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Background Pulseless electrical activity (PEA) is managed in accordance with international and national guidelines. These guidelines are not fully evidenced, resulting in emergency medical services in the United Kingdom amending guidelines to support paramedics when making resuscitation decisions. This review examined the local guidelines of services to identify the local clinical management of PEA, summarise the available evidence and prioritise future research. Methods The review was conducted according to the Joanna Briggs Institute systematic review of text and opinion. The review included locally amended guidelines and cited evidence sources for the management of PEA. A three-step search strategy was applied. Textual data was extracted to form conclusions which were categorised into similar meaning and developed into synthesised findings. Results Twenty-two documents met the inclusion criteria; Twenty-seven conclusions were extracted and analysed to generate 10 categories, forming three synthesised themes: the variability in the clinical management of PEA between ambulance services; the early identification of reversible causes and appropriate treatment options to increase survivability; and the consensus for further research. Conclusion This review identified variability in the clinical management of PEA; the autonomy of paramedics, which patients to transport to hospital and the factors applied to inform resuscitation decisions. A summary of the evidence in support of the local guidelines found that the early identification and treatment to reverse the cause of PEA was important to patient survival, however, this was acknowledged as complex and challenging to achieve. There was a consensus to improve patient outcomes using prognostic research.

Introduction Research shows that ambulance personnel can find it challenging to withhold or terminate resuscitation and manage patient death in the field. This scoping review provides a synthesis of published research that has addressed three main questions. Each relates to ambulance personnel enacting decisions to withhold or terminate resuscitation and manage patient death: How are they prepare; what supports and coping strategies are utilised; and what preparation and support needs have been identified? Methods Using Arksey and O'Malley's five-stage scoping review framework this review identifies what is known and what further research is needed in this area. Results Sixteen methodologically heterogenous papers were located. Half of the studies were conducted in the United States, with the remainder in Canada, Singapore, Spain, Sweden and the United Kingdom. Ambulance personnel receive little formal training and feel unprepared to manage situations where resuscitation is unsuccessful or unwarranted, particularly communicating with family, breaking bad news and managing death scenes. These aspects of termination of resuscitation are so challenging that distancing and avoidance are sometimes used as coping strategies, even when medical futility has been established. In addition to formal counselling for personal loss and stressors, ambulance personnel value downtime and informal peer debriefing, following difficult resuscitation decisions and patient deaths. Conclusion Ambulance personnel feel inadequately prepared to withhold or terminate resuscitation and manage patient death in the field. They want more opportunities to learn about death notification, communication with bereaved families and safe, sensitive management of death scenes. More research is needed to determine how best to prepare and support ambulance personnel for the challenges of resuscitation decision-making and patient death.

This study examined whether biases concerning age and/or disability status influenced resuscitation decisions. Medical students were randomly chosen to read 1 of 4 vignettes, organized in a 2 (age: infant vs school-age) × 2 (disability: preexisting vs no preexisting) between-subjects design. The vignettes described a pediatric patient experiencing an acute episode who required resuscitation. Following resuscitation, patients with existing disability would continue to have disability, whereas those without would develop disability. Participants indicated whether they would resuscitate, given a 10% chance of success. There was a significant main effect of disability: Medical students displayed a preference for resuscitating previously disabled children compared with previously healthy children when prognosis was held constant, F(1, 121) = 4.89, p = .03. This differential treatment of the two groups cannot easily be morally justified and poses a quandary for educators.

Purpose To determine outcomes and resuscitation decisions for extremely premature infants (EPI) of gestational ages between 23 and 24 weeks. Methods A retrospective chart review of EPI born at the University Hospital, in Albuquerque, NM was performed for the years 1995-2002. Inclusion criteria were 1) gestational age (GA) of 23-24 weeks with at least fair dating, 2) heartbeat at onset of labor, and 3) labor was not for the purpose of termination. Maternal demographic data, infant characteristics, and counseling information were double entered into EPI INFO VI, which was also used to perform statistical analysis. Results Of 116 deliveries identified by a database, 67 mothers and their 79 infants met our inclusion criteria. 56 were singleton gestations, 18 were twins and 5 were triplets. In general 28 infants (35.4%) survived to discharge, and 51 infants (64.6%) died before discharge. Maternal characteristics with respect to infant survival and degree of resuscitation were not significantly different in insurance type, ethnicity, alcohol, tobacco, or drug use, mode of delivery, or antenatal medications. Infant characteristics with respect to survival and degree of resuscitation were not significantly different in number of gestations or gender. Gestational age (GA), weight, and APGAR were significantly related to survival [GA: 23 wks 21% survived to discharge, 24 wks 46% survived, p=0.03; weight: 10% ≤600g survived, 57% ≥700g, p≤0.001; APGAR: 15.5% with 5 min score ≤5 survived to discharge, 61.7% with 5 min score ≥5 survived, p≤0.0001]. Increasing weight and APGAR were significantly related to decision to resuscitate [weight: 48% ≤600g were not resuscitated, 8.3% ≥700g were not resuscitated, p≤0.001; APGAR: 40% with 5 min score ≤5 were not resuscitated, 3% with 5 min score ≥5 were not resuscitated, p≤0.0001]. Conclusion The overall survival rate for EPI between 23 and 24 weeks gestation in this series was 35.4%. These data may assist clinicians and patients in making antenatal decisions about resuscitation of extremely premature infants.