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Abbreviations AHA: American Heart Association; CPR: Cardiopulmonary resuscitation; ERC: European Resuscitation Council; EMS: Emergency medical services; ILCOR: International Liaison Committee on Resuscitation; OHCA: Out-of-hospital cardiac arrests; OR: Odds ratio; RCT: Randomized clinical trials; ROSC: Return of spontaneous circulation.
Source publication
Current 2005 guidelines for advanced cardiac life support strongly recommend immediate defibrillation for out-of-hospital cardiac arrest. However, findings from experimental and clinical studies have indicated a potential advantage of pretreatment with chest compression-only cardiopulmonary resuscitation (CPR) prior to defibrillation in improving o...
Contexts in source publication
Context 1
... Figure 4, the studies are ordered according to their average EMS response times. OR point estimates of stu- dies with shorter EMS response times favored a defibril- lation-first approach. ...Context 2
... Our findings support the view of Weisfeld et al. as illustrated in Figure 4 and as shown in the subgroup analyses of patients with longer versus those with shorter response intervals. ...Context 3
... contrast, OR point estimates pointed toward superiority of prede- fibrillation chest compressions for those cardiac arrests with prolonged EMS response, while in patients with shorter EMS intervals these OR estimates pointed toward superiority of a defibrillation-first approach (Fig- ures 5 and 6). Owing to the smaller sample sizes in Figure 4 Odds ratio (OR) for primary endpoint "survival to hospital discharge" and response time. Horizontal bars indicate 95% confidence intervals. ...Similar publications
Objective
. To analyze the effect of basic resuscitation efforts on gasping and of gasping on survival.
Methods
. This is secondary analysis of a previously reported study comparing continuous chest compressions (CCC CPR) versus chest compressions plus ventilation (30:2 CPR) on survival. 64 swine were randomized to 1 of these 2 basic CPR approaches...
Citations
... Compared to the performance of BLS by bystanders, the use of AED demonstrated a higher significant improvement in prognosis. Prior meta-analysis has emphasized the importance of both chest compressions and the use of AED [18]. Our research demonstrates a greater positive effect for defibrillation. ...
Background: In recent years, several actions have been made to shorten the chain of survival in out-of-hospital cardiac arrest (OHCA). These include placing defibrillators in public places, training first responders, and providing dispatcher-assisted CPR (DA-CPR). In this work, we aimed to evaluate the impact of these changes on patients’ outcomes, including achieving return of spontaneous circulation (ROSC), survival to discharge, and survival with favorable neurological function. Methods: We retrospectively retrieved data of all calls to the national emergency medical service in Ashdod city, Israel, of individuals who underwent OHCA at the age of 18 and older between the years 2018 and 2021. Data was collected on prehospital and hospital interventions. The association between pre-hospital and hospital interventions to ROSC, survival to discharge, and neurological outcomes was evaluated. Logistic regression was used for multivariable analysis. Results: During the years 2018–2021, there were 1253 OHCA cases in the city of Ashdod. ROSC was achieved in 207 cases (32%), survival to discharge was attained in 48 cases (7.4%), and survival with favorable neurological function was obtained in 26 cases (4%). Factors significantly associated with good prognosis were shockable rhythm, witnessed arrest, DA-CPR, use of AED, and treatment for STEMI. All patients that failed to achieve ROSC outside of the hospital setting had a poor prognosis. Conclusions: This study demonstrates the prognostic role of the initial rhythm and the use of AED in OHCA. Hospital management, including STEMI documentation and catheterization, was also an important prognostication factors. Additionally, when ROSC is not achieved in the field, hospital transfer should be considered.
... Therefore, providers should deliver a shock immediately when the defibrillator is ready and a shockable rhythm is detected on ECG. [61][62][63][64][65] Biphasic waveform defibrillators are preferred over monophasic defibrillators because they are more safe and effective. 66,67 In unmonitored cardiac arrest, a single-shock strategy is suggested because the success rate of the first shock is around 90% and chest compression interruption is prolonged in stacked shocks. ...
... The available evidence (Table 1) suggests that we have a dearth of interventions that improve survival rates at hospital discharge and, even less so, neurological outcomes [1][2][3][4][5][6][7][8][9][10][11][12]. All benefits, if any, pertain to out-of-hospital cardiac arrest circumstances, while no new technology or improvement seems to work for in-hospital arrests. ...
... Such strategies might involve providing an interim period of high-quality CPR or medications rather than immediate shock until such a time that the waveform measure signifies the likelihood of a better outcome from defibrillation. 8,9 A major challenge to the routine use of waveform measures to help guide care is that these measures are conventionally calculated during pauses in CPR because chest compressions cause electrical artifact in the ECG. [10][11][12] Such interruptions generally contradict bestpractice guidelines which call for minimally-interrupted CPR to support resuscitation. 2 An improved strategy would use a waveform measure that achieves consistent prognostic performance throughout an arrest even during ongoing chest compressions. ...
Background:
Quantitative measures of the ventricular fibrillation (VF) ECG waveform can assess myocardial physiology and predict cardiac arrest outcomes, making these measures a candidate to help guide resuscitation. Chest compressions are typically paused for waveform measure calculation because compressions cause ECG artifact. However, such pauses contradict resuscitation guideline recommendations to minimize cardiopulmonary resuscitation interruptions. We evaluated a comprehensive group of VF measures with and without ongoing compressions to determine their performance under both conditions for predicting functionally-intact survival, the study's primary outcome.
Methods:
Five-second VF ECG segments were collected with and without chest compressions before 2755 defibrillation shocks from 1151 out-of-hospital cardiac arrest patients. Twenty-four individual measures and 3 combination measures were implemented. Measures were optimized to predict functionally-intact survival (Cerebral Performance Category score ≤2) using 460 training cases, and their performance evaluated using 691 independent test cases.
Results:
Measures predicted functionally-intact survival on test data with an area under the receiver operating characteristic curve ranging from 0.56 to 0.75 (median, 0.73) without chest compressions and from 0.53 to 0.75 (median, 0.69) with compressions ( P<0.001 for difference). Of all measures evaluated, the support vector machine model ranked highest both without chest compressions (area under the receiver operating characteristic curve, 0.75; 95% CI, 0.73-0.78) and with compressions (area under the receiver operating characteristic curve, 0.75; 95% CI, 0.72-0.78; P=0.75 for difference).
Conclusions:
VF waveform measures predict functionally-intact survival when calculated during chest compressions, but prognostic performance is generally reduced compared with compression-free analysis. However, support vector machine models exhibited similar performance with and without compressions while also achieving the highest area under the receiver operating characteristic curve. Such machine learning models may, therefore, offer means to guide resuscitation during uninterrupted cardiopulmonary resuscitation.
... Preclinical and clinical studies have shown that duration of untreated VF [2][3][4][5] and the level of coronary blood flow generated by cardiopulmonary resuscitation (CPR) are primary determinants of shock success. [6][7][8][9][10] Thus, shocks delivered early after prolonged untreated VF and/or during hemodynamically ineffective CPR are not likely to be effective 7,11 and may instead be detrimental by prompting interruptions in chest compression and causing electrical injury to the myocardium despite the widespread adoption of biphasic waveform defibrillation. 12,13 Accordingly, it would be desirable if the decision to deliver electrical shocks were not binary-based on the presence or absence of a "shockable" rhythm-but instead relied on the probability that a shock could result in the termination of VF followed by ROSC. ...
Background
The ventricular fibrillation amplitude spectral area (AMSA) predicts whether an electrical shock could terminate ventricular fibrillation and prompt return of spontaneous circulation. We hypothesized that AMSA can guide more precise timing for effective shock delivery during cardiopulmonary resuscitation.
Methods and Results
Three shock delivery protocols were compared in 12 pigs each after electrically induced ventricular fibrillation, with the duration of untreated ventricular fibrillation evenly stratified into 6, 9, and 12 minutes: AMSA‐Driven (AD), guided by an AMSA algorithm; Guidelines‐Driven (GD), according to cardiopulmonary resuscitation guidelines; and Guidelines‐Driven/AMSA‐Enabled (GDAE), as per GD but allowing earlier shocks upon exceeding an AMSA threshold. Shocks delivered using the AD, GD, and GDAE protocols were 21, 40, and 62, with GDAE delivering only 2 AMSA‐enabled shocks. The corresponding 240‐minute survival was 8/12, 6/12, and 2/12 (log‐rank test, P=0.035) with AD exceeding GDAE (P=0.026). The time to first shock (seconds) was (median [Q1–Q3]) 272 (161–356), 124 (124–125), and 125 (124–125) (P<0.001) with AD exceeding GD and GDAE (P<0.05); the average coronary perfusion pressure before first shock (mm Hg) was 16 (9–30), 10 (6–12), and 3 (−1 to 9) (P=0.002) with AD exceeding GDAE (P<0.05); and AMSA preceding the first shock (mV·Hz, mean±SD) was 13.3±2.2, 9.0±1.6, and 8.6±2.0 (P<0.001) with AD exceeding GD and GDAE (P<0.001). The AD protocol delivered fewer unsuccessful shocks (ie, less shock burden) yielding less postresuscitation myocardial dysfunction and higher 240‐minute survival.
Conclusions
The AD protocol improved the time precision for shock delivery, resulting in less shock burden and less postresuscitation myocardial dysfunction, potentially improving survival compared with time‐fixed, guidelines‐driven, shock delivery protocols.
... Preclinical and clinical studies have shown that duration of untreated VF [2][3][4][5] and the level of coronary blood flow generated by cardiopulmonary resuscitation (CPR) are primary determinants of shock success. [6][7][8][9][10] Thus, shocks delivered early after prolonged untreated VF and/or during hemodynamically ineffective CPR are not likely to be effective 7,11 and may instead be detrimental by prompting interruptions in chest compression and causing electrical injury to the myocardium despite the widespread adoption of biphasic waveform defibrillation. 12,13 Accordingly, it would be desirable if the decision to deliver electrical shocks were not binary-based on the presence or absence of a "shockable" rhythm-but instead relied on the probability that a shock could result in the termination of VF followed by ROSC. ...
... 29 In patients with unmonitored OHCA and an initial rhythm of ventricular brillation (VF) or pulseless ventricular tachycardia (pVT), there is no bene t from a period of CPR of 90-180 seconds prior to de brillation. [37][38][39][40][41][42][43] Rationale: Prolonged VF may deplete the energy stores of the heart, and rapid de brillation may be justi ed, regardless of the duration of arrest. In IHCA, the combination of intra-arrest vasopressin, epinephrine and methylprednisolone and postarrest hydrocortisone may be considered; ...
... Five RCTs, 100-104 4 observational cohort studies, 105-108 3 meta-analyses, [109][110][111] and 1 subgroup analysis of an RCT 112 addressed the question of CPR before defibrillation. The duration of CPR before defibrillation ranged from 90 to 180 seconds, with the control group having a shorter CPR interval lasting only as long as the time required for defibrillator deployment, pad placement, initial rhythm analysis, and AED charging. ...
As with other Parts of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), Part 5 is based on the International Liaison Committee on Resuscitation (ILCOR) 2015 international evidence review process. ILCOR Basic Life Support (BLS) Task Force members identified and prioritized topics and questions with the newest or most controversial evidence, or those that were thought to be most important for resuscitation. This 2015 Guidelines Update is based on the systematic reviews and recommendations of the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations , “Part 3: Adult Basic Life Support and Automated External Defibrillation.”1,2 In the online version of this document, live links are provided so the reader can connect directly to the systematic reviews on the ILCOR Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a combination of letters and numbers (eg, BLS 740). We encourage readers to use the links and review the evidence and appendix.
As with all AHA Guidelines, each 2015 recommendation is labeled with a Class of Recommendation (COR) and a Level of Evidence (LOE). The 2015 Guidelines Update uses the newest AHA COR and LOE classification system, which contains modifications of the Class III recommendation and introduces LOE B-R (randomized studies) and B-NR (nonrandomized studies) as well as LOE C-LD (based on limited data) and LOE C-EO (consensus of expert opinion).
The AHA process for identification and management of potential conflicts of interest was used, and potential conflicts for writing group members are listed at the end of each Part of the 2015 Guidelines Update. For additional information about the systematic review process or management of potential conflicts of interest, see “Part 2: Evidence Evaluation and Management of Conflicts of Interest” in this …
... Our literature review retained 13 articles. These included 5 RCTs, 107-111 4 observational cohort studies, 112-115 3 metaanalyses, [116][117][118] and 1 subgroup analysis of data reported in the RCT by Rea et al. 119 For the purposes of this evidence review, the GRADE table is limited to pooled data from the 5 RCTs. All of the studies were conducted in the out-of-hospital setting. ...
This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the “what” in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.
... Our literature review retained 13 articles. These included 5 RCTs, 107-111 4 observational cohort studies, 112-115 3 metaanalyses, [116][117][118] and 1 subgroup analysis of data reported in the RCT by Rea et al. 119 For the purposes of this evidence review, the GRADE table is limited to pooled data from the 5 RCTs. All of the studies were conducted in the out-of-hospital setting. ...
Gavin D. Perkins, Andrew H. Travers, Robert A. Berg, Maaret Castren,
Julie Considine, Raffo Escalante, Raul J. Gazmuri, Rudolph W. Koster, Swee Han Lim,
Kevin J. Nation, Theresa M. Olasveengen, Tetsuya Sakamoto, Michael R. Sayre,
Alfredo Sierra, Michael A. Smyth, David Stanton, Christian Vaillancourt, on behalf of the
Basic Life Support Chapter Collaborators
