Intended for healthcare professionals

Head To Head

Should we take patients to hospital in cardiac arrest?

BMJ 2014; 349 doi: (Published 23 September 2014) Cite this as: BMJ 2014;349:g5659
  1. Bruce D Adams, chair and professor of emergency medicine1,
  2. Jonathan Benger, professor of emergency care and consultant23
  1. 1University of Texas Health Sciences Center San Antonio, 7703 Floyd Curl Drive, Mail Code 7736, San Antonio, Texas, USA 78229
  2. 2University of the West of England, Bristol
  3. 3University Hospitals Bristol NHS Foundation Trust
  1. Correspondence to: B D Adams adamsb{at}, J Benger Jonathan.Benger{at}

Bruce D Adams says that rules for deciding when to stop resuscitation are fallible, but Jonathan Benger argues that ambulance crews are best placed to deliver immediate cardiopulmonary resuscitation, which is usually the only treatment available

Yes—Bruce D Adams

Out of hospital cardiac arrest is a leading cause of premature death, and overall long term survival is about 10% .1 Two schools of thought towards cardiopulmonary resuscitation (CPR) have emerged in the past decade: the “glass 90% empty” sceptics, who see one arresting patient after another “come in dead and stay dead,” versus the “glass 10% full” optimists, who look to return more survivors to productive life.2

Clinical decision rules derived over the past decade clarify when further resuscitation and transport to the hospital is futile and offer the potential to reduce ambulance transport and its inherent costs and risks. The best studied is the Basic Life Support Termination of Resuscitation (BLS-TOR) rule, which directs paramedics to stop CPR and not to transport the patient if they have not witnessed the cardiac arrest, no shock has been given (no shockable rhythm), and spontaneous circulation has not returned.3

If we treat BLS-TOR as a test, a “positive” result generally predicts death, but unlike other clinical tests its specificity must be 100% because a false positive result by definition represents the wrongful death of a neurologically intact survivor of cardiac arrest.4 Validation trials of BLS-TOR have almost always found a handful of survivors who would have been declared dead by the rule. For instance, the original BLS-TOR study of 1240 cardiac arrests advised no transport for 776 (63%) patients, four of whom survived to hospital discharge.3 The accuracy of paramedics applying the criteria can be problematic. In a subsequent validation study, paramedics chose to stop resuscitation in 3% of …

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