Improved Patient Survival Using a Modified Resuscitation Protocol for Out-of-Hospital Cardiac Arrest

Abstract

Background-Cardiac arrest continues to have poor survival in the United States. Recent studies have questioned current practice in resuscitation. Our emergency medical services system made significant changes to the adult cardiac arrest resuscitation protocol, including minimizing chest compression interruptions, increasing the ratio of compressions to ventilation, deemphasizing or delaying intubation, and advocating chest compressions before initial countershock. Methods and Results-This retrospective observational cohort study reviewed all adult primary ventricular fibrillation and pulseless ventricular tachycardia cardiac arrests 36 months before and 12 months after the protocol change. Primary outcome was survival to discharge; secondary outcomes were return of spontaneous circulation and cerebral performance category. Survival of out-of-hospital arrest of presumed primary cardiac origin improved from 7.5% (82 of 1097) in the historical cohort to 13.9% (47 of 339) in the revised protocol cohort (odds ratio, 1.80; 95% confidence interval, 1.19 to 2.70). Similar increases in return of spontaneous circulation were achieved for the subset of witnessed cardiac arrest patients with initial rhythm of ventricular fibrillation from 37.8% (54 of 143) to 59.6% (34 of 57) (odds ratio, 2.44; 95% confidence interval, 1.24 to 4.80). Survival to hospital discharge also improved from an unadjusted survival rate of 22.4% (32 of 143) to 43.9% (25 of 57) (odds ratio, 2.71; 95% confidence interval, 1.34 to 1.59) with the protocol. Of the 25 survivors, 88% (nϭ22) had favorable cerebral performance categories on discharge. Conclusions-The changes to our prehospital protocol for adult cardiac arrest that optimized chest compressions and reduced disruptions increased the return of spontaneous circulation and survival to discharge in our patient population. These changes should be further evaluated for improving survival of out-of-hospital cardiac arrest patients. (Circulation.

Cardiocerebral and cardiopulmonary resuscitation – 2017 update

“…5) in each area in which it was instituted; first in Rock and Walworth counties (WI, USA), in Kansas City (MO, USA), and in Arizona 39, 48, 49, 50…”

Advances in Resuscitation

“…27 Evidence from studies of minimally interrupted cardiac resuscitation and cardiocerebral resuscitation supports the new decreased emphasis on pulse checks to promote continuous CPR with minimal interruptions. 28,29 Beyond the timing of ventilation, care must be taken to avoid excessive ventilation. Observational studies on human cardiac arrest patients have documented this to be a pervasive problem, one that should be considered in the context of animal models of cardiac arrest that demonstrate that excessive ventilation translates to poorer hemodynamics and survival.…”

“…77,78 More pertinent to patients experiencing SCD is work demonstrating biphasic waveforms to be equivalent or superior to monophasic waveforms in defibrillating to an organized rhythm. 28,79 However, evidence is lacking on improved survival in OHCA resulting from the implementation of biphasic defibrillation.…”

“…87,88 On the other hand, studies assessing minimally interrupted cardiac resuscitation and passive ventilation suggest that intubation may not be advantageous. 28,89 In these approaches, an emphasis on chest compressions and defibrillation, rather than on airway and ventilation, has been associated with improved outcomes. As a result, in cases when placement of an advanced airway and ventilation for adult patients with SCD would interfere with CPR and defibrillation, these efforts should be delayed until the patient fails to respond or ROSC occurs.…”

Tracheal intubation by paramedics under limited indication criteria may improve the short-term outcome of out-of-hospital cardiac arrests with noncardiac origin

“…Outcome was reported to be worsened when AAM with ET was performed in cases of OHCA with shockable rhythms [5,6]. Recently, Garza et al reported that avoidance of tracheal intubation as an early airway management and an increase in the ratio of chest compression to ventilation improved survival rate in OHCA of cardiac origin [6].In Japan, certified paramedics who have completed training programs for tracheal intubation have used ET in patients with OHCA since July 2004. The program includes 180 hours of lectures and exercises in schools as well as experience with 30 cases in hospital operating rooms.…”