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 Hands Only Evidence

Following up on Cardiac Arrest Management is an EMT-Basic Skill and more so on Cardiac Arrest Management is an EMT-Basic Skill – The BLS Evidence.

I already pointed out the flaws in continuing to include ventilations in CPR. There is no good evidence of improved survival with these unnecessary interruptions of compressions.

What about Hands Only CPR (Continuous Compression Resuscitation or CCR)?

Where is the evidence for that?

There does not need to be any evidence that Hands Only CPR is better than conventional CPR to remove ventilations from CPR. There must be evidence that ventilations provide better survival than Hands Only CPR to keep ventilations in CPR.

However, there is evidence for improved survival with Hands Only CPR –

CONCLUSION: Instituting the new cardiocerebral resuscitation protocol for managing prehospital cardiac arrest improved survival of adult patients with witnessed cardiac arrest and an initially shockable rhythm.

Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Ewy GA.
Am J Med. 2006 Apr;119(4):335-40.
PMID: 16564776 [PubMed – indexed for MEDLINE]

Conclusion
In adult patients with a witnessed cardiac arrest and an initially shockable rhythm, implementation of an out-of-hospital treatment protocol based on the principles of cardiocerebral resuscitation was associated with a dramatic improvement in neurologically intact survival.

Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Barney R, Keilhauer FA, Bellino M, Zuercher M, Ewy GA.
Ann Emerg Med. 2008 Sep;52(3):244-52. Epub 2008 Mar 28.
PMID: 18374452 [PubMed – indexed for MEDLINE]

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.

Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.
Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB.
JAMA. 2008 Mar 12;299(10):1158-65.
PMID: 18334691 [PubMed – indexed for MEDLINE]

Free Full Text at JAMA

CONCLUSION: Among adult, witnessed, ventricular fibrillation/ventricular tachycardia, out-of-hospital cardiac arrest resuscitated with minimally interrupted cardiac resuscitation, adjusted neurologically intact survival to hospital discharge was higher for individuals receiving initial passive ventilation than those receiving initial bag-valve-mask ventilation.

Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest.
Bobrow BJ, Ewy GA, Clark L, Chikani V, Berg RA, Sanders AB, Vadeboncoeur TF, Hilwig RW, Kern KB.
Ann Emerg Med. 2009 Nov;54(5):656-662.e1. Epub 2009 Aug 6.
PMID: 19660833 [PubMed – indexed for MEDLINE]

But we have to ventilate quickly because the patient’s brain will die without ventilation.

Maybe. Maybe not.

Conclusions
This report demonstrates that if powerful cardiac compressions are started early, in this case less than two minutes after normothermic arrest, it is possible to maintain circulation and a sort of spontaneous respiratory movements resulting in gas exchange for more than 25 minutes. For this patient, this kind of respiration was sufficient for survival without neurological damage.

Favourable outcome after 26 minutes of “Compression only” resuscitation: a case report.
Steen-Hansen JE.
Scand J Trauma Resusc Emerg Med. 2010 Apr 16;18:19.
PMID: 20398354 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central

 

Unless there is evidence of benefit, benign neglect is the best treatment.

 

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Comments

  1. It’s amazing what we can do when we start practicing EVIDENCE based medicine. Great post.

  2. That writeup on the 26 minutes of CCR should be required reading for anyone learning CCR/CPR. It’s unthinkable that anyone could still claim that ventilation is necessary after reading something like that.

  3. Is it possible that the reason that hands only CPR is better is that the oxygen level is depleted to point that does not support the death process? Inducing a state of suspended animation by forcing the cells into an anaerobic metabolic state?

    Sorry if I am not using the correct scientific terms…

    • George,

      Is it possible that the reason that hands only CPR is better is that the oxygen level is depleted to point that does not support the death process?

      It is possible. The research looks at what is probable and sets criteria for examining certain specific hypotheses. We generally take the information from research and extrapolate well beyond what is reasonable, especially when we exclude certain possibilities.

      Inducing a state of suspended animation by forcing the cells into an anaerobic metabolic state?

      Anaerobic metabolism would not be suspended animation. There can still be a lot of metabolism, but it could be that the aerobic metabolism is more harmful than anaerobic metabolism. Anaerobic metabolism does produce acidotic conditions quickly, so that might not be good.

      I think it is more likely that the oxygen needs of the body are much less during cardiac arrest and therefore not much oxygen is needed for metabolism.

      We also fail to appreciate how much air is exchanged with chest compressions and the placement of a non-rebreather mask can produce plenty of oxygen diffusion into the lungs.

      Using a bag to squeeze air into the lungs and stomach does not appear to address any need of the body in cardiac arrest.

      We have assumed that ventilations are the only means of gas exchange and that a lot of gas exchange is essential.

      The evidence does not support this hypothesis, but we only gradually back away from it.

      1. We used to insist on at least 1 liter of air/oxygen per ventilation.

      We have realized that was a mistake.

      2. We used to ventilate at much higher ratios. 5 to 1, 15 to 2, 30 to 2 – the more we decrease the rate of ventilation the more survival increases.

      3. We used to think there was no such thing as too much oxygen, even though everyone should know that people die from oxygen toxicity.

      Ventilations in CPR are based on faith, not on science.

      Sorry if I am not using the correct scientific terms…

      Not a problem. The people using the fanciest scientific terms seem to be the ones who mislead us the most. It is by questioning the things that are taken for granted that we learn what really works.

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