CCC-CPR; ECG Transmission

Continuous-Chest-Compression CPR
Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am J Med 119(4):335-40, Apr 2006.

Abstract: In an attempt to improve survival rates, the emergency medical service directors in two rural Wisconsin counties initiated a new protocol for the prehospital management of adult cardiac arrest victims. The results observed after implementation of this protocol are presented and compared with those observed during a three-year period that preceded initiation of the project. Methods-The protocol, based upon the principles of cardiocerebral resuscitation, was significantly different from the standard CPR protocol. A major objective was to minimize interruptions of chest compressions. Each defibrillation, including the first, was preceded by 200 uninterrupted chest compressions. Single shocks, rather than stacked shocks, were utilized. Post-shock rhythm and pulse checks were eliminated, and chest compressions were resumed immediately after a shock was delivered. Initial airway management was limited to an oral pharyngeal device and supplemental oxygen. If the arrest was witnessed, assisted ventilations and intubation were delayed until either a return of spontaneous circulation or until three series of "compressions + analysis +/- shock" were completed. Results-In the three years preceding the change in protocol, during which standard CPR was utilized, there were 92 witnessed out-of-hospital adult cardiac arrests with initially shockable rhythms. Eighteen patients survived, and 14 of 92 (15%) were neurologically intact. After implementation of the new protocol in early 2004, there were 33 witnessed out-of-hospital adult cardiac arrests with initially shockable rhythms. Nineteen patients survived, and 16 of 33 (48%) were neurologically normal. Differences in both total and neurologically normal survival are significant (chi-squared=0.001). Conclusion-Instituting the new cardiocerebral resuscitation protocol for managing prehospital cardiac arrests improved survival of adult patients with witnessed cardiac arrests and initially shockable rhythms.

Comment: Now that we've all begun to adapt to the 2005 American Heart Association CPR Guidelines, here is evidence that continuous-chest-compression CPR (CCC-CPR) has the promise to further improve outcomes. Dr. Ewy has written about this before (Cardiocerebral resuscitation: The new cardiopulmonary resuscitation. Circulation 111(16): 2,134-42, Apr 26, 2005), presenting data showing that in a pig model, CCC-CPR resulted in the same outcomes as perfectly performed traditional CPR-and both outcomes were much better than those of the no-CPR group. When one takes into consideration the frequent interruptions in CPR (e.g., for intubation, AED placement) and the real-world time required to deliver two breaths, CCC-CPR may be superior. And its greatest benefit may be in layperson CPR, where only 15% are willing to perform mouth-to-mouth breathing.

In this study, CCC-CPR appeared to be superior to standard CPR. However, many of the suggested changes are part of the 2005 guidelines, such as minimizing interruptions, decreasing the number of ventilations and eliminating the stacked shocks and post-shock rhythm/pulse checks, so it is not clear that CCC-CPR would still be better. It holds great promise for layperson CPR, to increase bystander CPR rates and effectiveness. Further research is needed.

ECG Transmissions to EDs & Coronary Intervention Times
Vaught C, Young DR, Bell SJ, et al. The failure of years of experience with electrocardiographic transmission from paramedics to the hospital emergency department to reduce the delay from door to primary coronary intervention below the 90-minute threshold during acute myocardial infarction. J Electrocardiol 39(2):136-41, Apr 2006.