Abstract Objective To compare integrated automated load distributing band CPR (iA-CPR) with high-quality manual CPR (M-CPR) to determine equivalence, superiority, or inferiority in survival to ...hospital discharge. Methods Between March 5, 2009 and January 11, 2011 a randomized, unblinded, controlled group sequential trial of adult out-of-hospital cardiac arrests of presumed cardiac origin was conducted at three US and two European sites. After EMS providers initiated manual compressions patients were randomized to receive either iA-CPR or M-CPR. Patient follow-up was until all patients were discharged alive or died. The primary outcome, survival to hospital discharge, was analyzed adjusting for covariates, (age, witnessed arrest, initial cardiac rhythm, enrollment site) and interim analyses. CPR quality and protocol adherence were monitored (CPR fraction) electronically throughout the trial. Results Of 4753 randomized patients, 522 (11.0%) met post enrollment exclusion criteria. Therefore, 2099 (49.6%) received iA-CPR and 2132 (50.4%) M-CPR. Sustained ROSC (emergency department admittance), 24 h survival and hospital discharge (unknown for 12 cases) for iA-CPR compared to M-CPR were 600 (28.6%) vs. 689 (32.3%), 456 (21.8%) vs. 532 (25.0%), 196 (9.4%) vs. 233 (11.0%) patients, respectively. The adjusted odds ratio of survival to hospital discharge for iA-CPR compared to M-CPR, was 1.06 (95% CI 0.83–1.37), meeting the criteria for equivalence. The 20 min CPR fraction was 80.4% for iA-CPR and 80.2% for M-CPR. Conclusion Compared to high-quality M-CPR, iA-CPR resulted in statistically equivalent survival to hospital discharge.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
European resuscitation guidelines describe several acceptable placements of defibrillator pads during resuscitation of cardiac arrest. However, no clinical trial has compared defibrillation efficacy ...between any of the different pad placements. Houston Fire Department emergency medical system (EMS) used anterior-posterior (AP) defibrillator pad placement before becoming a study site in the circulation improving resuscitation care trial (CIRC). During CIRC, Houston Fire EMS used sternal-apical (SA) pad placement.
Data from electronic defibrillator records was compared between a pre-CIRC dataset and patients in the CIRC trial receiving manual cardiopulmonary resuscitation (CPR). Only shocks from patients with initial ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) were included. Measured outcome was defibrillation efficacy, defined as termination of VF/VT. The general estimatingequations model was used to study the association between defibrillation efficacy rates in the AP vs SA group.
In the pre-CIRC dataset, 207 included patients received 1023 shocks with AP pad placement, compared with 277 patients from the CIRC trial who received 1020 shocks with SA pad placement. There was no significant difference in defibrillation efficacy between AP and SA pads placement (82.1 % vs 82.2 %, p = 0.98).
No difference was observed in defibrillation efficacy between AP and SA pad placement in this study. A randomized clinical trial may be indicated.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Introduction An 80% chest compression fraction (CCF) during resuscitation is recommended. However, heterogeneous results in CCF studies were found during the 2015 Consensus on Science (CoS), ...which may be because chest compressions are stopped for a wide variety of reasons including providing lifesaving care, provider distraction, fatigue, confusion, and inability to perform lifesaving skills efficiently. Objective The effect of confounding variables on CCF to predict cardiac arrest survival. Methods A secondary analysis of emergency medical services (EMS) treated out-of-hospital cardiac arrest (OHCA) patients who received manual compressions. CCF (percent of time patients received compressions) was determined from electronic defibrillator files. Two Sample Wilcoxon Rank Sum or regression determined a statistical association between CCF and age, gender, bystander CPR, public location, witnessed arrest, shockable rhythm, resuscitation duration, study site, and number of shocks. Univariate and multivariate logistic regressions were used to determine CCF effect on survival. Results Of 2132 patients with manual compressions 1997 had complete data. Shockable rhythm ( p < 0.001), public location ( p < 0.004), treatment duration ( p < 0.001), and number of shocks ( p < 0.001) were associated with lower CCF. Univariate logistic regression found that CCF was inversely associated with survival (OR 0.07; 95% CI 0.01–0.36). Multivariate regression controlling for factors associated with survival and/or CCF found that increasing CCF was associated with survival (OR 6.34; 95% CI 1.02–39.5). Conclusion CCF cannot be looked at in isolation as a predictor of survival, but in the context of other resuscitation activities. When controlling for the effects of other resuscitation activities, a higher CCF is predictive of survival. This may explain the heterogeneity of findings during the CoS review.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background
Mild therapeutic hypothermia is argued being beneficial for outcome after cardiac arrest.
Materials and methods
Retrospective analysis of Circulation Improving Resuscitation Care (CIRC) ...trial data to assess if therapeutic cooling to 33 ± 1 °C core temperature had an association with survival. Of 4231 adult, out‐of‐hospital cardiac arrests of presumed cardiac origin initially enrolled, eligibility criteria for therapeutic hypothermia were met by 1812. Logistic regression was undertaken in a stepwise fashion to account for the impact on outcome of each significant difference and for the variable of interest between the groups.
Results
Out‐of‐ and in‐hospital cooled were 263 (15%), only after admission cooled were 230 (13%) and not cooled were 357 (20%) patients. The group cooled out of‐ and in hospital had 98 (37%) survivors as compared to the groups cooled in hospital only 80 (35%) and of those not cooled 68 (19%). After adjusting for known covariates (sex, age, witnessed cardiac arrest, no‐ and low‐flow time, shockable initial rhythm, random allocation, bystander cardiopulmonary resuscitation and percutaneous coronary intervention), the odds ratio for survival comparing no cooling to out‐of‐ plus in‐hospital cooling was 0·53 95% confidence interval (CI): 0·46–0·61, P < 0·001, and comparing to in‐hospital cooling only was 0·67 (95% CI: 0·50–0·89, P = 0·006).
Conclusion
Mild therapeutic hypothermia initiated out of hospital and/or in hospital was associated with improved survival within this secondary analysis of the CIRC cohort compared to no therapeutic hypothermia.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Purpose Mechanical chest compression devices, such as the AutoPulse® , have been developed to overcome problems associated with manual CPR (M-CPR). Animal and human studies have shown that ...AutoPulse CPR improves hemodynamic parameters over M-CPR. However, human studies conducted in the prehospital setting have conflicting results as to the AutoPulse's efficacy in improving survival. The Circulation Improving Resuscitation Care (CIRC) Trial is designed to evaluate the effectiveness of integrated AutoPulse-CPR (iA-CPR) (i.e., M-CPR followed by AutoPulse® -CPR) in a randomized controlled trial that addresses methodological issues that may have influenced the results of previous studies. Methods This paper describes the methodology of the CIRC trial. Results Unlike previous trials the CIRC trial studies iA-CPR where emphasis is placed on reducing “hands-off” time. The trial has six unique features: (1) training of all EMS providers in a standardized deployment strategy that reduces hands-off time and continuous monitoring for protocol compliance. (2) A pre-trial simulation study of provider compliance with the trial protocol. (3) Three distinct study phases (in-field training, run-in, and statistical inclusion) to minimize the Hawthorne effect and other biases. (4) Monitoring of the CPR process using either transthoracic impedance or accelerometer data. (5) Randomization at the subject level after the decision to resuscitate is made to reduce selection bias. (6) Use of the Group Sequential Double Triangular Test with sufficient power to determine superiority, inferiority, or equivalence. Conclusion This unique, large, multicenter study comparing the effectiveness of iA-CPR to M-CPR will contribute to the science of the treatment of out-of-hospital cardiac arrest as well as to the design of future trials.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background Guidelines recommend 2 min of CPR after defibrillation attempts followed by ECG analysis during chest compression pause. This pause may reduce the likelihood of return of ...spontaneous circulation (ROSC) and survival. We have evaluated the possibility of analysing the rhythm earlier in the CPR cycle in an attempt to replace immediate pre-shock rhythm analysis. Methods and results The randomized Circulation Improving Resuscitation Care (CIRC) trial included patients with out of hospital cardiac arrest of presumed cardiac aetiology. Defibrillator data were used to categorize ECG rhythms as shockable or non-shockable 1 min post-shock and immediately before next shock. ROSC was determined from end-tidal CO2 , transthoracic impedance (TTI), and patient records. TTI was used to identify chest compressions. Artefact free ECGs were categorized during periods without chest compressions. Episodes without ECG or TTI data or with undeterminable ECG rhythm were excluded. Data were analyzed using descriptive statistics. Of 1657 patients who received 3409 analysable shocks, the rhythm was shockable in 1529 (44.9%) cases 1 min post-shock, 13 (0.9%) of which were no longer shockable immediately prior to next possible shock. Of these, three had converted to asystole, seven to PEA and three to ROSC. Conclusion While a shockable rhythm 1 min post-shock was present also immediately before next possible defibrillation attempt in most cases, three patients had ROSC. Studies are needed to document if moving the pre-shock rhythm analysis will increase shocks delivered to organized rhythms, and if it will increase shock success and survival.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract only Background: Reports of pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) converting to an organized rhythm without defibrillator use are rare. We wish to report a ...series of such cases in the randomized Circulation Improving Resuscitation Care (CIRC) trial comparing outcome between integrated AutoPulse CPR (iA-CPR) and Manual-CPR (M-CPR) in patients with out-of-hospital cardiac arrest (OHCA) of presumed cardiac etiology. Methods: Defibrillator ECGs were studied to determine rhythm one minute after defibrillation attempts and rhythm immediately before the next defibrillation attempt. Rhythms were categorized as VF, pulseless VT, asystole or an organized rhythm. Organized rhythms were classified as either pulseless electrical activity (PEA) or as return of spontaneous circulation (ROSC) if accompanied by a steep increase in EtCO2, trans-thoracic impedance showing typical “dips,” and a detectable pulse. Results: In 1603 patients with analyzable date and a shockable rhythm there were 13 cases of VF/VT (10/3) conversions to PEA or ROSC during periods with external chest compressions without defibrillation attempts. In eight of the 10 VF cases chest compressions converted VF to PEA (5 iA-CPR vs 3 M-CPR) and in two to ROSC (2 iA-CPR vs 0 M-CPR). With VT one case converted to PEA (M-CPR ) and two to ROSC (2 iA-CPR vs 0 M-CPR). Examples will be presented. Conclusion: This study documents that conversion of VF or VT to an organized rhythm during CPR without electrical assistance is possible but rare.
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