Ewy, Gordon A.

Background: The 2010 AHA Guidelines state rescuers should perform chest compressions (CCs) of at least 2 inches in depth for adult cardiac arrest patients. Although the pediatric guidelines recommend adjustment of CC depth based upon anteroposterior chest dimension, there is no such recommendation for adults. Purpose: To determine 1) whether prehospital providers intuitively vary CC depth in adults according to patient size and 2) whether implementation of real-time audiovisual CPR feedback (RTAVF) impacts weight/CC depth variation. Methods: CC quality data were prospectively collected prior to (9/08-4/10; Pre-feedback) and after (5/10-12/10; Post-feedback) implementation of an RTAVF system (ZOLL Medical, Chelmsford MA) from 3 EMS agencies. The RTAVF includes a visual display of absolute CC depth and gives audio prompts when depth is outside of the Guideline-recommended range. Among 363 cases of adult, non-traumatic out-of-hospital cardiac arrest (OHCA), body weight was estimated by EMS in 249 patients (study group; 66%). CPR quality data were available for all cases via code review software. Results: 168 Pre-feedback and 81 Post-feedback study group cases (mean 64±16 years, 68% male). Mean estimated body weight was 201 lbs (quartiles 161, 231; range 70-451) and was not different between groups. CC depth increased significantly with RTAVF use (Pre-feedback = 1.77, 95% confidence interval [CI]:1.71-1.83 in.; Post-feedback = 2.10, CI: 2.04-2.15 in.; p<0.001). CC depth did not vary significantly by patient gender or age (p>0.4). Multivariate linear regression (r 2 =0.23, p<0.001 for model) revealed a significant increase in CC depth with estimated weight in both periods (0.07in/50lbs, p<0.001) after controlling for the presence of RTAVF. RTAVF was not an effect-modifier of the relationship between estimated weight and CC depth (p-value for interaction term=0.4). Conclusion: Although not specifically recommended in the 2010 AHA Guidelines for adults, rescuers may instinctively and/or intentionally adjust CC depth according to patient size. In this setting, weight/CC depth adjustments occurred both without and with real-time feedback. Follow-up studies are needed to determine the potential effect of size-adjusted CC depth on patient outcome.

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.

Objective: The 2010 AHA Guidelines stress the need for minimally interrupted, high quality CPR. We performed a prospective, before/after trial to determine if real-time audiovisual feedback (RTAVF) along with scenario-based training (SBT) would 1) achieve the 2010 CPR targets and 2) improve survival from OHCA. Methods: Data obtained from EMS care forms and defibrillators (E Series, ZOLL) from 2 EMS agencies (population base-500,000). Phase 1 (P1, before): 18 months of baseline data with the RTAVF mode disabled (9/08-3/10). Interventions: 1) Guideline-based SBT of ~450 EMTs, 2) RTAVF enabled, 3) EMT post-code debriefings. Phase 2 (P2, after): 8 months following implementation of interventions (5/10-12/10). For univariate analyses we used Fisher's exact test (proportions), t-test (means) or Kruskal-Wallis test (medians). To estimate odds ratios for survival to hospital discharge we used multivariable logistic regression and assessed final model diagnostics, fit, and discrimination. Results: The final analysis included 284 adult OHCAs (P1-176, P2-108). Mean age 65.4 years (SD ± 15.3) with 66.6% males. Quality measures improved significantly from P1 to P2: Median (Interquartile range) chest compression (CC) rate-121 CC/min (109-135) to 101 CC/min (100-106), p <0.001; CC depth-1.73 in. (1.42-1.97) to 2.09 in. (1.92-2.3), p <0.001; CC fraction-66.5% (59.3-75.9%) to 84.0% (77.8-88.7%), p <0.001. All-rhythms survival increased significantly (p=0.034) from P1 to P2 (18/176, 10.2% vs. 23/108, 19.4%), an absolute survival increase of 9.2% (95% CI: 0.5%-17.9%). Crude odds ratio for survival for P2 vs. P1 was 2.1 (95% CI: 1.1-4.2) and adjusted odds ratio was 5.8 (95% CI: 1.8-18.9), after controlling for confounders including age, sex, location, witnessed arrest, initial rhythm, and therapeutic hypothermia. Survival for arrests with a shockable rhythm was 27.7% (18/65) for P1 and 53.9% (14/26) for P2 (p=0.028). Conclusion: RTAVF combined with SBT was associated with a significant improvement in the proportion of compressions meeting the 2010 AHA Guidelines. This intervention was associated with a 90% relative increase in overall survival. We believe this is the first report to show an improvement in OHCA survival by achieving the 2010 AHA CPR Guidelines.

OBJECTIVE : To evaluate the impact of cardiocerebral resuscitation (CCR), an alternative emergency medical services (EMS) protocol, on out-of-hospital cardiac arrest (OOHCA) survival in the state of Arizona. CCR, emphasizes 200 preshock chest compressions, a single defibrillator shock (when indicated) followed immediately by 200 postshock chest compressions, early intravenous epinephrine and delayed endotracheal intubation. METHODS : The Save Hearts in Arizona Registry and Education (SHARE) program collected Utstein style data from 38 different fire departments (FDs) servicing approximately 70% of Arizona’s population. 2671 consecutive OOHCAs, of which 1847 were adult and presumed cardiac etiology were enrolled between October, 2004 and December, 2006. The CCR protocol was implemented in 11/38 (29%) FDs and the remaining FDs 27/38 (72%) utilized standard ACLS. The primary end-point was survival to hospital discharge of all cardiac arrests and for the subgroup with witnessed arrest and ventricular fibrillation (VF) on EMS arrival. Outcomes were obtained from the Office of Vital Statistics as well as local hospitals and were compared using chi square testing; alpha = 0.05. RESULTS: 457/1847 (24.7%) patients were treated by CCR FDs and 1390/1847 (75.3%) were treated by ACLS FDs. Overall survival in the CCR group was significantly better than in the ACLS group (9.2% (42/457) vs. 3.5% (49/1390), p < 0.001). Similarly, survival for witnessed VF arrests was significantly better in the CCR group than the ACLS group (29.3% (29/99) vs. 11.1% (30/271), p < 0.001). Odds ratios were adjusted for age, gender, location, bystander CPR performed, % witnessed, % VF and EMS dispatch to arrival time. The odds of overall survival was 2.7 times higher in the CCR group compared to the overall ACLS group (95% CI 1.7,4.4), and 3.0 times higher in the CCR subgroup of witnessed VF (95% CI 1.6,5.6). CONCLUSION: Survival of patients with OOHCA in Arizona was significantly better in fire departments utilizing the cardiocerebral resuscitation protocol than in fire departments utilizing ACLS. Implementing the cardiocerebral resuscitation protocol on a large scale is feasible and saves lives.

Background— The incidence and significance of gasping after cardiac arrest in humans are controversial. Methods and Results— Two approaches were used. The first was a retrospective analysis of consecutive confirmed out-of-hospital cardiac arrests from the Phoenix Fire Department Regional Dispatch Center text files to determine the presence of gasping soon after collapse. The second was a retrospective analysis of 1218 patients with out-of-hospital cardiac arrests in Arizona documented by emergency medical system (EMS) first-care reports to determine the incidence of gasping after arrest in relation to the various EMS arrival times. The primary outcome measure was survival to hospital discharge. An analysis of the Phoenix Fire Department Regional Dispatch Center records of witnessed and unwitnessed out-of-hospital cardiac arrests with attempted resuscitation found that 44 of 113 (39%) of all arrested patients had gasping. An analysis of 1218 EMS-attended, witnessed, out-of-hospital cardiac arrests demonstrated that the presence or absence of gasping correlated with EMS arrival time. Gasping was present in 39 of 119 patients (33%) who arrested after EMS arrival, in 73 of 363 (20%) when EMS arrival was <7 minutes, in 50 of 360 (14%) when EMS arrival time was 7 to 9 minutes, and in 25 of 338 (7%) when EMS arrival time was >9 minutes. Survival to hospital discharge occurred in 54 of 191 patients (28%) who gasped and in 80 of 1027 (8%) who did not (adjusted odds ratio, 3.4; 95% confidence interval, 2.2 to 5.2). Among the 481 patients who received bystander cardiopulmonary resuscitation, survival to hospital discharge occurred among 30 of 77 patients who gasped (39%) versus only 38 of 404 among those who did not gasp (9%) (adjusted odds ratio, 5.1; 95% confidence interval, 2.7 to 9.4). Conclusions— Gasping or abnormal breathing is common after cardiac arrest but decreases rapidly with time. Gasping is associated with increased survival. These results suggest that the recognition and importance of gasping should be taught to bystanders and emergency medical dispatchers so as not to dissuade them from initiating prompt resuscitation efforts when appropriate.