Compression-only Cardiopulmonary Resuscitation Research Articles

Abstract 64: Ability of Bystanders to Appropriately Provide Rescue Breathing in the Setting of a Chest Compression--Only CPR Campaign for Sudden Cardiac Arrest

BACKGROUND: For sudden collapse from out-of-hospital cardiac arrest (OHCA) in adults, bystander chest compression-only CPR (COCPR) results in equivalent or better survival compared with conventional CPR with rescue breathing. However, patients who arrest from a non-cardiac cause may also receive COCPR even though rescue breathing might benefit them. We sought to determine whether lay rescuers appropriately provided COCPR or conventional CPR depending on the suspected etiology of OHCA. METHODS: Analysis of a statewide, Utstein-style registry of adult OHCA during a large-scale campaign endorsing COCPR for adults who suddenly collapse. The relationship between bystander CPR (both COCPR and conventional CPR), presumed arrest etiology, and survival to hospital discharge were evaluated. Means and 95% confidence intervals (CI) were calculated. FINDINGS: A total of 7,652 adult OHCAs not witnessed by EMS were analyzed from 10/04 to 09/10. After exclusion of non-lay bystanders and arrests in medical facilities, presumed cardiac etiology and non-cardiac etiology OHCA totaled 4,913 and 1,202, respectively. The presumed specific non-cardiac etiologies were non-cardiopulmonary (e.g. overdose, suicide, subarachnoid hemorrhage) (57%), trauma (27%), and respiratory (16%). All-rhythm survival was 7.0% (CI: 6.3 - 7.8) for cardiac etiologies and 3.3% (CI: 2.3 - 4.3) for non-cardiac (p<0.001). Bystander CPR was provided for 33% (CI: 31.4 - 34.1) of victims with presumed cardiac causes versus 28% (CI: 25.6 - 30.7) for non-cardiac causes (p=0.002). Presumed respiratory causes of OHCA had a much lower proportion of COCPR (8.3%, CI: 4.4 - 12.2) than cardiac causes (18.0%, CI: 16.9 - 19.1, p<0.001). Survival for non-cardiac cases was: 4.4% (CI 0.9 - 7.8) for conventional CPR, 3.5% (CI: 0.9 - 6.0) for COCPR, and 3.1% (CI: 2.0 - 4.3) for no CPR (p = 0.66). CONCLUSIONS: In the setting of a large-scale, statewide public health campaign endorsing lay rescuer COCPR for adults who suddenly collapse and are not breathing normally, bystanders were much less likely to perform COCPR on OHCA victims who might benefit from rescue breathing. Furthermore, when COCPR was performed on presumed non-cardiac cause arrest victims, there was no demonstrable negative impact on survival.

Abstract 175: Effects of Dispatcher-Assisted Cardiopulmonary Resuscitation Recommended in the 2005 AHA Guidelines for CPR

BACKGROUND The AHA 2010 guidelines for cardiopulmonary resuscitation (CPR) recommended that dispatchers should assertively provide compression-only CPR instructions to untrained rescuers. However, it is unclear whether dispatcher-instructed CPR recommended in the AHA 2005 guidelines can improve survival. METHODS We compared the effects of dispatcher-instructed CPR recommended in the 2005 CPR guidelines with those recommended in the 2000 CPR guidelines from the data of the All-Japan Utstein Registry, a prospective, nationwide, observational registry. The study endpoints were return of spontaneous circulation (ROSC) on hospital arrival and 30-day favorable neurological outcome after cardiac arrest. RESULTS Of the 58,448 adult patients with bystander-witnessed out-of-hospital cardiac arrest due to presumed cardiac etiology in the year 2005, 2008 and 2009, 23,165 who received instructions in CPR given by dispatchers over the telephone were included; 17,282 received the instructions of CPR recommended in the 2005 guidelines, and 5,883 received in the 2000 guidelines. The performance of dispatcher-instructed CPR (chest compression plus mouth-to-mouth ventilation or chest compression only) of the 2005 guidelines group showed a higher proportion than that of the 2000 guidelines group (42% vs.33%, p<0.0001), especially those with compression-only CPR (33% vs.18%, p<0.0001). The 2005 guidelines group had significantly higher rates of ROSC and favorable neurological outcome than the 2000 guidelines group in the whole cohort (ROSC; 12.2% vs. 8.4%, p<0.001, favorable neurological outcome; 5.3% vs. 2.9%, p<0.001), and in the subgroups of patients who received compression-only CPR (ROSC; 13.0% vs. 8.6%, p<0.001, favorable neurological outcome; 6.0% vs. 2.6%, p<0.001). The adjusted odds ratios after dispatcher-instructed CPR recommended in the 2005 guidelines was 1.56 (95% CI, 1.37-1.72) for ROSC and 2.17 (95% CI, 1.79-2.65) for favorable neurological outcome. CONCLUSION Dispatcher-instructed CPR recommended in the 2005 guidelines improved ROSC and favorable neurological outcome in adult patients with bystander-witnessed out-of-hospital cardiac arrest due to presumed cardiac etiology.

Abstract 92: Dispatcher Instruction in Chest Compression-Only CPR Increases Implementation of Bystander CPR: The Utstein Osaka Project

Background: Although it has been reported that dispatcher-assisted bystander CPR contributes to increasing survival from out-of-hospital cardiac arrest (OHCA), the association between actual implementation of CPR by bystanders and the type of dispatcher instruction has not been sufficiently examined. Objectives: To investigate the association between the implementation of bystander CPR and type of dispatcher instruction (chest compression-only CPR (CC-only) or conventional CPR with chest compressions plus rescue breathing). Methods: We registered all patients aged >=18 years suffering from OHCA of presumed cardiac origin before emergency medical service (EMS) arrival, and for whom resuscitation was attempted resuscitation by EMS personnel in Osaka Prefecture, Japan from January 2005 to December 2009. Data were prospectively collected by EMS personnel using an Utstein-style database. Odds ratios for implementation of CPR of each type of dispatcher instruction were calculated using multiple logistic regression adjusting for confounding variables. Results: During the study period, 17,792 OHCAs of cardiac origin before EMS arrival were registered. In 7953 (44.7%) of them, the dispatcher provided CPR instruction to bystanders, and the proportion increased from 39.7% to 48.1% during the study period (P for trend=0.037). The proportion of CC-only instruction increased from 5.1% to 12.9% (P for trend=0.005). The proportion of CPR with chest compressions by bystanders was significantly higher in the CC-only CPR instruction group than in the conventional CPR instruction group (70.2% [1146/1632] vs. 62.0% [3924/6321]; adjusted odd ratio, 1.54 [95% confidence interval, 1.36-1.73]). Even if the dispatcher instructed conventional CPR with rescue breathing, only 33.0% of bystanders performed rescue breathing with chest compressions. Conclusion: Dispatcher instruction of chest compression-only CPR is effective to increase actual CPR by bystanders.

Abstract 188: Arterial Oxygen Saturation May Be the Limiting Factor for O 2 Delivery During Compression-Only CPR

Background Previous studies show that there is no difference in outcomes between bystander conventional and chest-compression-only (CCO) CPR. However, several points need to be addressed: 1) the equivalent, but low, survival rate indicates that there is much room for improvement. The question is whether effective ventilation can be achieved during CPR regardless of approach. 2) the subgroup of patients whose cardiac arrest was not of cardiac origin did not sustain any benefit from ventilation. This finding would imply that adequate ventilation was not achieved. Because cardiac output (CO) generated by chest-compression is low, O 2 delivery (DO 2 ) is mainly dependent on arterial O 2 content. We hypothesize that DO 2 is the rate limiting factor and improvement in DO 2 is mainly determined by O 2 content of arterial blood, since CO is at best only 1/3 of the normal value. Methods We modeled DO 2 in a range of 0 to critical DO 2 (8.2 ml/kg/min) at variable CO and O 2 contents of arterial blood. We assumed a 70kg patient with a hemoglobin level (Hb) of 15g/dl. Arterial O 2 Content (ml/L) = Hb × Arterial O 2 Saturation × 1.34 ×10. DO 2 (ml/min) = Arterial O 2 Content (ml/L) × CO (L/min). Result The half-critical DO 2 at arterial blood O 2 saturation of 80% can be achieved with CO of 1.8L/min. While to achieve the same level of DO 2 at O 2 saturation 40%, require CO of 3.6 L/min. Critical O 2 delivery and half-critical DO 2 are represented with horizontal yellow and red lines respectively. The vertical mahogany and blue lines represent the CO where half-critical delivery at O 2 saturations of 80% and 40%, respectively. Conclusion Since the CO obtained with chest compression is at best 1/3 of the normal value; to reach half-critical O 2 delivery requires an O 2 saturation of 80%. CCO seems unlikely to produce O 2 saturation greater than 80%. Therefore, effective ventilation during CPR is essential. Further study is needed to demonstrate whether confirmed adequate ventilation improves outcome during CPR.

Abstract 215: Does the Relation of CPR Performer to Victim Affect Survival of Out-of-Hospital Cardiac Arrest?

Backgrounds and Aim Early cardiopulmonary resuscitation (CPR) with a considerable quality is essential for survival of out-of-hospital cardiac arrests (OHCAs). The present study was conducted to test our hypothesis that relation of CPR performer to cardiac arrest victim may affect the survival of out-of-hospital cardiac arrests (OHCAs). Methods Data from 2068 OHCAs with CPR before emergency medical technician arrival, that occurred at other locations than care facilities from April, 2003 to March, 2010 in Ishikawa prefecture, were prospectively collected and analyzed. The performers of CPR were categorized into 4 groups; family and relatives, friends, strangers and healthcare providers. The backgrounds, characteristics and outcomes of OHCAs were compared among the 4 groups and between family and other 3 or 2 groups. Results (see Table) Family and relatives were less frequently the CPR performers in witnessed OHCAs, and were more frequently the CPR performers in OHCAs that occurred at home. They more frequently initiate the CPR following telephone-CPR and perform chest compression-only CPR. When analyzed collectively for all OHCAs, family member or relative as a CPR performer was associated with poor outcomes. When analyzed for subgroups of OHCAs, the effects of relations to victim were significant only for unwitnessed OHCAs and the OHCAs that occurred at other locations than home. Critical time factors related to survival did not significantly differ among or between the groups. Multiple logistic regression analysis for OHCAs that occurred at other locations than home, but not for all OHCAs, disclosed that family member or relative as a CPR performer is an independent factor associated with 1-Y survival. Conclusions The relations to victims dependently affect the outcomes of OHCAs. Although the quality of CPR was not determined in this study, this observation should be considered to plan a better strategy for improving the quality of CPR and outcomes of OHCAs.

Basic and advanced paediatric cardiopulmonary resuscitation – Guidelines of the Australian and New Zealand Resuscitation Councils 2010

Guidelines for basic and advanced paediatric cardiopulmonary resuscitation (CPR) have been revised by Australian and New Zealand Resuscitation Councils. Changes encourage CPR out-of-hospital and aim to improve the quality of CPR in-hospital. Features of basic CPR include: omission of abdominal thrusts for foreign body airway obstruction; commencement with chest compression followed by ventilation in a ratio of 30:2 or compression-only CPR if the rescuer is unwilling/unable to give expired-air breathing when the victim is 'unresponsive and not breathing normally'. Use of automated external defibrillators is encouraged. Features of advanced CPR include: prevention of cardiac arrest by rapid response systems; restriction of pulse palpation to 10 s to diagnosis cardiac arrest; affirmation of 15:2 compression-ventilation ratio for children and for infants other than newly born; initial bag-mask ventilation before tracheal intubation; a single direct current shock of 4 J/kg for ventricular fibrillation (VF) and pulseless ventricular tachycardia followed by immediate resumption of CPR for 2 min without analysis of cardiac rhythm and avoidance of unnecessary interruption of continuous external cardiac compressions. Monitoring of exhaled carbon dioxide is recommended to detect non-tracheal intubation, assess quality of CPR, and to help match ventilation to reduced cardiac output. The intraosseous route is recommended if immediate intravenous access is impossible. Amiodarone is strongly favoured over lignocaine for refractory VF and adrenaline over atropine for severe bradycardia, asystole and pulseless electrical activity. Family presence at resuscitation is encouraged. Therapeutic hypothermia is acceptable after resuscitation to improve neurological outcome. Extracorporeal circulatory support for in-hospital cardiac arrest may be used in equipped centres.

Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest

Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest

Improving bystander cardiopulmonary resuscitation

Summary estimates indicate that bystander cardiopulmonary resuscitation (CPR) can improve the chances of out-of-hospital cardiac arrest survival two-fold to three-fold. And yet, only a minority of arrest victims receive bystander CPR. This summary will review the challenges and approaches to achieve early and effective bystander CPR. Given the host of barriers, a successful strategy to improve bystander CPR must enable more timely and comprehensive arrest identification, encourage and empower bystanders to act, and help assure effective CPR. Arrest identification can be simplified so that bystanders should start CPR when a person is unconscious and not breathing normally. Evidence from observational studies and interventional trials supports the effectiveness of chest compression-only CPR for bystanders. As a consequence, the emphasis of bystander CPR training has been modified to feature and assure chest compressions. Bystanders should initiate CPR with compressions and consider the addition of rescue breathing based on their CPR training and skills as well as special circumstances of the victim. Bystander CPR training has evolved to incorporate this emphasis. Although general community-level CPR training remains a cornerstone strategy, training directed to those most likely to witness an arrest also has a useful role. In particular, 'just-in-time' dispatcher-assisted CPR instruction can increase bystander CPR and improve the likelihood of survival. Recent developments in bystander CPR have simplified arrest recognition and improved CPR training, while retaining CPR effectiveness. The goal of these developments is to increase and improve bystander CPR and in turn improve resuscitation.

Improving Patient Outcomes with Compression-Only CPR: Will Bystander CPR Rates Improve?

Improving Patient Outcomes with Compression-Only CPR: Will Bystander CPR Rates Improve?

Chest-compression-only versus Standard Cardiopulmonary Resuscitation: a Meta-analysis

This meta-analysis evaluated chest-compression-only cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest vs. standard bystander CPR (chest compression plus rescue ventilation). Several previous randomized trials and observational cohort studies have shown benefits of chest-compression-only CPR that were not statistically significant. Medline and Embase were systematically reviewed for studies published between January 1985 and August 2010, in which chest-compression-only CPR was compared to standard bystander CPR for out-of-hospital cardiac arrest.

Abordagem otimizada na ressuscitação cardiocerebral

A ressuscitação cardiocerebral (RCC) é uma nova abordagem à ressuscitação de pacientes com parada cardíaca fora do hospital (PCFH). O primeiro componente principal da RCC são as compressões torácicas contínuas (CTC), também chamadas de RCP com compressões torácicas isoladas ou "RCP somente com compressões torácicas" ("Hands-only" CPR), recomendadas como parte da RCC por todos os observadores que testemunhem um colapso súbito de origem presumidamente cardíaco. O segundo componente é um novo algoritmo de tratamento de Suporte Avançado de Vida em Cardiologia (ACLS) para Serviços Médicos de Emergência (SME). Esse algoritmo enfatiza compressões torácicas ininterruptas a despeito de outros procedimentos contínuos como parte do esforço de resgate. Um terceiro componente foi recentemente adicionado à RCC, e é o cuidado agressivo pós-ressuscitação. A RCC tem aumentado a participação de testemunhas e tem melhorado as taxas de sobrevivência em varias comunidades. Essa é a hora para outras comunidades re-examinarem seus próprios desfechos com parada cardíaca e considerar a possibilidade de se juntar a essas cidades e comunidades que dobraram e até mesmo triplicaram as suas taxas de sobrevivência de PCFH.

Chest Compression-Only CPR Improves Mortality Compared to Standard CPR

This meta-analysis shows a significantly increased chance of survival with chest-compression only cardiopulmonary resuscitation (CPR) compared to standard CPR, with an absolute increase in survival of 2.4% and a relative increase of 22%, number needed to treat (NNT)=41. Level of evidence: 1++ (Meta-analysis of RCTs with homogeneity and a very low risk of bias).

Compression-Only CPR Is Less Effective Than Conventional CPR in Some Patients

Findings of several large studies (JW Emerg Med Nov 12 2010; JW Emerg Med Oct 22 2010; JW Emerg Med Jul 28 2010) led to guideline revisions

Differential effects of ageing and BLS training experience on attitude towards basic life support

Purpose of study To determine the effects of ageing and training experience on attitude towards performing basic life support (BLS). Methods We gave a questionnaire to attendants of the courses for BLS or safe driving in authorised driving schools. The questionnaire included questions about participants’ backgrounds. The questionnaire explored the participant's willingness to perform BLS in four hypothetical scenarios related to early emergency call, cardiopulmonary resuscitation (CPR) under their own initiative, telephone-assisted compression-only CPR and use of an automated external defibrillator (AED), respectively. Results There were significant differences in gender, occupation, residential area, experience of BLS training, and knowledge of AED use among the young (17–29 y, N = 6122), middle-aged (30–59 y, N = 827) and elderly (>59 y, N = 15,743) groups. In all four scenarios, the proportion of respondents willing to perform BLS was lowest in the elderly group. More respondents in the elderly group were willing to follow the telephone-assisted instruction rather than performing CPR under their own initiative. Multiple logistic regression analysis confirmed ageing as an independent factor related to negative attitude in all scenarios. Gender, occupation, resident area, experience with BLS training and knowledge about AED use were other independent factors. Prior BLS training did not increase willingness to make an emergency call. Conclusion The aged population has a more negative attitude towards performing BLS. BLS training should be modified to help the elderly gain confidence with the essential elements of BLS, including making early emergency calls.

Response to Letters Regarding Article, “Bystander-Initiated Rescue Breathing for Out-of-Hospital Cardiac Arrests of Noncardiac Origin”

We thank Dr Rai, Dr Arrich, and their colleagues for their relevant comments on our article.1 As Rai and colleagues pointed out, the recent randomized, controlled trial2 of dispatcher instructions to bystanders for performing cardiopulmonary resuscitation (CPR) failed to show statistical differences between chest compression-only and conventional CPR with rescue breathing in its subgroup analysis: the good neurological outcome after out-of-hospital cardiac arrests (OHCAs) of noncardiac origin was 6.9% (13/188) in the conventional CPR group and 4.4% (9/204) in the compression-only CPR group ( P =0.28). This might be due to its small sample size, and the results are consistent with ours. Since survival after OHCAs of noncardiac origin is generally low regardless of type of CPR, a large sample size is needed to address this issue, and our study …

Letter by Arrich et al Regarding Article, “Bystander-Initiated Rescue Breathing for Out-of-Hospital Cardiac Arrests of Noncardiac Origin”

To The Editor: With interest we have read the article by Kitamura and colleagues about bystander initiated rescue breathing for out-of-hospital cardiac arrest of noncardiac origin.1 The authors included a large number of patients from a population based registry and concluded that rescue breathing has an incremental benefit for out-of-hospital cardiac arrests of noncardiac origin. We would like to discuss some aspects of the study design: The main question was a comparison between compression-only CPR to conventional CPR including …

Increasing Bystander CPR Rates

JAMA Chest Compression–Only CPR by Lay Rescuers and Survival From Out-of-Hospital Cardiac Arrest Bentley J. Bobrow, MD; Daniel W. Spaite, MD; Robert A. Berg, MD; Uwe Stolz, PhD, MPH; Arthur B. Sanders, MD; Karl B. Kern, MD; Tyler F. Vadeboncoeur, MD; Lani L. Clark, BS; John V. Gallagher, MD; J. Stephan Stapczynski, MD; Frank LoVecchio, DO; Terry J. Mullins, MBA; Will O. Humble, MPH; Gordon A. Ewy, MD Context: Chest compression–only bystander cardiopulmonary resuscitation (CPR) may be as effective as conventional CPR with rescue breathing for out-of-hospital cardiac arrest. Objective: To investigate the survival of patients with out-of-hospital cardiac arrest using compression-only CPR (COCPR) compared with conventional CPR. Design, Setting, and Patients: A 5-year prospective observational cohort study of survival in patients at least 18 years old with out-of-hospital cardiac arrest between January 1, 2005, and December 31, 2009, in Arizona. The relationship between layperson bystander CPR and survival to hospital discharge was evaluated using multivariable logistic regression. Main Outcome Measure: Survival to hospital discharge. Results: Among 5272 adults with out-of-hospital cardiac arrest of cardiac etiology not observed by responding emergency medical personnel, 779 were excluded because bystander CPR was provided by a health care professional or the arrest occurred in a medical facility. A total of 4415 met all inclusion criteria for analysis, including 2900 who received no bystander CPR, 666 who received conventional CPR, and 849 who received COCPR. Rates of survival to hospital discharge were 5.2% (95% confidence interval [CI], 4.4%-6.0%) for the no bystander CPR group, 7.8% (95% CI, 5.8%-9.8%) for conventional CPR, and 13.3% (95% CI, 11.0%-15.6%) for COCPR. The adjusted odds ratio (AOR) for survival for conventional CPR vs no CPR was 0.99 (95% CI, 0.69-1.43), for COCPR vs no CPR, 1.59 (95% CI, 1.18-2.13), and for COCPR vs conventional CPR, 1.60 (95% CI, 1.08-2.35). From 2005 to 2009, lay rescuer CPR increased from 28.2% (95% CI, 24.6%-31.8%) to 39.9% (95% CI, 36.8%-42.9%; P P P Conclusion: Among patients with out-of-hospital cardiac arrest, layperson compression-only CPR was associated with increased survival compared with conventional CPR and no bystander CPR in this setting with public endorsement of chest compression–only CPR. JAMA. 2010;304(13):1447-1454. doi:10.1001/jama.2010.1392

Compression-Only CPR by Lay Bystanders Gains Ground

For more than a decade, growing evidence has suggested that rescue breathing might add little value, or perhaps even be detrimental, during

Anesthesia Literature Review

Anesthesia Literature Review

Time-dependent effectiveness of chest compression-only and conventional cardiopulmonary resuscitation for out-of-hospital cardiac arrest of cardiac origin

BackgroundLittle is known about the effect of the type of bystander-initiated cardiopulmonary resuscitation (CPR) for prolonged out-of-hospital cardiac arrest (OHCA). ObjectivesTo evaluate the time-dependent effectiveness of chest compression-only and conventional CPR with rescue breathing for witnessed adult OHCA of cardiac origin. MethodsA nationwide, prospective, population-based, observational study of the whole population of Japan included consecutive OHCA patients with emergency responder resuscitation attempts from 1 January 2005 to 31 December 2007. Multiple logistic regression analysis was performed to assess the contribution of the bystander-initiated CPR technique to favourable neurological outcomes. ResultsAmong 55014 bystander-witnessed OHCA of cardiac origin, 12165 (22.1%) received chest compression-only CPR and 10851 (19.7%) received conventional CPR. For short-duration OHCA (0–15min after collapse), compression-only CPR had a higher rate of survival with favourable neurological outcome than no CPR (6.4% vs. 3.8%; adjusted odds ratio (OR), 1.55; 95% confidence interval (CI), 1.38–1.74), and conventional CPR showed similar effectiveness (7.1% vs. 3.8%; adjusted OR, 1.78; 95% CI, 1.58–2.01). For the long-duration arrests (>15min), conventional CPR showed a significantly higher rate of survival with favourable neurological outcome than both no CPR (2.0% vs. 0.7%; adjusted OR, 1.93; 95% CI, 1.27–2.93) and compression-only CPR (2.0% vs. 1.3%; adjusted OR, 1.56; 95% CI, 1.02–2.44). ConclusionsFor prolonged OHCA of cardiac origin, conventional CPR with rescue breathing provided incremental benefit compared with either no CPR or compression-only CPR, but the absolute survival was low regardless of type of CPR.