Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Cardiac Arrest Management is an EMT-Basic Skill – The BLS Evidence

Yesterday, there were a lot of comments on Cardiac Arrest Management is an EMT-Basic Skill. I haven’t gone through many of the comments, but there are some things that I do need to clarify.

What is a good outcome from cardiac arrest?

Survival – Anything short of discharge from the hospital with similar brain function to what the patient had before the cardiac arrest is not a good outcome.

What has been shown to work in cardiac arrest?

High quality chest compressions. When defibrillation interrupts chest compressions, survival suffers.

Effective chest compressions are essential for providing blood flow during CPR. For this reason all patients in cardiac arrest should receive chest compressions (Class I, LOE B).47–51 [1]

Rapid defibrillation.

All BLS providers should be trained to provide defibrillation because VF is a common and treatable initial rhythm in adults with witnessed cardiac arrest.195 For victims with VF, survival rates are highest when immediate bystander CPR is provided and defibrillation occurs within 3 to 5 minutes of collapse.4,5,10,11,196,197 Rapid defibrillation is the treatment of choice for VF of short duration, such as for victims of witnessed out-of-hospital cardiac arrest or for hospitalized patients whose heart rhythm is monitored (Class I, LOE A).30,31 [2]

Ventilations?

At this time there is insufficient evidence to support the removal of ventilations from CPR provided by EMS professionals. [3]

This is nonsense.

 

Survival DOES NOT get worse when we remove ventilations.

 

Where is the evidence to support continued inclusion of ventilations?

This is just the fraud of alternative medicine applied to what is supposed to be real medicine.

Unless there is evidence that the treatment is better than placebo (or better than no treatment), it is just an experimental treatment based on expert opinion.

All expert opinions need to come with expiration dates.

If NEW research does NOT demonstrate efficacy of the treatment within 5 years (the next ACLS revision) the expert opinion MUST be discarded as unsupportable.

 

No good evidence = a worthless opinion.

 

Original cartoon

There is evidence that chest compressions improve survival.

There is no evidence that chest compressions with ventilations improves survival over continuous chest compressions.

That means the ventilations are only based on moldy decaying expert opinions.

See also –

Cardiac Arrest Management is an EMT-Basic Skill – The Hands Only Evidence

Footnotes:

[1] Chest Compressions
Part 5: Adult Basic Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Adult BLS Sequence
Early CPR
Free Full Text Article from Circulation with links to PDF download

47.↵ Olasveengen TM, Wik L, Steen PA. Standard basic life support vs. continuous chest compressions only in out-of-hospital cardiac arrest. Acta Anaesthesiol Scand. 2008;52:914–919. Medline
48.↵ Ong ME, Ng FS, Anushia P, Tham LP, Leong BS, Ong VY, Tiah L, Lim SH, Anantharaman V. Comparison of chest compression only and standard cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Singapore. Resuscitation. 2008;78:119–126. CrossRefMedline
49.↵ Bohm K, Rosenqvist M, Herlitz J, Hollenberg J, Svensson L. Survival is similar after standard treatment and chest compression only in out-of-hospital bystander cardiopulmonary resuscitation. Circulation. 2007;116:2908–2912. Abstract/FREE Full Text
50.↵ Iwami T, Kawamura T, Hiraide A, Berg RA, Hayashi Y, Nishiuchi T, Kajino K, Yonemoto N, Yukioka H, Sugimoto H, Kakuchi H, Sase K, Yokoyama H, Nonogi H. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest. Circulation. 2007;116:2900–2907. Abstract/FREE Full Text
51.↵ SOS-KANTO Study Group. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. Lancet. 2007;369:920–926. CrossRefMedline

All of the links to the studies are at the Circulation page. None of these studies show a benefit from ventilation.

[2] AED Defibrillation (Box 5, 6)
Part 5: Adult Basic Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Adult BLS Skills
Free Full Text Article from Circulation with links to PDF download

4.↵ Chan PS, Nichol G, Krumholz HM, Spertus JA, Nallamothu BK. Hospital variation in time to defibrillation after in-hospital cardiac arrest. Arch Intern Med. 2009;169:1265–1273. Abstract/FREE Full Text
5.↵ Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010;3:63–81. Abstract/FREE Full Text
10.↵ Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med. 2000;343:1206–1209. CrossRefMedline
11.↵ Agarwal DA, Hess EP, Atkinson EJ, White RD. Ventricular fibrillation in Rochester, Minnesota: experience over 18 years. Resuscitation. 2009;80:1253–1258. CrossRefMedline
195.↵ The Public Access Defibrillation Trial Investigators. Public-access defibrillation and survival after out-of-hospital cardiac arrest. N Engl J Med. 2004;351:637–646. CrossRefMedline
196.↵ Rea TD, Cook AJ, Stiell IG, Powell J, Bigham B, Callaway CW, Chugh S, Aufderheide TP, Morrison L, Terndrup TE, Beaudoin T, Wittwer L, Davis D, Idris A, Nichol G. Predicting survival after out-of-hospital cardiac arrest: role of the Utstein data elements. Ann Emerg Med. 2010;55:249–257. CrossRefMedline
197.↵ Caffrey SL, Willoughby PJ, Pepe PE, Becker LB. Public use of automated external defibrillators. N Engl J Med. 2002;347:1242–1247. CrossRefMedline

All of the links to the studies are at the Circulation page.

[3] Technique: Chest Compressions (Box 4)
Part 5: Adult Basic Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Adult BLS Skills
Free Full Text Article from Circulation with links to PDF download

I included the evidence above to support chest compressions and defibrillation.

There is no evidence to support ventilations.

We should not be using ventilations in the initial treatment of cardiac arrest.

.

Comments

  1. Rogue, do those studies address the distinction between primary cardiac arrest and secondary cardiac arrest as defined and distinguished by Dr. Gordon Ewy? While I agree that in cases of primary cardiac arrest (the most common form of cardiac arrest, according to Dr. Ewy) where the heart stops while there is an adequate supply of oxygen in the blood, ventilation and oxygenation is unnecessary, I believe that there may still be a role for oxygenation and ventilation in cases of secondary cardiac arrest (where the cause of the arrest was due to global hypoxia). Do these studies address any distinction between the two?

    • Justin Sleffel,

      Rogue, do those studies address the distinction between primary cardiac arrest and secondary cardiac arrest as defined and distinguished by Dr. Gordon Ewy?

      No. These were studies of bystander CPR vs. bystander compression only CPR.

      While I agree that in cases of primary cardiac arrest (the most common form of cardiac arrest, according to Dr. Ewy) where the heart stops while there is an adequate supply of oxygen in the blood, ventilation and oxygenation is unnecessary, I believe that there may still be a role for oxygenation and ventilation in cases of secondary cardiac arrest (where the cause of the arrest was due to global hypoxia). Do these studies address any distinction between the two?

      Nobody is recommending treating anoxic arrest without ventilation.

      Not ventilating anoxic patients is a theoretical concern.

      This either has not been a problem in the systems that have adopted compression only CPR or the increased survival from primary cardiac arrest is greater than any decreased survival from anoxic patients not receiving initial ventilation.

      Either way, continuing to ventilate patients in the absence of evidence of anoxia is not supported by any good evidence.

      .

  2. So, in reference to cardiac arrest management, and the subsequent reporting to CARES and the like. Can you explain to us all what the Utstein survivor category is and if it is just a survival to discharge or if it has any correlation to having an intact neurological status at said discharge?

    • Can’t say, clowns will eat me,

      So, in reference to cardiac arrest management, and the subsequent reporting to CARES and the like. Can you explain to us all what the Utstein survivor category is and if it is just a survival to discharge or if it has any correlation to having an intact neurological status at said discharge?

      Utstein does not appear to have a requirement, other than using a validated score.

      Neurological Outcome at Discharge From Hospital
      Documentation of a patient’s neurological status at many specific points is desirable (eg, on discharge from the hospital, at 6 months, at 1 year); however, recording neurological outcomes after discharge has been difficult. Survival without higher neurological function is suboptimal; therefore, it is important to attempt to assess neurological outcome at discharge. A simple validated neurological score such as the Cerebral Performance Category (CPC) should be recorded, if available.9

      AHA Scientific Statement
      Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports
      Update and Simplification of the Utstein Templates for Resuscitation Registries: A Statement for Healthcare Professionals From a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa)
      Free Full Text from Circulation with link to PDF Download

      I like Dr. Amal Mattu’s assessment of neurological function – ability to pay taxes.

      This criterion would not apply to those who were not paying taxes before, but it does cut through all sorts of silliness that people come up with to complicate this.

      The brain function after discharge from the hospital should be about the same as before the cardiac arrest. Anything else is not good brain function.

      If I could dress myself, drive a car, cook for myself, and did not need home health care before a cardiac arrest, then any changes in these would indicate cardiac arrest with poor neurological function.

      .

  3. I think the cartoon you posted is an excellent way of illustrating your stance, and the entire premise of evidence-based medicine, not only on this issue, but on many others as well. The point is that a treatment being performed without any evidence supporting the efficacy of said treatment is not treatment at all, but voodoo medicine. This applies to the use of selective cardiotoxins in the case of dysrhythmias, high-flow O2, spinal immobilization, the three nitro rule, Lasix for CHF or hypertensive crisis, etc. Many people are still of the opinion that we should do everything that we think MIGHT work on the off chance that something WILL work, and don’t stop to consider that some of those “treatments” may actually lead to worse outcomes than withholding that treatment in the first place. For example, there is a school of thought that therapeutic hypothermia works in part because it slows the damage caused by high doses of epinepherine. That 80mg of Lasix might put someone on dialysis for the rest of their life, if it doesn’t send them into outright renal failure. Withholding NTG may just kill someone.

    The point of the matter MUST be that continuous, uninterrupted chest compressions and timely defibrillation (provided that defibrillation doesn’t interfere with the delivery of chest compressions) are the ONLY treatments shown to improve survival to neurologically-intact hospital discharge. Therefore, any other treatments dictated by local protocol should be timed in such a way as to minimize interruption of chest compressions and prevent delayed defibrillation. Local protocols will indeed continue to dictate our treatment pathways, but we as paramedics need to remain educated and take steps in our own treatment pathways to integrate what has been proven to WORK with what our protocols require. That means doing continuous chest compressions until we have enough personnel present to do all of the “paramedic stuff” while someone else does the chest compressions. Minimize interruptions. Start the line and push the drugs while someone maintains continuous chest compressions. Intubation should be performed with compressions ongoing, and if that’s not possible, then it should be done during a rhythm check, not during an otherwise-unnecessary interruption in CPR. Go for IO access if you can’t get a line, consider a King Tube or other blind-insertion airway device if your protocols dictate that you use an advanced airway. CONTINUE CPR while the defibrillator is charging and resume it IMMEDIATELY after administering the shock.

    A lot of people seem to have difficulty separating ACLS guidelines from local protocols and have an even harder time integrating what has been proven to WORK with what their guidelines and protocols tell them they have to do. No one is advocating that Paramedics should go rogue (Ha!) and start doing things their own way. I think Rogue is advocating for systemic change in the way we treat cardiac arrest, and we as medical professionals have the responsibility to try to integrate our protocols and guidelines with what we know will work. Maybe then, we’ll hit on something huge.

  4. In the years that I have been in EMS the last ten have seen the most changes in ACLS. We have gone away from stack shocking, by far the the most accepted by the masses. However in teaching ACLS I have seen medical folks reluctant to perform chest compression. It seems that everyone is still in the belief that airway is king and will save the dead person on the table. Hell there are ED doc’s out there that take King airway’s out of codes when brought in, even if the pt is being ventilated well. I think it is more a pride thing. Look I can put a small tube in your throat.

    Currently cardio cerebral Resuscitation method is showing a 3 fold increase in ROSC. This is were we need to be for codes in or out of the hospital . It is a matter of getting past the ego’s.

    • Che King,

      In the years that I have been in EMS the last ten have seen the most changes in ACLS. We have gone away from stack shocking, by far the the most accepted by the masses. However in teaching ACLS I have seen medical folks reluctant to perform chest compression. It seems that everyone is still in the belief that airway is king and will save the dead person on the table.

      This is true.

      The person is not usually dead because of respiratory arrest, but because of cardiac arrest.

      The proven treatments for cardiac arrest do not include ventilation.

      Hell there are ED doc’s out there that take King airway’s out of codes when brought in, even if the pt is being ventilated well. I think it is more a pride thing. Look I can put a small tube in your throat.

      Just because a person is board certified in emergency medicine does not mean that the person understands research.

      More emergency physicians are using extraglottic airways and leaving the EMS King/LMA/CombiTube in place – or they are putting them in themselves. ACLS is starting to change that, because everyone is required to learn about these airways to successfully complete the course.

      Currently cardio cerebral Resuscitation method is showing a 3 fold increase in ROSC. This is were we need to be for codes in or out of the hospital . It is a matter of getting past the ego’s.

      I completely agree about the need to switch to Hands Only CPR (CCR).

      .

    • Hell there are ED doc’s out there that take King airway’s out of codes when brought in, even if the pt is being ventilated well. I think it is more a pride thing. Look I can put a small tube in your throat.

      By virtue of geography, we bring all of our codes to a Level 1 trauma center/teaching hospital. In the resuscitation room, an EM intern is responsible for airway management. Many of them look like we shot a puppy if we come in with the patient intubated.

      I don’t think it’s so much ego for them as it is “I needed that tube to get another checkmark on my residency.”

      • BH,

        There are also a lot of doctors who do not understand research or who do not keep up to date on resuscitation.

        Some will sit through an ACLS class, but constantly have people paging them, or they are squeezing a daytime ACLS class between a couple of night shifts, or they just do not pay attention. It is rare that anyone, even the ACLS instructors, actually read the book. Reading the book is supposed to be a prerequisite for the class.

        ACLS states that interruptions of compressions are bad.

        Most doctors cannot intubate during compressions.

        Therefore, intubation is worse than extraglottic airways.

        Dr. Weingart clearly states that he places extraglottic airways, rather than waste time on intubation.

        EMCrit Podcast 34 – 2010 ACLS Guidelines

        We need to educate some of the doctors about what good patient care is.

        .

  5. While cardiac arrest management might be a BLS skill, post cardiac arrest management is an ALS skill and one best started as soon as possible. Airway management is very often a part of that because most of the time the patient doesn’t magically wake up and need no further intervention. Add to that the beneficial effects of therapeutic hypothermia and the very real possibility that that particular therapy might work better if started earlier in rural settings, then you have a different picture than the superficial one you present in a long post.

    As a paramedic I can (and have) applied an SAED to patients and pressed the shock button. So have many of my BLS co-workers. For that matter, so can a fire department first responder, or even the junior partner in a law firm. I’ve seen all of that. What they can NOT do is provide the post ROSC support that will give the patient a better chance at CPC Category 1 or 2 discharge and I can.

    ROSC is just the first step in cardiac arrest survival.

    • Too Old To Work,

      While cardiac arrest management might be a BLS skill, post cardiac arrest management is an ALS skill and one best started as soon as possible.

      If starting ALS as soon as possible is important, where is the research to show what early ALS makes a difference in survival?

      I am writing about cardiac arrest, not about post-resuscitation care. Should include cardiac catheterization in here? We could also discuss the dispatch criteria, the types of ambulances used, and many other things that are not cardiac arrest, but are related to cardiac arrest. Maybe billing is best started as soon as possible. How long do you want my posts to be?

      I will write about post-resuscitation care and point out the flaws with the rush to give ALS treatments, but that will be a different post.

      Only BLS = more survivors.

      .

  6. Isn’t there evidence that starting TH during the code improves odds? Promoting BLS lead in a code is dangerous in a system where the standards are as low as mine.

    • CS,

      Isn’t there evidence that starting TH during the code improves odds?

      I am not aware of any recommendation for starting TH before ROSC. Even after ROSC, I don’t think there is a study that demonstrates improved survival if started by EMS, but it is still a new use for this treatment, so we can expect a lot of research.

      The problem is that we cannot expect the same for the treatments we automatically use as if they were based on improved survival.

      Promoting BLS lead in a code is dangerous in a system where the standards are as low as mine.

      Promoting anything less than a reboot may be dangerous. You can always hope the state, or feds, take over under RICO laws or something similar.

      .

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