Research Review

Selected SCA Research Reviews


CARDIAC ARREST SURVIVAL IS RARE WITHOUT PREHOSPITAL RETURN OF SPONTANEOUS CIRCULATION. PREHOSPITAL EMERGENCY CARE 2012; 16:451-455.
WAMPLER, DA ET AL.

This paper addresses the issue of scene resuscitation. It is generally accepted that treating the patient at the scene of collapse is the best strategy for optimizing survival. However, many EMS systems continue to implement the “scoop and go” technique.

These authors retrospectively reviewed almost 2,500 cases between the years 2008-2010, from two large urban EMS systems, for which resuscitation was attempted. Using the denominator of resuscitations attempted eliminates the majority of the cases that would have been considered DOAs.

They report that 36% of cases achieved ROSC in the field, and for these cases, survival was 17.2% (154 survivors/894 cases). Survival for those cases without field ROSC was very low at 0.69% (11 survivors/1,589 cases).

They recommend that resuscitative efforts focus on achieving field ROSC and that transport should be reserved for patients with field ROSC or a shockable rhythm. The author’s suggestions mirror the NAEMSP’s 2011 position on termination of resuscitation for OHCA patients. EMS systems and communities should evaluate their TOR practices and investigate strategies to reduce futile transports.

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EDITORIAL. CAN DRUGS EVER IMPROVE OUTCOME AFTER CARDIAC ARREST? RESUSCITATION 83 (2012) 663-664.
OLASVEENGEN, TM.

This is an informative editorial that reviews current evidence for the use of medications during resuscitation. There is little evidence for efficacy of many of the resuscitation drugs used today. The author discusses the ongoing search for a vasopressor that facilitates resuscitation by optimizing cerebral and coronary blood flow. While epinephrine was first included in the AHA guidelines in 1974, its adoption was based mainly on animal data. Since 1974, we understand that while epi’s, alpha receptor stimulation increases cerebral perfusion pressure and is helpful during resuscitation, the beta stimulation effects cause concerns including increased O2 demand and post-arrest myocardial dysfunction. Recently there has been evidence and some speculation that suggests it may make more sense to use a non-adrenergic vasopressor (such as phenylephrine or methoxamine), or to use a beta blocker in combination with a non adrenergic vasopressor. Studies that include good chest compression which ensure adequate circulation and quality resuscitation components as well as goal directed post arrest care would be needed to provide evidence that this strategy improves outcome. While we are not there yet, it makes sense not to administer epinephrine cavalierly.

The editorial highlights the 2012 Resuscitation article by de Oliveria, et al. who reviewed the use of beta-blockers in cardiac arrest. They make a compelling argument for their use, at least in animal models, and suggest that perhaps the time has come to but this treatment to the test. (de Oliveira, FC et al. Use of beta-blockers for the treatment of cardiac arrest due to ventricular fibrillation/pulseless ventricular tachycardia: a systematic review. Resuscitation 20120;83:674-83.)

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NOVEL ADHESIVE GLOVE DEVICE (AGD) FOR ACTIVE COMPRESSION-DECOMPRESSION (ACD) CPR RESULTS IN IMPROVED CAROTID BLOOD FLOW AND CORONARY PERFUSION PRESSURE IN PIGLET MODEL OF CARDIAC ARREST. RESUSCITATION 83(2012) 750-754.
UDASSI, JP ET AL.

These researchers studied the effect of providing active compression-decompression manual CPR on the quality of blood flow and perfusion, using a glove with a Velcro palm in a series of piglets. The piglets had a adhesive attached Velcro pad designed to mate with the glove Velcro on their chests. As noted in the impressively inclusive title, they were able to demonstrate both improved carotid blood flow and coronary perfusion pressure in the Velcro group. ACD CPR experienced notoriety during the early 2000s in the US followed by a restriction of the use of ACD devices. Currently, the 2010 COSTR treatment recommendation states that there is insufficient evidence to support or refute the use of ACD-CPR. (Part 7: CPR Techniques and Devices. Circulation 2010, 122:S338-344.) It appears that there will be some compelling evidence to review during the next guidelines process, particularly in regard to this low tech adhesive glove device (AGD).

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EXCESSIVE CHEST COMPRESSION RATE IS ASSOCIATED WITH INSUFFIEIENT COMPRESSION DEPTH IN PREHOSPITAL CARDIAC ARREST. RESUSCITATION 83(2012) 1319-1323.
MONSIEURS, KG ET AL.

In this Belgian study, the authors describe the relationship between compression rate and depth. Using an accelerometer, they compared depths achieved at 80-120 compressions/min with those at >120. The study used data from actual prehospital cardiac arrest cases. The deepest compressions occurred at a rate of 86, and depth became progressively more shallow as rates increased. This is good knowledge to help reinforce the correct rate, and to support faster is not necessarily better.

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WIDE VARIABILITY IN DRUG USE IN OUT-OF-HOSPITAL CARDIAC ARREST: A REPORT FROM THE RESUSCITATION OUTCOMES CONSORTIUM. RESUSCITATION 83(2012)1324-1330.
GLOVER, BM ET AL.

AHA and ILCOR guidelines 2010 recommend that the administration of drugs during resuscitation should be secondary to the provision of good quality CPR and defibrillation. This manuscript from the Resuscitation Outcomes Consortium reports the use of resuscitation drugs among the ROCs 11 sites and 74 EMS agencies. Despite the knowledge that there is limited data to show beneficial effects of many of the pharmacological agents routinely used during resuscitation, this study shows that among 16,221 out-of-hospital cases, 83 percent of patients received at least one drug. Variability in the administration of atropine and lidocaine for shock resistant VF/VT ranged from 29 to 95% for atropine and 0.2 to 73% for sodium bicarbonate. Epinephrine use was between 57 and 98%. Interestingly, but not surprisingly, no survival benefit could be attribute to the use of lidocaine or atropine, and use of epinephrine, atropine and sodium bicarbonate was negatively associated with survival to hospital discharge. It seems we are getting closer to seeing some clinical trials developed to actually evaluate these drugs during real, optimal CPR conditions in the near future.

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EFFECT OF REAL-TIME FEEDBACK DURING CARDIOPULMONARY RESUSCITATION OUTSIDE HOSPITAL: PROSPECTIVE, CLUSTER-RANDOMISED TRIAL. BRITISH MEDICAL JOURNAL 2011;342:D512.
HOSTLER D, ET AL.

Although this study showed that the use of real-time feedback during an actual resuscitation moved CPR parameters closer to recommended guidelines, the use of real-time feedback did not affect the clinical endpoints of ROSC or survival to hospital discharge. The authors suggest that the ability for real-time feedback to influence outcomes is only as good as the information used to formulate the CPR guidelines. They also suggest that the use of real-time feedback in systems with good quality baseline CPR performance may only produce small improvements insufficient to significantly impact survival.

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THE EFFECTIVENESS OF ULTRABRIEF AND BRIEF EDUCATIONAL VIDEOS FOR TRAINING LAY RESPONDERS IN HANDS-ONLY CARDIOPULMONARY RESUSCITATION: IMPLICATIONS FOR THE FUTURE OF CITIZEN CARDIOPULMONARY RESUSCITATION TRAINING. CIRC CARDIOVASC QUAL OUTCOMES. 2011 MAR 1;4(2):220-6.
BOBROW B, ET AL.

Bystander CPR is provided to about 1/3rd of out-of-hospital sudden cardiac arrest victims in the US. The low rate may be in part related to bystander’s fears about their ability to correctly perform complicated traditional CPR. Compression-only CPR is much simpler than traditional CPR and can be quickly and easily learned. Several excellent short videos are available.  For example, here are links to two from YouTube: http://www.youtube.com/watch?v=M8i5bfBxQhM and http://www.youtube.com/watch?v=EcbgpiKyUbs which can be viewed individually by laypersons or used in training sessions. While the AHA has promoted their version of compression only CPR for several years, there is little evidence to show that it has improved CPR rates nationwide. However, resuscitation experts in Arizona have demonstrated an improvement in survival over a period of years using their own version of compression only CPR in conjunction with aggressive public health support and messaging. It may be that the extreme simplicity of the videos coupled with a more personalized approach to enlisting layperson participation in Arizona was the key to their success.

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SURVIVAL AFTER APPLICATION OF AUTOMATIC EXTERNAL DEFIBRILLATORS BEFORE ARRIVAL OF THE EMERGENCY MEDICAL SYSTEM: EVALUATION IN THE RESUSCITATION OUTCOMES CONSORTIUM POPULATION OF 21 MILLION. J AM COLL CARDIOL. 2010 APR 20;55(16):1713-20
WEISFELDT ML ET AL.

Use of AEDs by laypersons in the United States has remained at around 2-3%, despite increasingly available devices in high traffic areas. In a study completed in Amsterdam, researchers surveyed travelers in a rail station to determine bystander’s level of preparedness to provide emergency defibrillation. Among 1,018 responders from 38 nations, only 47% said they would be willing to use an AED, and 53% were unable to recognize an AED. This suggests that the general public still needs a substantial amount of education about how to recognize and operate an AED as well as to convey our expectations to the public, that their help is essential during such an emergency.

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FEASIBILITY OF INTRA-ARREST HYPOTHERMIA INDUCTION: A NOVEL NASOPHARENGEAL APPROACH ACHIEVES PREFERENTIAL BRAIN COOLING. RESUSCITATION 2010 AUG;81(8):1025-30.
BOLLER M, ET AL.

This study involved 10 pigs that received 60 minutes of nasopharyngeal cooling using the RhinoChill device during various states of blood flow prior to ROSC. In this study, the device produced a drop of about 1 degree C in brain temperatures at 16 minutes, and a similar drop in aortic temperatures in one hour within the group of 4 animals receiving CPR. While hypothermia therapy provided in the hospital setting has proven to have a strong survival benefit for patients, beginning the therapy in the prehospital setting, either before or after ROSC has not yet been shown to provide additional survival or neurologic benefits.

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INDUCTION OF PREHOSPITAL THERAPEUTIC HYPOTHERMIA AFTER RESUSCITATION FROM NONVENTRICULAR FIBRILLATION CARDIAC ARREST. CRIT CARE MED 2012 MAR;40(3):747-53.
BERNARD SA ET AL; FOR THE RAPID INFUSION OF COLD HARTMANNS (RICH) INVESTIGATORS.

While the effect of pre-hospital cooling on survival remains uncertain at this writing, several groups are investigating the even earlier implementation of this therapy, during the intra-arrest period. The provision of both pre-hospital and intra-arrest cooling has scientific basis. The addition of any procedure during SCA resuscitation should be carefully scrutinized to ensure that it does not interfere with the basic therapies known to improve survival. Systems using unproven therapies should ensure that neurologic outcome at hospital discharge is measured and evaluated for all SCA cases.

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A GEOSPATIAL ASSESSMENT OF TRANSPORT DISTANCE AND SURVIVAL TO DISCHARGE IN OUT OF HOSPITAL CARDIAC ARREST PATIENTS: IMPLICATIONS FOR RESUSCITATION CENTERS. RESUSCITATION 2010 MAY; 81(5):513-523.
CUDNIK, MT ET AL: AND THE ROC INVESTIGATORS.

This article adds to existing literature that demonstrates a survival advantage for OHCA patients who bypass local hospitals to receive care at resuscitation centers despite a longer transport time.

While there are not yet enforced standards for resuscitation centers or resuscitation systems of care, recommendations have been made to describe the basic elements of these systems. There has been a call for the development of standards with which to categorize, verify and designate the components of a resuscitation care system.

Typically, a specialized resuscitation center would provide a comprehensive package of post resuscitation care including therapeutic hypothermia, access to PCI therapies, and goal directed therapies; delivered by an experienced staff in an institution which cares for a relatively large volume of post resuscitation patients. This study confirms the results of several other investigations that have shown improved outcomes related to the capability of the treating institution rather than the transport time, and addresses some of the knowledge gaps related to the effect of transport distance and destination hospital on survival for this population.

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REGIONAL VARIATION IN OUT-OF-HOSPITAL CARDIAC ARREST INCIDENCE AND OUTCOME. JAMA. 2008 SEP 24;300(12):1423-31.
NICHOL G, ET AL.

This article describes the wide variation in both incidence and outcome in sudden cardiac arrest across the 10 sites included in the Resuscitation Outcomes Consortium. Survival rates for EMS treated cardiac arrest ranged from 3 to 16.3% (median 8.4%). The incidence of EMS treated SCA varied from 48.0 to 70.1 per 100/000 (median 52.1%), and the incidence of ventricular fibrillation ranged from 7.7 to 39.9% (median 22.0%).

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EMERGENCY MEDICAL SERVICE DISPATCH CARDIOPULMONARY RESUSCITATION PREARRIVAL INSTRUCTIONS TO IMPROVE SURVIVAL FROM OUT-OF-HOSPITAL CARDIAC ARREST: A SCIENTIFIC STATEMENT FROM THE AMERICAN HEART ASSOCIATION. CIRCULATION. 2012 JAN 31;125(4):648-55.
LERNER EB, ET AL.

This scientific statement reviews the process of providing CPR dispatch instructions to bystanders who call 9-1-1 and describes best practices and performance measurement.

Implementation of dispatcher CPR instructions can significantly increase bystander CPR participation and can more than double a person’s chance of survival from out-of-hospital cardiac arrest.

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COMMUNITY APPROACHES TO IMPROVE RESUSCITATION AFTER OUT-OF-HOSPITAL SUDDEN CARDIAC ARREST. CIRCULATION. 2010 MAR 9;121(9):1134-40.
REA TD, ET AL.

This article is available for free download from the pub med site. It provides a well referenced and comprehensive review of strategies for improving bystander CPR and engaging communities and laypersons in efforts to improve survival in any community.

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