Cardiopulmonary Resuscitation and Termination of Resuscitation for Out-of-Hospital Cardiac Arrest in China
Out-of-hospital cardiac arrest (OHCA) is a life-threatening emergency where every second counts. For many patients in China, pre-hospital emergency medical services (EMS) personnel are the first to provide professional cardiopulmonary resuscitation (CPR)—a critical step that can mean the difference between survival and death. But while organizations like the American Heart Association (AHA) and European Resuscitation Council have clear guidelines for when to stop CPR (known as termination of resuscitation, or TOR), China currently lacks a national consensus on this issue. This gap leaves EMS teams to rely on their own knowledge and international guidelines, raising questions about consistency and efficiency. To address this, researchers from the Beijing Emergency Medical Center and Zhejiang University surveyed thousands of EMS personnel across China to understand their CPR practices and TOR decision-making—and the results highlight both progress and areas for improvement.
In February 2021, the team distributed a questionnaire to EMS staff in 23 provinces, 5 autonomous regions, and 4 municipalities across China. Over four weeks, they collected 4318 valid responses—representing a broad cross-section of pre-hospital emergency workers. The survey asked about demographics (age, gender, education, training), daily exposure to OHCA, CPR practices, and how decisions to terminate resuscitation are made. The study was approved by the Beijing Emergency Medical Center’s Ethics Committee (No. 2021-001), and data were analyzed using statistical software (SPSS 26.0) to ensure rigor.
Most respondents were between 30–40 years old (47%), with a nearly even split between men (47%) and women (53%). The majority had a bachelor’s degree (45%) and worked in municipal or county emergency centers (72%). While 94% had completed adult basic life support training, only 36% had formal emergency medicine training—and over 45% had less than 5 years of experience.
When it comes to OHCA, most EMS personnel see fewer than 5 cases per month (74%), with only 2% handling more than 20. The success rate of pre-hospital CPR aligns with national data: 82% terminate 1 or fewer resuscitations per month due to return of spontaneous circulation (ROSC)—when the heart restarts beating on its own.
But when it comes to stopping CPR, practices vary widely. Over two-thirds (69%) believe emergency doctors should make TOR decisions, while 30% think families should decide. Most (73%) limit CPR to 30 minutes, but 11% go beyond 60 minutes. Only 33% consider a patient’s age when deciding to resuscitate, and just 25% use end-tidal carbon dioxide (ETCO2)—a measure of how effectively CPR is circulating blood and oxygen—to guide TOR. For those who do use ETCO2, 63% stop compressions if levels stay below 10 mmHg for 30 minutes.
Reasons for failing to achieve ROSC include long emergency response times, no bystander CPR, underlying health conditions, multiple failed defibrillations, and poor team cooperation. These factors mirror global challenges but highlight specific gaps in China’s system—like limited bystander CPR training and uneven emergency resource distribution.
The findings reveal a critical issue: while China’s EMS system meets basic pre-hospital needs, there’s no consistent approach to when to stop CPR. For example, international guidelines like the AHA’s advanced life support (ALS) TOR rules—which recommend stopping if an unwitnessed arrest has no bystander CPR, no shock delivered, and no ROSC—or the “NUE rule” (Non-shockable rhythm, Unwitnessed arrest, Eighty years or older)—which helps identify patients unlikely to benefit from continued resuscitation—aren’t widely or consistently applied.
This inconsistency has real-world consequences. Unnecessary CPR wastes precious resources and can transfer medical disputes to hospitals. It also means some patients who might not benefit from prolonged resuscitation don’t get the compassionate end-of-life care they need.
The study also found that factors like education, professional title, and training predict whether EMS staff use ETCO2 or consider age for TOR. For example, those with adult advanced life support (ALS) training were more likely to use ETCO2—a sign that targeted training could improve consistency.
China’s pre-hospital EMS system is capable of providing basic emergency care, but the lack of national TOR guidelines leaves room for improvement. The survey shows that key indicators like ETCO2 and patient age aren’t consistently used to guide life-or-death decisions. For EMS teams to work more efficiently and ethically, clear, evidence-based guidelines are needed—guidelines that align with international best practices while addressing China’s unique healthcare context.
As OHCA remains a major public health challenge, standardizing TOR practices could save lives, reduce resource waste, and give EMS personnel the confidence to make tough decisions with clarity and compassion.
This study was published in the Chinese Medical Journal in 2022 by Xiaojun He, Yang Liu, Sijia Tian, Jun Liang, Shengmei Niu, and Jinjun Zhang. doi: 10.1097/CM9.0000000000001718
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