The Case for Continuous Chest Compressions

A recent editorial Surviving Cardiac Arrest: Location, Location, Location. JAMA. 2008 Sep 24;300(12):1462-3 examined survival rates for cardiac arrest in various communities around the country.

This comment in particular caught my eye:

In a small study from rural Wisconsin, Kellum et al. implemented an EMS protocol consisting of an initial series of uninterrupted chest compressions, passive oxygen administration with no active ventilation, rhythm analysis with a single shock, 200 immediate postshock chest compressions before pulse check or rhythm reanalysis, and delayed tracheal intubation. In comparison of data for 3 years before (n=92) and after (n=89) the protocol change, neurologically intact survival for patients with witnessed shockable rhythms improved from 15% to 39%, comparable with the best site in the ROC study […] These data show that protocol and technique can be more important than location for survival of OCHA.

The best site in the ROC study is, of course, Seattle.

I was immediately reminded of the following comments from Controversial Topics From the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2005; 112: III-133-III-136.

Animal evidence and one large case series suggests that ventilation is unnecessary for the first few minutes after primary VF cardiac arrest. But ventilation is important in asphyxial arrest (e.g. most arrests in children and many noncardiac arrests, such as drowning and drug overdose). Some conference participants suggested that recommendations provide the option of omitting ventilation for the first few minutes unless the victim is a child or the possibility of asphyxial cardiac arrest exists (e.g. drowning). To simplify lay rescuer education, the consensus among conference participants was to strive for a universal sequence of resuscitation (emphasis added).

And then in the next section:

The obvious challenge was how to translate the need to increase chest compressions into recommendations that would be simple and appropriate for both asphyxial and VF cardiac arrest. There was agreement that continuous chest compressions could be appropriate in the first minutes of VF arrest, but ventilations would be more important for asphyxial arrest and all forms of prolonged arrest. There was also agreement that it would be too complicated to teach lay rescuers different sequences of CPR for different circumstances (emphasis added). For simplicity, a universal compression-ventilation ratio of 30:2 for lone rescuers of victims from infancy (excluding neonates) through adulthood was agreed on by consensus based on integration of the best human, animal, maniken, and theoretical models available. For two-rescuer CPR in children, a compression-ventilation ratio of 15:2 was recommended.

Are we in EMS lay rescuers or are we professionals? If the latter, then why should uninterrupted chest compressions be a novel therapy during the first 2 minutes of a resuscitation attempt for witnessed sudden cardiac death (down times > 4 minutes and no bystander CPR prior to EMS arrival)? More EMS systems are adopting this approach as a best practice, but why did we treat ourselves as laypersons in the first place?

 

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