Should we resuscitate or not—that is the question!

Sudden cardiac arrest is a major public health problem; every year about 350,000 people die in Europe after such an event (1). The 2015 American Heart Association (AHA) as well as the European Resuscitation Council (ERC) guidelines for cardiopulmonary resuscitation (CPR) describe basic life support (BLS) and advanced life support (ALS) rules for termination of resuscitation (TOR) (2). Several studies have evaluated the generalizability of the TOR rules in BLS and ALS emergency medical services (EMS) systems (Table 1) (3-12). The BLS TOR rule suggests that resuscitative efforts may be aborted in patients whose arrest was not witnessed by EMS, in whom return of spontaneous circulation (ROSC) is not achieved in the field and when no shocks are delivered (Table 1). The ALS TOR rule can be applied when the arrest was not witnessed, when bystander CPR was not provided, when no ROSC is achieved despite ALS care in the field, and when no shocks are delivered. Recent studies demonstrated that ALS EMS providers can also use the BLS TOR rule (Table 1). This has been included as the “universal termination of resuscitation (TOR) rule” in the ERC guidelines (2). However, an ongoing debate exists whether TOR rules can be applied to victims of out-of-hospital cardiac arrests (OHCA) of both cardiac and non-cardiac etiologies.