Compression-Only CPR

Resuscitation highlights in 2011

The recommendations for electrical therapies described in this section are designed to improve survival from SCA and life-threatening arrhythmias. Whenever defibrillation is attempted, rescuers must coordinate high-quality CPR with defibrillation to minimize interruptions in chest compressions and to ensure immediate resumption of chest compressions after shock delivery. The high first-shock efficacy of newer biphasic defibrillators led to the recommendation of single shocks plus immediate CPR instead of 3-shock sequences that were recommended prior to 2005 to treat VF. Further data are needed to refine recommendations for energy levels for defibrillation and cardioversion using biphasic waveforms.

Extracorporeal Cardiopulmonary Resuscitation: Prehospital or In-Hospital Cannulation?

Background
\nAccording to data from Department of Health, in 2011 heart diseases was the second commonest leading cause of death in Hong Kong [13]. Shortening the time from cardiac arrest to Cardio-pulmonary Resuscitation (CPR) could increase the chance of survival. If the brain of the patient who suffers from cardiac arrest does not receive oxygen within 4 minutes, severe brain damage might occur [14]. In some countries like US and Finland, dispatcher will give CPR instruction to caller when cardiac arrest is recognized. Therefore, the patient could receive early CPR before the arrival of paramedics. If dispatcher-assisted CPR is implemented in Hong Kong, the chance of survival of out-of-hospital cardiac arrest (OHCA) patient could be increased.
\n
\nObjective
\n1. To evaluate whether it is evident that dispatcher-assisted CPR and dispatcher instruction [22] would improve survival of OHCA.
\n2. To evaluate whether these measures could be implemented in Hong Kong.
\n
\nData Source
\nPubMed was searched for articles in English language with no limit set for time of the study. The keywords were dispatcher-assisted CPR and out of hospital. No inclusion criteria were set on the publication type and other details.
\n
\nResults
\nInitial PubMed search resulted in 24 articles. After reviewing the abstracts, 10 articles were selected for full-text assessment. Finally, four relevant articles were selected for the literature review. Of the four papers, two were retrospective cohort studies; one was before-after comparison study while the remaining one was randomized control trial. 
\n
\nThree papers (Rea et al, Eisenberg et al, and Kuisma et al.) used the survival to hospital discharge as the effect measure for the primary outcome to evaluate the effectiveness of dispatcher-assisted CPR. The remaining paper (Hallstrom et al.) mainly studied the potential benefit and harm from dispatcher-assisted CPR.
\nUsing no bystander CPR as the reference group, the multivariate adjusted odds ratio of survival was 1.45 (95% CI, 1.21, 1.73) for dispatcher-assisted bystander CPR and 1.69 (95% CI, 1.42, 2.01) for bystander CPR without dispatcher assistance [2]. The percentage of total bystander-initiated CPR increased from 45% to 56% after the programme (difference: 11.1%, 95% CI, ±9.3%). Besides, the percentage discharged for dispatcher-assisted CPR group after the programme was 15% higher than that before the programme [6]. The most important findings are related to the number of cardiac arrest calls in that when the dispatcher handled on less than 4 Ventricular Fibrillation (VF) calls during the study period, the survival to hospital discharge was 22.1% compared to 38.2% and 39.4% when the dispatcher handled 4 to 9 calls or more than 9 calls (p = 0.0227 for the three groups) [8]. With telephone guided CPR, the survival to hospital discharge was 43.1% compared with 31.7% when CPR instructions were not provided (p = 0.0453) [8]. In patients (n = 3,320) receiving advanced cardiac life support (ACLS) a total of 993 (29.9%) was found to be benefited from dispatcher-assisted CPR [7].
\n
\nConclusion
\nInstructions by dispatcher can improve bystander CPR rates, which in turn increases the chance of survival [26]. Dispatcher-assisted CPR is worth considering to be recommended to all callers reporting a patient in cardiac arrest in Hong Kong.

The first description of modern cardiopulmonary resuscitation (CPR) included the instruction to compress the chest “about 60 times per minute”1; however, the optimal compression rate was unknown. Franz Koenig is credited with describing the original technique for external cardiac massage, which included a compression rate of 30 to 40 per minute.2 But in the first published description of external cardiac massage in 1892, Friedrich Maass documented a better clinical response with a rate of 120 per minute.2 To this day, the optimal compression rate is the subject of controversy. Animal data indicate that cardiac output increases with compression rates up to as high as 150 per minute.3 In a canine model of prolonged cardiac arrest, compression rates of 120 per minute compared with 60 per minute increased mean aortic (systolic and diastolic) and coronary perfusion pressures, and 24-hour survival (61% versus 15%, P =0.03).4 In a study of 9 patients undergoing CPR, a compression rate of 120 per minute generated higher aortic peak pressures and coronary perfusion pressures compared with a compression rate of 60 per minute (the rate recommended by the 1980 American Heart Association [AHA] guidelines). This evidence is supported by another study of 23 patients in cardiac arrest in which compressions at 120 per minute resulted in significantly higher end-tidal carbon dioxide values compared with compressions at 80 per minute.5 Article see p 3004 The first large, prospective, observational study of the influence of chest compression rate on patient survival was published in this journal in 2005.6 The number of delivered chest compressions was recorded by trained observers during in-hospital resuscitation attempts. A higher chest compression rate was associated with a higher rate of return of spontaneous circulation (ROSC). The mean chest compression rate for initial survivors was 90 …

This meta-analysis aims to compare chest compression-only cardiopulmonary resuscitation (CO-CPR) with standard CPR (sCPR), which includes mouth-to-mouth ventilation, as potential strategies for managing out-of-hospital cardiac arrest (OHCA). We systematically searched various databases and registries such as MEDLINE, Embase, The Cochrane Library, and Clinicaltrials.gov to retrieve relevant studies. We used the revised Cochrane "Risk of Bias" tool for randomized trials (RoB 2.0) to assess the risk of bias in included studies. Revman 5.4 was used to pool dichotomous outcomes under a random effects model. A total of 4 randomized controlled trials were included in our meta-analysis. Our results indicate that CO-CPR was associated with a significantly increased survival to hospital discharge compared to sCPR [relative risk (RR) 1.22, 95% confidence interval (CI): 1.01 to 1.46] with minimal heterogeneity (I2=0%). No significant difference was observed between the two groups regarding 1-day survival (RR 1.07, 95% CI: 0.94 to 1.23), survival to hospital admission with a good neurological outcome (cerebral performance category 1 or 2) (RR 1.10, 95% CI: 0.80 to 1.51), return of spontaneous circulation (RR 1.05, 95% CI: 0.95 to 1.17), and survival to hospital admission (RR 1.08, 95% CI: 0.93 to 1.25). This meta-analysis found that chest CO-CPR significantly improves survival to hospital discharge compared to sCPR for managing OHCA, while yielding comparable results for other resuscitation outcomes.

Bystander CPR – Are we asking the right questions?

Articles, see p 2046 and p 2060 The International Liaison Committee on Resuscitation (ILCOR) is made up of the world’s major resuscitation councils. Part of its function is to periodically perform systematic reviews of resuscitation topics that are the foundation for council-specific resuscitation guidelines for basic and advanced life support for both adults and children. ILCOR’s Pediatric Task Force regularly reviews pediatric resuscitation science to generate evidence-informed treatment recommendations to guide the care of pediatric victims of out-of-hospital cardiac arrest (OHCA).1 ILCOR’s ability to do so has historically been limited by the number and size of the pediatric studies available for its systematic reviews. For more than a decade, the All-Japan Utstein Registry of its Fire and Disaster Management Agency has prospectively collected adult and pediatric OHCA data from across Japan. The registry has an impressive history of accurate and complete data capture, with no missing, incomplete, or inconsistent data for patients included in many of its studies.2 This registry has allowed observational study of many important clinical questions. Two such questions are addressed in the 2 articles from this registry published in this issue of Circulation : What is the outcome of children with OHCA resuscitated by lay rescuers using chest compression–only cardiopulmonary resuscitation (CC-CPR) compared with conventional CPR (with ventilation)2? And what are the associations between the duration of CPR for pediatric OHCA and patient outcomes.3 Bystander CPR rates in many parts of the world remain low, and the inability or unwillingness to provide ventilation as part of conventional CPR has been one of the often-cited explanations. This, coupled with the greater complexity associated with teaching lay rescuers ventilation and the interruptions to chest compressions to give breaths, has led guidelines and training organizations to encourage CC-CPR by lay rescuers for adult (primarily …

Basic life support (BLS), advanced cardiovascular life support (ACLS), and post–cardiac arrest care are labels of convenience that each describe a set of skills and knowledge that are applied sequentially during the treatment of patients who have a cardiac arrest. There is overlap as each stage of care progresses to the next, but generally ACLS comprises the level of care between BLS and post–cardiac arrest care. ACLS training is recommended for advanced providers of both prehospital and in-hospital medical care. In the past, much of the data regarding resuscitation was gathered from out-of-hospital arrests, but in recent years, data have also been collected from in-hospital arrests, allowing for a comparison of cardiac arrest and resuscitation in these 2 settings. While there are many similarities, there are also some differences between in- and out-of-hospital cardiac arrest etiology, which may lead to changes in recommended resuscitation treatment or in sequencing of care. The consideration of steroid administration for in-hospital cardiac arrest (IHCA) versus out-of-hospital cardiac arrest (OHCA) is one such example discussed in this Part. The recommendations in this 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) after the publication of the ILCOR 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 1 and was completed in February 2015.2 In this in-depth evidence review process, the ILCOR task forces examined topics and then generated prioritized lists of questions for systematic review. Questions were first formulated in PICO (population, intervention, comparator, outcome) format,3 and then a search strategy and inclusion and exclusion criteria were defined and a search for relevant articles was performed. The evidence was evaluated by using …

Bystander cardiopulmonary resuscitation (CPR) improves out-of-hospital cardiac arrest (OHCA) survival. In settings with prolonged ambulance response times, skilled bystanders may be even more crucial. In 2010, American Heart Association (AHA) and European Resuscitation Council (ERC) introduced compression-only CPR as an alternative to conventional bystander CPR under some circumstances. The purpose of this citation review and document analysis is to determine whether the evidentiary basis for 2010 AHA and ERC guidelines attends to settings with prolonged ambulance response times or no formal ambulance dispatch services. Primary and secondary citations referring to epidemiological research comparing adult OHCA survival based on the type of bystander CPR were included in the analysis. Details extracted from the citations included a study description and primary outcome measure, the geographic location in which the study occurred, EMS response times, the role of dispatchers, and main findings and summary statistics regarding rates of survival among patients receiving no CPR, conventional CPR or compression-only CPR. The inclusion criteria were met by 10 studies. 9 studies took place exclusively in urban settings. Ambulance dispatchers played an integral role in 7 studies. The cited studies suggest either no survival benefit or harm arising from compression-only CPR in settings with extended ambulance response times. The evidentiary basis for 2010 AHA and ERC bystander CPR guidelines does not attend to settings without rapid ambulance response times or dispatch services. Standardized bystander CPR guidelines may require adaptation or reconsideration in these settings.

Introduction: A citizen responder (CR) system to activate volunteer citizens by a smartphone application (HeartRunner) to nearby cardiac arrests was implemented in 2017 in the Capital Region of Denmark. Participating in resuscitation may not only involve provision of cardio-pulmonary resuscitation (CPR) but also include provision of emotional support for relatives to the cardiac arrest patient. We examined the proportion of CR who reported provision of support to relatives to out-of-hospital cardiac arrest (OHCA) patients during resuscitation attempt. Hypothesis: We hypothesized that CR not only deliver CPR but also provide emotional support to relatives of OHCA patients. Methods: All CR activated by the HeartRunner app received a follow-up questionnaire 90 minutes after the alarm including questions about how CRs participated in resuscitation and whether they provided emotional support to relatives present during the resuscitation attempt. All surveys from March 12, 2020 to June 1, 2021, from CR who accepted an alarm and arrived at the cardiac arrest location were included. Results: A total of 1,868 CR responded to the survey (median age 37 years (IQR 28-37). Half (54.4%) were male and 23.9% health care professionals. CRs arrived before the emergency medical services (EMS) in almost 1/3 (28.9%) of OHCA cases with CR activation, with 227 CRs (41.9%) performing CPR and 139 (25.7%) attaching an automated external defibrillator. In total, more than 433 CRs (23.2%) reported provision of support for relatives at the OHCA location. Even though a higher proportion of support was observed among CR who arrived before the EMS, almost 12% reported provision of support to relatives even when arriving after EMS (Figure). Conclusions: Citizen responders provide not only resuscitative efforts but offer emotional support to relatives to OHCA patients. Citizen responders may be an important resource for both EMS personnel and relatives who are present at the cardiac arrest scene.

A randomized clinical trial of active compression-decompression CPR vs. standard CPR in out-of-hospital cardiac arrest in two cities: J Am Med Assoc 1995; 273/16 (1261–1268)

Early bystander cardiopulmonary resuscitation (CPR) and defibrillation are both vital components in the chain of survival following out-of-hospital cardiac arrest (OHCA) (1,2). Fortunately, bystander CPR rates in industrialized countries have recently increased from 30% to 50% (3-8). A Swedish analysis reported that CPR performed prior to emergency medical services (EMS) arrival was associated with a 30-day survival rate following OHCA more than twice as high as that associated with no CPR before EMS arrival (5). Further, bystander interventions (bystander CPR and defibrillation) were also associated with an increased likelihood of 1-month neurologically intact survival following OHCA according to an analysis of a Japanese nationwide registry (7). As neurological assessments fluctuate for at least 90 days following cardiac arrest, the American Heart Association (AHA) has recommended that longer-term end points (i.e., 90 days) coupled with neurocognitive and quality-of-life assessments should be considered (9). The AHA further suggests that researchers utilize either Cerebral Performance Categories or modified Rankin Scale for global outcomes of neurological assessment in patients following cardiac arrest (9). However, little is known regarding the impact of bystander intervention on long-term (i.e., >90 days following OHCA) neurologically intact survival (3,10).

Objectives: This study aimed to analyze the effects of combinations of rescue breathing and chest compression in CPR performed by a bystander (BCPR) on the outcomes of out-of-hospital cardiac arrest (OHCA) events. Particular attention was paid to unwitnessed case by bystander. Methods: This retrospective study analyzed the prospectively collected data of 212,003 unwitnessed and 117,920 bystander-witnessed OHCA cases between 2014 and 2016 in Japan. BCPR classification was based on two clinical components: whether or not DA was provided, and whether standard CPR (with breaths) or compression-only CPR was performed. Main Outcome Measures: A neurologically favorable outcome at one month. Results: Univariate analysis showed that, in unwitnessed cases, there was no significant association between the provision of BCPR and a neurologically favorable outcome (BCPR vs. no-BCPR: 0.65% (686/106,152) vs. 0.66% (694/105,851)). In bystander-witnessed cases, the rates were 5.6% (3,538/62,814) vs. 3.5% (1,911/55,106). After classifying BCPR according to the two clinical components, the outcomes of unwitnessed cases were improved for standard BCPR with DA and compression-only, for standard BCPR without DA, but not for compression-only BCPR with DA. Multivariate logistic regression analysis focusing on the two clinical components in unwitnessed BCPR cases showed worse neurologically favorable outcomes with DA provision but better outcomes for standard BCPR, without significant interaction. In bystanderwitnessed cases, DA provision was associated with better outcomes, with significant interaction. Conclusions: Compared with no-BCPR, compression-only BCPR with DA does not improve neurologically favorable outcomes. Standard BCPR without DA resulted in the best outcomes in unwitnessed OHCA cases.

Introduction: Between 1980 and 2008, survival rates following an out-of-hospital cardiac arrest (OHCA) have remained unchanged, averaging 7.6%. Despite the use of new and emerging technologies, new medications, and automated external defibrillators, survival remains low. Recently, a new focus in cardiopulmonary resuscitation (CPR) has shown dramatic improvements in survival post OHCA. This new model, called pit-crew CPR, focuses on minimizing interruptions in chest compressions and has each team member playing a specific role in the resuscitation, akin to the pit-crew of a car race. Certain districts in the United States and Canada have adopted the pit-crew, or a similar, high quality, maximum time-on-chest CPR model, with much success. We aim to determine whether the pit-crew model of CPR improves survival following OHCA in Saskatoon, SK. Methods: In Saskatoon, EMS and Fire crews respond to OHCAs and have been exclusively using the pit-crew model of CPR since Jan 1st, 2015. This study is a before and after retrospective chart analysis, comparing two groups - pre and post implementation of the pit-crew CPR model. The primary outcome is survival to hospital discharge post OHCA. Secondary outcomes include survival to admission and any return of spontaneous circulation (as per the Utstein definition). The inclusion criteria are patients >18 years old with a witnessed OHCA of presumed cardiac origin who receive CPR by EMS/Fire within the Saskatoon Ambulance service (MD Ambulance) catchment area. Patients were excluded if the OHCA was unwitnessed, or if there was a presumed non-cardiac cause for the arrest, e.g. trauma. Results: In the pre-pit-crew model cohort, between Jan 1st, 2011 and Sept 31st, 2014, 455 OHCAs were analyzed. In this cohort 10.5% survived to discharge, 31.9% survived to admission and ROSC was achieved in 39% of cases. The percentage of patients with initial rhythms of VF/VT, asystole or PEA were 28.5% (26%), 41.5% (1%) and 23.6% (10%) respectively, with survival to discharge shown in parentheses. The post-pit-crew cohort is still in the data collection phase. Conclusion: Our pre-pit crew cohort data has been collected and analyzed. With ongoing data acquisition for the post-pit crew cohort, we hope to have the full data set complete by the end of 2018. It will be at that time when we are able to determine whether the pit-crew model of CPR improves survival to discharge following OHCA in Saskatoon.