Literature Review: Cardiac Resuscitation

     Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA 299(10):1,158–65, 2008.

Abstract
     The objective was to investigate whether the survival of patients with out-of-hospital cardiac arrest would improve with minimally interrupted cardiac resuscitation (MICR), an alternate EMS protocol.

     Design, setting and patients—A prospective study of survival to hospital discharge between Jan. 1, 2005, and Nov. 22, 2007. Patients with out-of-hospital cardiac arrests in two metropolitan cities in Arizona were assessed before and after MICR training of fire department emergency medical personnel. In a second analysis of protocol compliance, patients from the two metropolitan cities and 60 additional fire departments in Arizona who received MICR were compared with patients who did not receive MICR but received standard advanced life support.

     Intervention—Instruction for EMS personnel in MICR, an approach that includes an initial series of 200 uninterrupted chest compressions, rhythm analysis with a single shock, 200 immediate post-shock chest compressions before pulse check or rhythm reanalysis, early administration of epinephrine, and delayed endotracheal intubation.

     Main outcome measure—Survival to hospital discharge.

     Results—Among the 886 patients in the two metropolitan cities, survival to hospital discharge increased from 1.8% before MICR training to 5.4% after. In the subgroup of 174 patients with witnessed cardiac arrest and ventricular fibrillation, survival increased from 4.7% before MICR training to 17.6% after. In the analysis of MICR protocol compliance involving 2,460 patients with cardiac arrest, survival was significantly better among patients who received MICR than those who did not (9.1% vs. 3.8%). This was also true of patients with witnessed ventricular fibrillation (28.4% vs. 11.9%).

     Conclusions—Survival to hospital discharge of patients with out-of-hospital cardiac arrest increased after implementation of MICR as an alternate EMS protocol. These results need to be confirmed in a randomized trial.

Comment
     Chest compressions and circulation are increasingly being recognized as the most important parts of CPR. Over the last several CPR guidelines, we have seen the ratio of compressions to ventilations go from 5:1 to 15:2 to 30:2. This study, along with a number of others in both animal and human patients, suggests that the optimal ratio may be even higher—especially in the first few minutes, when ventilations may not be needed at all.

     There are several limitations to this study. First, many of the MICR patients may have received ventilations during the 200 compressions, as that was allowed in the protocols, so this is not truly a study of "chest compression only" CPR. Second, before starting MICR many providers were following the 2000 guidelines (with a 15:2 ratio, early endotracheal intubation and three stacked defibrillations, with long pauses in CPR), so we cannot say how MICR compares to the 2005 guidelines (hard and fast compressions with minimal interruption, single shock, delayed intubation). And third, by the end of the two-year MICR interval, survival rates decreased to pre-MICR levels, which calls into question whether the improvements can be sustained.

     But the most important message from this study is that we can do considerably better than we do now, and substantially increase our patients' likelihood of survival. Whether it was the compressions-only approach, the quality of the compressions (which we know are often poor and would expect to be better with more attention and training), the reduction in CPR interruptions, the early epinephrine or a combination, this gives us a reason to carefully examine and improve our approach to resuscitation.

Angelo Salvucci, Jr., MD, FACEP, is an emergency physician and medical director for the Santa Barbara County and Ventura County (CA) EMS Agencies, and chair of the California Commission on EMS.

     Study authors Gordon A. Ewy, MD, & Bentley J. Bobrow, MD, respond:

     We are delighted that our article was selected for literature review in this issue of EMS. We want to clarify for readers that "minimally interrupted cardiac resuscitation" is the same as "cardiocerebral resuscitation," which is discussed in this issue's cover report on page 41.

     These results may well need to be confirmed in a randomized trial to get national and international Guideline changes, but we are so convinced that cardiocerebral resuscitation dramatically improves survival that we do not believe it is practical to do such a study. We agree with Ornato and Peberdy that for out-of-hospital cardiac arrest (OHCA), with the attendant difficulty of getting appropriate funding and informed consent, that it is time for a better tool.¹ That tool is evaluating OHCA survival results in your EMS system on an ongoing basis. We hope that work will encourage your system to make appropriate changes that will improve outcomes. We are convinced that the present version of cardiocerebral resuscitation should be the first of those changes.

Reference

1. Ornato JP, Peberdy MA. Measuring progress in resuscitation: It's time for a better tool. Circ 114:2754–2756, 2006.