A Resuscitation Protocol That Minimizes Hands-Off Time Improves Survival
A prehospital protocol emphasizing minimal interruption of chest compressions was associated with improved survival to hospital discharge.
Recent research suggests that minimizing interruptions during cardiopulmonary resuscitation improves coronary perfusion pressure and increases the likelihood of return of spontaneous circulation (ROSC). The Kansas City, Missouri, emergency medical services system changed its cardiac arrest protocol to emphasize early chest compressions and de-emphasize airway management for resuscitation of adult patients with primary cardiac arrest (ventricular fibrillation [VF] or pulseless ventricular tachycardia). Changes included increasing the compression-to-ventilation ratio from 5:1 to 50:2 (with 200 mandatory compressions without interruption), managing the airway initially with only a nonrebreather mask followed by bag-mask ventilation, and not attempting intubation until after the third round of chest compressions or ROSC; a maximum of 10 seconds was allowed for intubation attempts.
In a retrospective study, researchers compared ROSC, survival to discharge, and cognitive function in 1097 patients with primary cardiac arrest during the 36 months before the change and 339 patients during the 12 months after. Overall, survival to discharge increased significantly from 7% before the change to 14% after (odds ratio, 1.8). In the subset of adult patients with witnessed arrest and an initial rhythm of VF (143 before the change and 57 after), survival to discharge increased significantly from 22% to 44% (OR, 2.7), and rates of ROSC increased significantly from 38% to 60% (OR, 2.4). In this subset, cerebral performance category scores at discharge (assessed only in the after group) were favorable (scores of 1 or 2) in 88% of 25 survivors.
Comment: The concept of minimally interrupted cardiac resuscitation is important for revising how we think about CPR. Our focus should be to provide sufficient and sustained perfusion to the ailing myocardium. Prolonged or repeated interruptions (e.g., frequent pulse checks or attempts to intubate) significantly undermine the process. The American Heart Association guidelines likely will be revised to incorporate this concept. In the meantime, push hard, push fast, and minimize "hands-off" time.
Aaron E. Bair, MD, MSc, FAAEM, FACEPPublished in Journal Watch Emergency Medicine June 5, 2009
Garza AG et al. Improved patient survival using a modified resuscitation protocol for out-of-hospital cardiac arrest. Circulation 2009 May 19; 119:2597.