[Grovenet] Critically important new information on CPR . . . .

Tue May 5 14:38:06 PDT 2009

Very interesting, Bob. Thanks!

Jane B-P

Phoenix Acupuncture and Chinese Medicine
Home of the TAO (Team Against Obesity)
www.phoenix-acupuncture.net

-----Original Message-----
From: Bob Browning <rab at jurislex.com>
To: Grovenet <grovenet at rdrop.com>
Sent: Tue, 5 May 2009 10:20 am
Subject: [Grovenet] Critically important new information on CPR . . . .

Just in case one of you are around me if and when I
have another heart attack!!

bob

+++++++++++++++++++++++

Protocol
stressing uninterrupted compressions can improve survival after
out-of-hospital cardiac-arrest
May 4, 2009  | Marlene Busko

Kansas City, MO - Survival among adults
with bystander-witnessed, out-of-hospital cardiac arrest with an
initial rhythm of ventricular fibrillation (VF) improved from 22% to
44% following changes to a resuscitation protocol, a new study reports 
[1].

The historical protocol followed AHA 2000 guidelines, while
the revised protocol modified this and advocated CPR before
defibrillation, increased chest compressions, and decreased emphasis on
ventilations and intubation in order to promote cardiac perfusion, lead
author Dr Alex G Garza (Georgetown University School of
Medicine, Washington, DC) told heartwire.

"The study adds to the body of science demonstrating that chest
compressions&#8212;and limiting interruptions to chest compressions—are 
one
of the most important interventions that can be provided 
for
out-of-hospital cardiac arrest," he said. The results speak for
themselves, he added, noting that they found "dramatic" improvements in
the percentages of patients who survived until hospital discharge and
who had good neurological outcomes.

"For too long we have taught the 'ABC's' [airway, breathing,
circulation] when in fact it should probably be 'CBA,' meaning 'focus
on circulation (compressions) first,' " said Garza.

The retrospective cohort study, which compared cardiac-arrest
survival in Kansas City three years before and one year after a
modified resuscitation protocol was implemented, is published online
May 4, 2009 in Circulation.
Low survival rates

For
too long we have taught the ABCs [airway, breathing, circulation] when
in fact it should probably be 'CBA,' meaning 'focus on circulation
(compressions) first.'

Despite multiple research efforts and a push to increase the
availability of defibrillators, survival rates after out-of-hospital
cardiac arrest remain low in the US, the researchers write.

In 2005, in an effort to improve resuscitation outcomes, the Kansas
City, MO emergency medical system revised their protocol to reflect
what happens in the three-phase, time-dependent model for cardiac
arrest.

In this model, the "electrical phase" occurs from 0 to five minutes
after the cardiac arrest, and this is when defibrillation is the
optimal therapy, the researchers write. At five to 10 minutes after a
cardiac arrest, in the "circul
ation phase," an optimal
chest-compression strategy is needed to improve coronary perfusion
pressure, to set up a successful defibrillation. Optimal treatment for
the third phase, the "metabolic phase," which begins 10 minutes after
cardiac arrest, is less clear.

In places such as casinos and airports, swift defibrillation upon
cardiac arrest has "unquestionably" improved survival, the group
writes. Unfortunately, in most other scenarios, when emergency medical
personnel arrive, cardiac-arrest patients are typically in the
circulatory phase rather than the electrical phase, they add.

In the current study, emergency medical service providers were
trained in the new resuscitation protocol, which mandated that rescue
workers perform at least three rounds of 200 chest compressions before
attempting intubation, maintain a 50:2 ratio of compression to
ventilation, restrict aggressive ventilation, and minimize pauses for
ventilation.

The researchers compared patients who had an out-of hospital cardiac
arrest during January 1, 2003 to March 31, 2006 (historical cohort) vs
April 1, 2006 to March 31, 2007 (revised-protocol cohort).

Overall survival increased from 7.5% to 13.9%.

In the subset of patients most likely to survive&#8212;those with 
cardiac
arrest that was witnessed by bystanders and who had an initial
shockable rhythm of VF:

  Return of spontaneous circulation improved from 37.8% (54 of 143
patients) to 59.6% (34 of 57 patients).

  Survival until hospital d
ischarge improved from 22.4% (32 of 143
patients) to 43.9% (25 of 57 patients).

Of the 25 survivors, 88% had a good neurological outcome when
discharged from the hospital.

"I think that emergency medical services should look at their data
to see whether they actually routinely arrive at a cardiac arrest
during the first five minutes (the 'electrical phase'), and if not, it
would be a good practice to perform CPR before defibrillation," said
Garza. Recent evidence suggests that aggressive ventilation and
intubation are detrimental for establishing good coronary perfusion
pressure, he added.

"The jury is still out on the optimal number of compressions.
However, our data and that of others suggest that more is probably
better."
Third study to support new strategy

Emergency
medical services should&nbsp;. . . see
whether
they actually routinely arrive at a cardiac arrest during the first
five minutes. If not, it would be a good practice to perform CPR before
defibrillation.

When asked by heartwire to comment on the
study, Dr Gordon A Ewy
(University of Arizona, Tucson) said: "This is the third study that
essentially shows that our new form of CPR for primary cardiac arrest,
which we call cardiocerebral resuscitation [as opposed to
cardiopulmonary resuscitation], significantly improves survival."

This study confirms what he and colleagues observed in Arizona and
what Dr Michael J Kellum
(Mercy Health System, Janesvill
e, WI) and colleagues in Wisconsin
reported, after emergency personnel modified their AHA-guideline-based
cardiac-arrest resuscitation protocols to incorporate a newer approach 
[2].

"The less often chest compressions are interrupted during
resuscitation, the better the survival," said Ewy. "During cardiac
arrest, your hands are their heart, and every time you stop
compressions for anything, vital forward blood flow stops."

For many years, Ewy has advocated the merits of continuous chest
compression without assisted breathing.

It is hoped that studies such as the one by Garza and colleagues
will lead to more appropriate guidelines, he said.

Sources

  Garza AG, Gratton MS, Salomone JA, et al.
Improved
patient survival using a modified resuscitation protocol for
out-of-hospital cardiac arrest. Circulation 2009; DOI:
10.1161/CIRCULATIONAHA.108.815621. Available at: 
http://circ.ahajournals.org.

  Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral
resuscitation improves survival of patients with out-of-hospital
cardiac arrest. Am J Med 2006; 119:335-340.

Related links

  GASP! Agonal breathing common, predicts survival after
out-of-hospital cardiac arrest

[Arrhythmia/EP &gt; Arrhythmia/EP; Nov 26, 2008]

  CPR by paramedics for cardiac arrest: First focus is
to restore pulse in the field

[Clinical cardiology &gt; Clinical cardiology; Nov 04, 2008]

  AHA promotes chest-compression-only
bystander-initiated CP
R

[Acute Coronary Syndromes &gt; Acute coronary syndromes; Mar 31,
2008]

  Streamlined "CPR" by EMS can improve survival in
out-of-hospital cardiac arrest

[Acute Coronary Syndromes &gt; Acute coronary syndromes; Mar 12,
2008]

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