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

- Rogue Medic

Proposed 2015 ACLS Chest compression only CPR vs conventional CPR Recommendation


 
The AHA (American Heart Association) and ILCOR (International Liaison Committee On Resuscitation) 2015 resuscitation guidelines evidence reviews appear to be merely justifications for continuing to use treatments that do not improve survival with good neurological function, which is the only outcome that matters. What do the AHA and ILCOR intend to recommend for ventilation of patients who appear to be adults and pulseless due to non-respiratory conditions?
 

Full Question:
Among adults who are in cardiac arrest outside of a hospital (P), does provision of chest compressions (without ventilation) by untrained/trained laypersons (I), compared with chest compressions with ventilation (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, bystander CPR performance, CPR quality (O)?
[1]

 

Do we really want to increase the rate of survival of permanently comatose patients?
 


Image credit.
 

That is not a goal. That is only a first step if we can do something to change the outcome for this comatose patient. There is no reason to believe that ventilations during CPR will do anything to improve the neurological outcome of these patients. We want to improve the survival of neurologically intact patients, not fill nursing homes with comatose patients until sepsis finishes them off.
 

We suggest performing chest compressions alone for trained laypersons if they are incapable of delivering airway and breathing manoeuvres to cardiac arrest victims (weak recommendation, very low quality of evidence).[1]

 

The AHA and ILCOR want us to provide this intervention that is based on tradition and disproven pathophysiology, rather than based on any valid evidence, except if we are incapable of providing the intervention.

Ventilations do not improve outcomes. However, ventilations may be harmful, so we should avoid using them in all cases where ventilations are not supported by valid evidence. Ventilations are not supported by valid evidence for non-respiratory causes of adult cardiac arrest.
 

We suggest the addition of ventilations for trained laypersons who are capable of giving CPR with ventilations to cardiac arrest victims and willing to do so (weak recommendation, very low quality of evidence).[1]

 

Each study cited to support ventilations showed no significant difference between compression only and standard CPR according to the AHA/ILCOR evidence review. That is the way to imitate Rube Goldberg. That is not support for any kind of medical intervention.
 

This recommendation places a relatively high value in [1] harm avoidance (not performing CPR or performing ineffective chest compressions and ventilations) and [2] simplifying resuscitation logistics, than potential benefit of an intervention of routine ventilations and compressions.[1]

 

That statement misrepresents harm avoidance and simplification of resuscitation logistics, since it encourages the potentially harmful treatment that has no valid evidence that the intervention increases any benefit that matters. How does adding ventilations simplify resuscitation logistics?

There is no evidence that passive ventilation provides inadequate oxygenation during chest compressions.

There is no evidence that passive ventilation provides inadequate removal of carbon dioxide during chest compressions.

Where is the need for any positive pressure ventilation to decrease blood return to the heart and increase the likelihood of vomiting?

Why continue to recommend doing something harmful for no benefit to the patient?

Footnotes:

[1] Chest compression only CPR vs conventional CPR
ILCOR Scientific Evidence Evaluation and Review System
Questions Open for Public Comment
Closing Date – February 28, 2015
Question page

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Comments

  1. Live human study http://journal.cpha.ca/index.php/cjph/article/view/3788 Teaching the general public chest compression’s only specific to opioid OD patients.

    The response I got from the Doctor that wrote the medical directive.

    To James Thompson Oct 8, 2012
    CC ‘Aaron Orkin (aorkin@gmail.com)’

    Hi James

    Yes I helped craft them in accordance with the guidelines and feel the approach to chest compression only is the right way to go for many reasons. Happy to discuss with you at any time. Aaron Orkin (copied here) and Toronto public Health were more involved than I was as I was just the expert brought in to help out.
    Cell is 4165245434 or we could set up a face to face by email if you prefer.

    Laurie

    From: James Thompson [mailto:jgary.thompson@mail.utoronto.ca]
    Sent: Wednesday, October 03, 2012 5:02 PM
    To: Laurie Morrison MorrisonL@smh.ca
    Subject: naloxone training

    Dr. Morrison:

    I have just found out that RESCU was part of Toronto Public Health’s naloxone protocols. I think they should be changed, as there is no scientific evidence for chest compressions only in opiate overdose.
    See Attached ILCOR and Amer. Heart Assoc. Guidelines 2010

    Please reply ASAP

    Remember the Magic
    Gary Thompson
    @GaryCPR

    Dr. Morrison was not “Happy to discuss” when told her bringing a tape recorder she phoned the police. I get a phone call “Can you come to the station?” “Sure be right there” Police constable “Gary I want to shake your hand you have been saving lives, bad news is Dr. Morrison wants no contact” “Fine by me she is a nut”

    Dr. Morrison follow the guidelines you wrote and all medicine says past, present and future Give respiratory assist, then you MAY give Naloxone, continue respiratory assist (rescue breathing) until patient breaths adequately on their own.

    ILCOR 2010 page 345 & 367
    http://circ.ahajournals.org/content/122/16_suppl_2/S345.full.pdf+html
    AHA Guidelines 2010 Part 12:7 page 840-1
    http://circ.ahajournals.org/content/122/18_suppl_3/S829.full#sec-80
    World Health Organization 2013 page 7-9
    https://www.unodc.org/docs/treatment/overdose.pdf
    Canadian Red Cross http://www.redcross.ca/what-we-do/first-aid-and-cpr/first-aid-at-home/first-aid-tips/compression-only-cpr
    Sandoz manufactures of Naloxone Part 10 overdose
    http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ca7a8abd-9301-40f5-9300-6398f4d467b3#nlm34088-5

  2. New CPR Guidelines Oct 15, 2015 ILCOR Part 3 ‘Adult Basic Life Support and Automated External Defibrillation’
    See page 5 ‘Opioid Overdose Response Education’ Read my comments hyperlink BLS 891
    http://circ.ahajournals.org/content/132/16_suppl_1/S51.full.pdf+html

    Hyperlink BLS 891 read all comments https://volunteer.heart.org/apps/pico/Pages/PublicComment.aspx?q=891

    Soon to happen all over Ontario?? My deputation Toronto Board of Health https://youtu.be/QhsDjmI9H9c Read comments
    Don’t Forget to Breathe

Trackbacks

  1. […] links to medical journals. Comment #3 ‘Analogy car-lungs’ for a simple explanation. http://roguemedic.com/2015/02/proposed-2015-acls-chest-compression-only-cpr-vs-conventional-cpr-reco… Quote first paragraph from article “What do the AHA and ILCOR intend to recommend for […]

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