Background The 2010 international guidelines for CPR recently recommended an increase in the minimum compression depth from 38 to 50 mm, although there are limited human data to support this. We sought to study patterns of CPR compression depth and their associations with patient outcomes in out-of-hospital cardiac arrest (OOHCA) cases treated by the 2005 guideline standards. Methods and Results We studied emergency medical services treated OOHCA patients from the Resuscitation Outcomes Consortium Epistry - Cardiac Arrest for whom electronic CPR compression depth data were available, from May 2006 to June 2009. We calculated anterior chest wall depression in millimeters and the period of active CPR (chest compression fraction) for each minute of CPR. We controlled for covariates including compression rate and calculated adjusted odds ratios for any return of spontaneous circulation (ROSC), 1-day survival, and hospital discharge. We included 1,029 adult patients from 7 U.S. and Canadian cities with these characteristics: mean age 68 years; male 62 %; bystander witnessed 40%; bystander CPR 37%; initial rhythms - VF/VT 24%, PEA 16%, asystole 48%, other non-shockable 12%; outcomes - ROSC 26%, 1-day survival 18%, discharge 5%. For all patients, median compression rate was 106 per minute, median compression fraction 0.65, and median compression depth 37.3 mm with 52.8% of cases having depth < 38 mm and 91.6% having depth < 50 mm. We found an inverse association between depth and compression rate (P<0.001). Adjusted odds ratios for all depth measures (mean values, categories, and in range) showed strong trends towards better outcomes with increased depth for all three survival measures. Conclusions We found suboptimal compression depth in half of patients by 2005 guideline standards and almost all by 2010 standards, as well as an inverse association between compression depth and rate. We found a strong association between survival outcomes and increased compression depth but no clear evidence to support or refute the 2010 recommendations of > 50 mm. While compression depth is an important component of CPR and should be measured routinely, the most effective depth is currently unknown.

Background-The 2010 American Heart Association guidelines suggested an increase in cardiopulmonary resuscitation compression depth with a target >50 mm and no upper limit. This target is based on limited evidence, and we sought to determine the optimal compression depth range. Methods and Results-We studied emergency medical services-treated out-of-hospital cardiac arrest patients from the Resuscitation Outcomes Consortium Prehospital Resuscitation Impedance Valve and Early Versus Delayed Analysis clinical trial and the Epistry-Cardiac Arrest database. We calculated adjusted odds ratios for survival to hospital discharge, 1-day survival, and any return of circulation. We included 9136 adult patients from 9 US and Canadian cities with a mean age of 67.5 years, mean compression depth of 41.9 mm, and a return of circulation of 31.3%, 1-day survival of 22.8%, and survival to hospital discharge of 7.3%. For survival to discharge, the adjusted odds ratios were 1.04 (95% CI, 1.00-1.08) for each 5-mm increment in compression depth, 1.45 (95% CI, 1.20-1.76) for cases within 2005 depth range (>38 mm), and 1.05 (95% CI, 1.03-1.08) for percentage of minutes in depth range (10% change). Covariate-adjusted spline curves revealed that the maximum survival is at a depth of 45.6 mm (15-mm interval with highest survival between 40.3 and 55.3 mm) with no differences between men and women. Conclusions-This large study of out-of-hospital cardiac arrest patients demonstrated that increased cardiopulmonary resuscitation compression depth is strongly associated with better survival. Our adjusted analyses, however, found that maximum survival was in the depth interval of 40.3 to 55.3 mm (peak, 45.6 mm), suggesting that the 2010 American Heart Association cardiopulmonary resuscitation guideline target may be too high. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00394706. 14 found that longer perishock and preshock pauses were independently associated with a decrease in survival to hospital discharge in patients presenting in a shockable rhythm. Idris et al 15 described an association between chest compression rate and return of spontaneous circulation.Chest compression depth is another aspect of CPR for which data are limited. Current CPR guidelines for compression rate and depth have been, for the most part, derived with relatively little robust human data to support them. 3,16 The 2005 guidelines recommended a depth range of 38 to 50 mm, whereas the new 2010 guidelines recommend a depth of ≥50 mm (2 in) with no upper limit specified. For compression depth, clinical studies to date have been small, with insufficient power to evaluate clinically important outcomes. 7,[17][18][19][20][21][22] Our group studied 1029 OHCA cases and found lower-than-recommended compression depth in half of patients by 2005 guideline standards and almost all by 2010 standards, as well as an inverse association between compression depth and rate. 23 We found a strong association between survival outcomes and increase...

clinicaltrials.gov Identifier: NCT00120965.

BACKGROUND In a departure from the previous strategy of immediate defibrillation, the 2005 resuscitation guidelines from the American Heart Association–International Liaison Committee on Resuscitation suggested that emergency medical service (EMS) personnel could provide 2 minutes of cardiopulmonary resuscitation (CPR) before the first analysis of cardiac rhythm. We compared the strategy of a brief period of CPR with early analysis of rhythm with the strategy of a longer period of CPR with delayed analysis of rhythm. METHODS We conducted a cluster-randomized trial involving adults with out-of-hospital cardiac arrest at 10 Resuscitation Outcomes Consortium sites in the United States and Canada. Patients in the early-analysis group were assigned to receive 30 to 60 seconds of EMS-administered CPR and those in the later-analysis group were assigned to receive 180 seconds of CPR, before the initial electrocardiographic analysis. The primary outcome was survival to hospital discharge with satisfactory functional status (a modified Rankin scale score of ≤3, on a scale of 0 to 6, with higher scores indicating greater disability). RESULTS We included 9933 patients, of whom 5290 were assigned to early analysis of cardiac rhythm and 4643 to later analysis. A total of 273 patients (5.9%) in the later-analysis group and 310 patients (5.9%) in the early-analysis group met the criteria for the primary outcome, with a cluster-adjusted difference of −0.2 percentage points (95% confidence interval, −1.1 to 0.7; P = 0.59). Analyses of the data with adjustment for confounding factors, as well as subgroup analyses, also showed no survival benefit for either study group. CONCLUSIONS Among patients who had an out-of-hospital cardiac arrest, we found no difference in the outcomes with a brief period, as compared with a longer period, of EMS-administered CPR before the first analysis of cardiac rhythm. (Funded by the National Heart, Lung, and Blood Institute and others; ROC PRIMED ClinicalTrials.gov number, NCT00394706.)

Aim Outcomes for pediatric out-of-hospital cardiac arrest (OHCA) are poor. Our objective was to determine temporal trends in incidence and mortality for pediatric OHCA. Methods Adjusted incidence and hospital mortality rates of pediatric non-traumatic OHCA patients from 2007-2012 were analyzed using the 9 region Resuscitation Outcomes Consortium - Epidemiological Registry (ROC-Epistry) database. Children were divided into 4 age groups: perinatal (< 3 days), infants (3 days - 1 year), children (1 - 11 years), and adolescents (12 - 19 years). ROC regions were analyzed post-hoc. Results We studied 1,738 children with OHCA. The age- and sex-adjusted incidence rate of OHCA was 8.3 per 100,000 person-years (75.3 for infants vs. 3.7 for children and 6.3 for adolescents, per 100,000 person-years, p<0.001). Incidence rates differed by year (p<0.001) without overall linear trend. Annual survival rates ranged from 6.7-10.2%. Survival was highest in the perinatal (25%) and adolescent (17.3%) groups. Stratified by age group, survival rates over time were unchanged (all p>0.05) but there was a non-significant linear trend (1.3% increase) in infants. In the multivariable logistic regression analysis, infants, unwitnessed event, initial rhythm of asystole, and region were associated with worse survival, all p<0.001. Survival by region ranged from 2.6-14.7%. Regions with the highest survival had more cases of EMS-witnessed OHCA, bystander CPR, and increased EMS-defibrillation (all p<0.05). Conclusions Overall incidence and survival of children with OHCA in ROC regions did not significantly change over a recent 5 year period. Regional variation represents an opportunity for further study to improve outcomes.

Background The rate and effect of coronary interventions and induced hypothermia after out-of-hospital cardiac arrest (OHCA) are unknown. We measured the association of early (≤24 hours after arrival) coronary angiography, reperfusion, and induced hypothermia with favorable outcome after OHCA. Methods We performed a secondary analysis of a multicenter clinical trial (NCT00394706) conducted between 2007 and 2009 in 10 North American regions. Subjects were adults (≥ 18 years) hospitalized after OHCA with pulses sustained ≥ 60 minutes. We measured the association of early coronary catheterization, percutaneous coronary intervention, fibrinolysis, and induced hypothermia with survival to hospital discharge with favorable functional status (modified Rankin Score ≤3). Results From 16,875 OHCA subjects, 3,981 (23.6%) arrived at 151 hospitals with sustained pulses. 1,317 (33.1%) survived to hospital discharge, with 1,006 (25.3%) favorable outcomes. Rates of early coronary catheterization (19.2%), coronary reperfusion (17.7%) or induced hypothermia (39.3%) varied between hospitals, and were higher in hospitals treating more subjects per year. Odds of survival and favorable outcome increased with hospital volume (per 5 subjects/year OR 1.06; 95%CI: 1.04–1.08 and OR 1.06; 95%CI: 1.04, 1.08, respectively). Survival and favorable outcome were independently associated with early coronary angiography (OR 1.69; 95%CI 1.06–2.70 and OR 1.87; 95%CI 1.15–3.04), coronary reperfusion (OR 1.94; 95%CI 1.34–2.82 and OR 2.14; 95%CI 1.46–3.14), and induced hypothermia (OR 1.36; 95%CI 1.01–1.83 and OR 1.42; 95%CI 1.04–1.94). Interpretation Early coronary intervention and induced hypothermia are associated with favorable outcome and are more frequent in hospitals that treat higher numbers of OHCA subjects per year.

Bystander automated external defibrillator use before emergency medical services arrival in shockable observed public OHCA was associated with better survival and functional outcomes. Continued emphasis on public automated external defibrillator utilization programs may further improve outcomes of OHCA.

Objective To simplify airway management and minimize cardiopulmonary resuscitation (CPR) chest compression interruptions, some emergency medical services (EMS) practitioners utilize supraglottic airway (SGA) devices instead of endotracheal intubation (ETI) as the primary airway adjunct in out-of-hospital cardiac arrest (OHCA). We compared the outcomes of patients receiving ETI with those receiving SGA following OHCA. Methods We performed a secondary analysis of data from the multicenter Resuscitation Outcomes Consortium (ROC) PRIMED trial. We studied adult non-traumatic OHCA receiving successful SGA insertion (King Laryngeal Tube, Combitube, and Laryngeal Mask Airway) or successful ETI. The primary outcome was survival to hospital discharge with satisfactory functional status (Modified Rankin Scale ≤3). Secondary outcomes included return of spontaneous circulation (ROSC), 24-h survival, major airway or pulmonary complications (pulmonary edema, internal thoracic or abdominal injuries, acute lung injury, sepsis, and pneumonia). Using multivariable logistic regression, we studied the association between out-of- hospital airway management method (ETI vs. SGA) and OHCA outcomes, adjusting for confounders. Results Of 10,455 adult OHCA, 8487 (81.2%) received ETI and 1968 (18.8%) received SGA. Survival to hospital discharge with satisfactory functional status was: ETI 4.7%, SGA 3.9%. Compared with successful SGA, successful ETI was associated with increased survival to hospital discharge (adjusted OR 1.40; 95% CI: 1.04, 1.89), ROSC (adjusted OR 1.78; 95% CI: 1.54, 2.04) and 24-h survival (adjusted OR 1.74; 95% CI: 1.49, 2.04). ETI was not associated with secondary airway or pulmonary complications (adjusted OR 0.84; 95% CI: 0.61, 1.16). Conclusions In this secondary analysis of data from the multicenter ROC PRIMED trial, ETI was associated with improved outcomes over SGA insertion after OHCA.