I received this e-mail from my Healthcare newsletter. 

It seems like the answer is…….You really need to concentrate on those compressions folks. 

PLEASE READ THIS IN IT’S ENTIRETY.   This study has found some very interesting information.

May 4, 2009 (Kansas City, Missouri) — Survival among adults with bystander-witnessed, out-of-hospital cardiac arrest with an initial rhythm of ventricular fibrillation (VF) improved from 22% to 44% following changes to a resuscitation protocol, a new study reports [1].

The historical protocol followed AHA 2000 guidelines, while the revised protocol modified this and advocated CPR before defibrillation, increased chest compressions, and decreased emphasis on ventilations and intubation in order to promote cardiac perfusion, lead author Dr Alex G Garza (Georgetown University School of Medicine, Washington, DC) told heartwire .

“The study adds to the body of science demonstrating that chest compressions–and limiting interruptions to chest compressions–are one of the most important interventions that can be provided for out-of-hospital cardiac arrest,” he said. The results speak for themselves, he added, noting that they found “dramatic” improvements in the percentages of patients who survived until hospital discharge and who had good neurological outcomes.

“For too long we have taught the ‘ABC’s’ [airway, breathing, circulation] when in fact it should probably be ‘CBA,’ meaning ‘focus on circulation (compressions) first,’ ” said Garza.

The retrospective cohort study, which compared cardiac-arrest survival in Kansas City three years before and one year after a modified resuscitation protocol was implemented, is published online May 4, 2009 in Circulation.

Low Survival Rates

For too long we have taught the ABCs [airway, breathing, circulation] when in fact it should probably be ‘CBA,’ meaning ‘focus on circulation (compressions) first.’

Despite multiple research efforts and a push to increase the availability of defibrillators, survival rates after out-of-hospital cardiac arrest remain low in the US, the researchers write.

In 2005, in an effort to improve resuscitation outcomes, the Kansas City, MO emergency medical system revised their protocol to reflect what happens in the three-phase, time-dependent model for cardiac arrest.

In this model, the “electrical phase” occurs from 0 to five minutes after the cardiac arrest, and this is when defibrillation is the optimal therapy, the researchers write. At five to 10 minutes after a cardiac arrest, in the “circulation phase,” an optimal chest-compression strategy is needed to improve coronary perfusion pressure, to set up a successful defibrillation. Optimal treatment for the third phase, the “metabolic phase,” which begins 10 minutes after cardiac arrest, is less clear.

In places such as casinos and airports, swift defibrillation upon cardiac arrest has “unquestionably” improved survival, the group writes. Unfortunately, in most other scenarios, when emergency medical personnel arrive, cardiac-arrest patients are typically in the circulatory phase rather than the electrical phase, they add.

In the current study, emergency medical service providers were trained in the new resuscitation protocol, which mandated that rescue workers perform at least three rounds of 200 chest compressions before attempting intubation, maintain a 50:2 ratio of compression to ventilation, restrict aggressive ventilation, and minimize pauses for ventilation.

The researchers compared patients who had an out-of hospital cardiac arrest during January 1, 2003 to March 31, 2006 (historical cohort) vs April 1, 2006 to March 31, 2007 (revised-protocol cohort).

Overall survival increased from 7.5% to 13.9%.

In the subset of patients most likely to survive–those with cardiac arrest that was witnessed by bystanders and who had an initial shockable rhythm of VF:

• Return of spontaneous circulation improved from 37.8% (54 of 143 patients) to 59.6% (34 of 57 patients).
• Survival until hospital discharge improved from 22.4% (32 of 143 patients) to 43.9% (25 of 57 patients).

Of the 25 survivors, 88% had a good neurological outcome when discharged from the hospital.

“I think that emergency medical services should look at their data to see whether they actually routinely arrive at a cardiac arrest during the first five minutes (the ‘electrical phase’), and if not, it would be a good practice to perform CPR before defibrillation,” said Garza. Recent evidence suggests that aggressive ventilation and intubation are detrimental for establishing good coronary perfusion pressure, he added.

“The jury is still out on the optimal number of compressions. However, our data and that of others suggest that more is probably better.”

Third Study to Support New Strategy

Emergency medical services should . . . see whether they actually routinely arrive at a cardiac arrest during the first five minutes. If not, it would be a good practice to perform CPR before defibrillation.

When asked by heartwire to comment on the study, Dr Gordon A Ewy(University of Arizona, Tucson) said: “This is the third study that essentially shows that our new form of CPR for primary cardiac arrest, which we call cardio-cerebral resuscitation [as opposed to cardiopulmonary resuscitation], significantly improves survival.”

SMM:This name change sounds very logical!  We aren’t really resuscitating the heart and lungs, we are just using them!

This study confirms what he and colleagues observed in Arizona and what Dr Michael J Kellum(Mercy Health System, Janesville, WI) and colleagues in Wisconsin reported, after emergency personnel modified their AHA-guideline-based cardiac-arrest resuscitation protocols to incorporate a newer approach [2].

“The less often chest compressions are interrupted during resuscitation, the better the survival,” said Ewy. “During cardiac arrest, your hands are their heart, and every time you stop compressions for anything, vital forward blood flow stops.”

SMM: Without the circulation, what good is the oxygen?  Our heart pumps continuously, it certainly does not take a break, does it??

For many years, Ewy has advocated the merits of continuous chest compression without assisted breathing.

It is hoped that studies such as the one by Garza and colleagues will lead to more appropriate guidelines, he said.

If you would like the references for this literature, please go to:

Medscape.com

Until next month, I sincerely wish you safety and happy thoughts,

SMM, or Shannon M. Madden