of transport time would not survive.1 In a further analysis of the studies that were reviewed for development of the 2003 guideline and in review of studies published since the 2003 guideline, it is unclear as to the appropriate duration that EMS providers should resuscitate a patient, with minimally interrupted CPR, before TOR.

Looking at studies that were published before the 2003 guideline, in 1982, Mattox and Feliciano51 published the results of 100 patients with traumatic cardiopulmonary arrest and greater than 3 minutes of CPR. All patients in this study died before discharge from the hospital. In 1984, Copass et al.52 reviewed 3 years of data of 131 blunt (n = 107) and penetrating (n = 24) traumatic cardiopulmonary arrest patients in Seattle, Washington. Survivors (n = 29) had an average of 12 minutes of CPR versus 28 minutes of CPR in nonsurvivors (p < 0.01). Based on these results, the authors of both of these studies recommended a “scoop and run” system. Furthermore, these studies show that longer resuscitation are associated with poor chances of survival.

In 1991, Esposito et al.29 reviewed 112 patients who had EDT for traumatic cardiopulmonary arrest. There were two survivors overall, with one survivor who arrested in the ED having good neurologic outcome. The other survivor had 15 minutes of CPR that was initiated during transport and had poor neurologic outcome. Overall, the average CPR time for survivors was 7.5 minutes, and the CPR time for nonsurvivors averaged at 33 minutes. In 1992, Durham et al.53 also looked at outcomes of EDT. Of 389 patients, 207 arrived to the ED with CPR in progress. In this study, there were no survivors with blunt trauma. Average CPR time for survivors of penetrating trauma from stab wounds was 5.1 minutes compared with 9.1 minutes for nonsurvivors and 5.2 minutes for survivors of gunshot wounds compared with 9.4 minutes for nonsurvivors of gunshot wounds.

There are two other studies worth noting that were available for analysis of the effect of duration of CPR on resuscitation outcomes at the time of the 2003 guideline. In 1995, Fulton et al.30 described the results of 245 patients with traumatic cardiopulmonary arrest that were resuscitated at the University of Louisville Hospital. In this study, there were six total survivors, with only three of the survivors having a good neurologic outcome. The duration of CPR for each of the six survivors was less than 10 minutes. The difference in the duration of CPR between the survivors with good neurologic outcome compared with the survivors without good neurologic outcome was not described. In 1996, Pasquale et al.22 studied the utility of a predefined criteria to determine that a patient presenting to an ED in traumatic cardiopulmonary arrest could be considered dead on arrival and, therefore, not require ED resuscitation. Of note, this criterion arbitrarily included 15 minutes of CPR without (ROSC). In this study of 106 patients, there were 3 survivors with a mean duration of CPR of 2.33 minutes compared with a mean duration of CPR of the nonsurvivors of 23.64 minutes.

Since the publication of the 2003 guideline, there have been six articles published, which have specifically examined the relationship between time of CPR and the ability to achieve meaningful outcomes. Powell et al.,41 as referenced by the WTA guideline on EDT, examined 959 patients with EDT with 26 of 62 survivors requiring prehospital CPR. In this study, all of the survivors had 10 minutes or less of CPR with the exception of 5 survivors who had a range between 11 minutes and 15 minutes of CPR. Four of these five had only mild or no neurologic deficits (0.42% of the entire study population). Pickens et al.34 examined 173 patients with prehospital CPR for traumatic arrest with 3 of 14 survivors with greater than 10 minutes of CPR ranging between 11 minutes and 17 minutes and good neurologic outcome (1.7% of the study population). All survivors with a discharge Glasgow Coma Scale (GCS) score greater than 10 had pulses restored before ED arrival. Furthermore, the authors also found that survivors had significantly shorter length of CPR compared with nonsurvivors (p = 0.014).

Moriwaki et al.36 report on 477 patients with traumatic cardiopulmonary arrest from blunt trauma. In this study, a cluster of 12 survivors achieved ROSC in less than 10 minutes, and there was only 1 survivor achieving ROSC after 17 minutes of CPR. No information is provided for the one outlier in this study, and the initial rhythm, vital signs, and mechanism of injury were not described.54 Furthermore, it is not clear if the single isolated survivor had a good neurologic outcome.

Moore et al.,50 also referenced by the WTA guideline on EDT, report on 56 survivors of EDT, with 19 patients receiving prehospital CPR. All patients had CPR for 10 minutes or less, except one with a gunshot wound to the chest with 15 minutes of CPR and a moderate neurologic deficit. Mollberg et al.38 also report outcomes from EDT. In their study of 120 patients who had EDT for penetrating thoracic trauma, patients were analyzed in two groups: Group 1, those who had witnessed arrest with signs of life in the field and less than 15 minutes of CPR; Group 2, those who had witnessed arrest without signs of life in the field or witnessed arrest with signs of life in the field and greater than 15 minutes of CPR. Of the 120 total patients in the study, 78 required prehospital CPR (Group 1, 34; Group 2, 44). Mean CPR time for Group 1 was 13.3 minutes, and mean CPR time for Group 2 was 20.7 minutes. There were six survivors in the first group and no survivors in the second group. The duration of CPR for the six survivors, beyond less than 15 minutes, is not reported.

Finally, Tarmey et al.37 report outcomes of traumatic cardiopulmonary arrest in a military population presenting to a field hospital in Afghanistan. Of the 52 patients in the study, there were four survivors each with a good neurologic outcome. All patients that arrested in the field died, and the survivors arrested either during transport or at the hospital. The median CPR time for survivors was 8 minutes. One survivor had a prolonged CPR of 24 minutes with 21 minutes of CPR during transport. The survivor with a prolonged down time had aggressive resuscitation during transport including administration of blood products and hemorrhage control.

Collectively, the studies that allow for analysis of the effect of duration of CPR on survival show that survivors of traumatic cardiopulmonary arrest have significantly shorter CPR time compared with that of nonsurvivors. The 2003 guideline promoted 15 minutes of CPR before TOR based on the dead-on-arrival criteria in the article by Pasquale et al., despite the fact that in that study, survivors had a significantly an average CPR time shorter than 15 minutes.

Analysis of the studies available at the time of the development of the 2003 guideline and the studies that have been published since the 2003 guideline demonstrates the potential for a lower threshold than 15 minutes because 10 minutes of resuscitation seems to capture the overwhelming majority of patients who are likely to survive the arrest. However, owing to the heterogeneity of the studies, it is difficult to analyze these results in a collective manner, and as such, it is unclear as to the appropriate duration that EMS providers should perform CPR before TOR. In addition, most of these studies are retrospective, and all are limited by the prehospital CPR time documented by the providers. The accuracy of these times may be limited because they are often estimated after the resuscitation has ended. Regardless, for those studies that allow for analysis of a percentage of patients that have successful resuscitation, only 9 (0.75%) of 1,200 patients, including those that had EDT, survived to hospital discharge neurologically intact after more than 10 minutes of CPR. With a specific look at EDT studies, there were 4 (2.8%) of 142 survivors with a favorable neurologic outcome and more than 10 minutes of CPR. Analysis of time as a determinate for TOR is shown is Table 6.

TABLE 6

TABLE 6

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EMS Procedures

Regarding the performance of procedures by EMS providers before arrival to the hospital, it should be noted that this has shown mixed results. Copass et al.52 showed that survival from traumatic arrest was associated with endotracheal intubation and placement of intravenous lines by EMS providers. However, subsequent studies have questioned the role of airway management by EMS providers in the critically ill trauma patient.55–57 Specifically examining trauma patients that had EDT, Seamon et al.39 showed that patients were 2.63 times less likely to survive for every additional procedure performed by EMS providers (OR, 0.38; 95% CI, 0.18–0.79, p = 0.0096).

The findings in the study of Seamon et al. are contrasted by a study by Warner et al.,58 which suggests that there may be a role for needle thoracostomy in selected patients with 3 (25%) of 12 patients in PEA from traumatic cardiopulmonary arrest achieving ROSC with prehospital needle thoracostomy. Hospital discharge information for the three patients was not reported in this study. Therefore, while it may seem logical for EMS providers to perform certain procedures on a patient in traumatic arrest (e.g., airway management or needle thoracostomy), the literature is not clear whether the performance of these procedures by EMS providers will add benefit to the care of the patient. This does not, however, preclude the development of protocols that ensure proper overall management of the trauma patient by addressing easily reversible causes of the arrest with adequate oxygenation/ventilation and hemorrhage control with direct pressure or tourniquets.

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Exclusions to TOR Protocols

In developing TOR protocols, EMS medical directors may consider exclusions under certain situations. Since the literature supporting inclusion or exclusion of these situations in TOR protocols is lacking, medical directors should consider system-specific factors with regard to these situations: pediatric patients, pregnant and hypothermic patients, patients struck by lightning, and environmental conditions deemed unsafe for EMS providers. Patients with a minor traumatic mechanism and a presumed medical cause for cardiopulmonary arrest should also be not included in these guidelines and rather managed based on nontraumatic cardiopulmonary arrest guidelines.4

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Direct Medical Oversight

The previous NAEMSP/ACSCOT TOR position on traumatic arrest included the statement that “...online medical control may be necessary to determine the appropriateness of termination of resuscitation.”1 To date, there is no scientific literature to support or refute the need for direct medical oversight in the application of TOR protocols. Since standardized written protocols are more likely to be consistently applied in a systematic manner and the requirement for medical consult has the potential to increase scene time and pull providers away from patient care, there may be benefit to not requiring direct medical oversight in the application of TOR protocols. Further research is needed to fully understand the proper role of direct medical oversight in the application of TOR protocols.

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From Position Statement to Protocol Development

There is no doubt that anecdotal case reports will continue to be published demonstrating the rare case of a patient surviving traumatic cardiopulmonary arrest after prolonged asystole. However, in the development of protocols for withholding and TOR, it is important to consider the balance between providing the greatest amount of care possible to an individual patient and doing the greatest good for the population. The criteria for withholding and termination as outlined in this article and in Tables 2 and 3 takes into account the importance of caring for the individual and the recognition that pursuing futile care in the out-of-hospital environment has the potential to cause significant harm to the EMS system and to the greater populace.

Despite the scientific evidence, there are operational challenges that may make it difficult to use these positions for the development of functional EMS system protocols. Perhaps, the greatest challenge is the recommendation for TOR after a period of unsuccessful resuscitative efforts. System medical directors need to consider the potential advantage to quickly loading a patient into a transport unit and moving toward a trauma center and how this will impact a TOR protocol. The use of a time determinant in a TOR protocol is complicated by a need for a process to terminate while in transit and consideration of what should be done with a patient once the resuscitation has been terminated. A decision should be made if the EMS providers should continue with transport to the trauma center without lights and sirens, stop at the side of the road and wait for the medical examiner, or continue with transport directly to the medical examiner or identified morgue59 or if there is another method to handle this situation. Geographic location of the arrest and other factors in the state regulatory environment may affect these decisions. Of note, the State of Maryland recently implemented a new protocol to direct EMS providers to pronounce the patient dead in the field and then transfer the care of the patient to local law enforcement and the coroner.60

As there are operational challenges that are to be expected in the development of protocols for withholding and TOR, it is important to note that the purpose of this article is to present the best available evidence. It is up to the system medical director to determine the best method to create these protocols accounting for the system specific factors and balancing the best available evidence.

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CONCLUSION

In the setting of cardiopulmonary arrest secondary to trauma from both blunt and penetrating mechanisms, an evidence-guided protocol for withholding resuscitation includes clear evidence that the patient is dead, and a protocol for TOR should include the following elements: no evidence of signs of life including no pulse, no respirations, no blood pressure; and no ROSC after initiation of resuscitation by the EMS providers, which should include minimally interrupted chest compressions.

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AUTHORSHIP

M.G.M. contributed in the primary study design, overall leadership for development of the manuscript, literature review, data analysis, writing, editing, review, and refinement with NAEMSP. S.M.G. contributed in the literature review, statistical analysis, data analysis, writing, and editing. S.R.K. contributed in the literature review, writing, and editing. A.M. contributed in the literature review, writing, and editing. E.M.B. contributed in the writing, editing, review, and refinement with ACSCOT.

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DISCLOSURE

The authors declare no conflicts of interest.

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Keywords:

Termination; withholding treatment; trauma; cardiopulmonary arrest; EMS

© 2013 Lippincott Williams & Wilkins, Inc.