Switching to Chest-Compressions Only Method Doubled Survival in Out-of-Hospital Cardiac Arrest

TUCSON, AZ - Adoption of chest-compressions-only resuscitation over traditional cardiopulmonary resuscitation (CPR) for bystander intervention in out-of-hospital cardiac arrest dramatically improved survival rates in Arizona and other regions of the US, a new report shows [1].

The report, by Drs Gordon Ewy and Arthur Sanders (University of Arizona College of Medicine, Tucson), was published online in the Journal of the American College of Cardiology on November 28, 2012.

According to Ewy, in 2003 they decided to change the approach used in treatment of patients experiencing sudden cardiac arrest because survival rates with traditional CPR had remained low for so long. 

The changes included using chest compressions only for bystander resuscitation without breathing into the mouth, and even when the emergency services arrived, it was recommended to continue chest compressions and defibrillator shocks for several minutes before attempting to intubate the patient. With these changes, survival of patients with primary cardiac arrest in Arizona increased over a five-year period from 17.7% to 33.7%. Similar results were seen in two rural counties in Wisconsin that also made such changes.

Cardiocerebral resuscitation

The authors call the new method cardiocerebral resuscitation (CCR), which they say should now replace cardiopulmonary resuscitation (CPR).

"It is the heart and brain that need resuscitation, not the lungs," Ewy commented. "Once cardiac arrest occurs, chest compressions are the heartbeat. If these are stopped, blood flow to the brain and heart stops too. But for the first 10 minutes or so after cardiac arrest, the blood is still well oxygenated, so breathing help is not necessary and takes the focus away from the lifesaving chest compressions." He notes this does not apply if the victim has had a respiratory arrest such as drowning or drug overdose, where mouth-to-mouth resuscitation would be needed.

Ewy further points out that only one in four patients who have had a witnessed cardiac arrest actually receive CPR, and one of the major reasons why bystanders do not perform CPR is because they are reluctant to give mouth-to-mouth resuscitation on a stranger. "Our studies in pigs showed that chest compressions only were just as good as chest compression plus mouth to mouth in terms of survival. And we established that when performing CPR in humans, the average time taken to give the two breaths was 16 seconds—much longer than the two seconds recommended. Sixteen seconds is far too long to be without a heartbeat. So we decided in 2003 that we would switch to chest compressions only."

Sixteen seconds is far too long to be without a heartbeat.

Ewy says they felt justified in making this decision because survival rates with the traditional recommendations were so low. "So we didn't have a randomized controlled trial, but sometimes public-health decisions have to be made without such data. We didn't have randomized trials showing that wearing seatbelts in cars saves lives, but it seemed like a reasonable approach. We felt survival rates from out-of-hospital cardiac arrest were too low and we needed to do something to improve them. And we had enough data to convince our local authorities to make the change." This approach of obtaining baseline data and, if not optimal, making changes and continuously reevaluating the results is called continuous quality improvement.

"Know your data"

Ewy says others should follow their example. His message to healthcare providers is: "Know your data. If survival of patients with out-of-hospital cardiac arrest who are in VF in your area is less than 30%, you should be doing something different. Change to cardiocerebral resuscitation."

The change to chest compressions only is now being taken up around the world. Ewy notes that it has already been adopted in many Asian countries, and the American Heart Association has now changed its recommendations to favor this approach, but the Europeans have not yet instituted the new approach.

In Arizona, a third level has been added, with different, more aggressive recommendations on how to treat these patients once in the hospital. "We are now advising that they if they come with a pulse having been resuscitated but are still in a coma, they are cooled down quickly to 33°C for 24 hours and then taken to the cath lab. Most cardiac arrest in adults is caused by a blocked coronary artery. If you open it up, they do better."

Was it performance rather than protocol?

In an accompanying commentary [2], Dr Thomas Rea (University of Washington, Seattle,) suggests that it might have been the impressive effort to measure and improve that led to the enhanced survival seen in Arizona, rather than the new protocols recommended. He points out that there are also some communities that practice traditional guideline-based CPR and achieve similar or even better survival, but these communities typically also invest in a measure-and-improve quality-assurance program.

He writes: "Future study may help attribute the relative benefit of protocol vs performance as it relates to the question of CPR vs CCR. Until then, the citizens of Arizona should thank their community stakeholders and resuscitation leadership who decided to explicitly engage in continuous quality improvement. Their team effort has saved hundreds of lives. The challenge for Arizona is to sustain this effort. For other communities, the Arizona experience should compel stakeholders to measure and improve sudden-cardiac-arrest care and outcome."