Summary Background Mechanical chest compression devices have the potential to help maintain high-quality cardiopulmonary resuscitation (CPR), but despite their increasing use, little evidence exists ...for their effectiveness. We aimed to study whether the introduction of LUCAS-2 mechanical CPR into front-line emergency response vehicles would improve survival from out-of-hospital cardiac arrest. Methods The pre-hospital randomised assessment of a mechanical compression device in cardiac arrest (PARAMEDIC) trial was a pragmatic, cluster-randomised open-label trial including adults with non-traumatic, out-of-hospital cardiac arrest from four UK Ambulance Services (West Midlands, North East England, Wales, South Central). 91 urban and semi-urban ambulance stations were selected for participation. Clusters were ambulance service vehicles, which were randomly assigned (1:2) to LUCAS-2 or manual CPR. Patients received LUCAS-2 mechanical chest compression or manual chest compressions according to the first trial vehicle to arrive on scene. The primary outcome was survival at 30 days following cardiac arrest and was analysed by intention to treat. Ambulance dispatch staff and those collecting the primary outcome were masked to treatment allocation. Masking of the ambulance staff who delivered the interventions and reported initial response to treatment was not possible. The study is registered with Current Controlled Trials, number ISRCTN08233942. Findings We enrolled 4471 eligible patients (1652 assigned to the LUCAS-2 group, 2819 assigned to the control group) between April 15, 2010 and June 10, 2013. 985 (60%) patients in the LUCAS-2 group received mechanical chest compression, and 11 (<1%) patients in the control group received LUCAS-2. In the intention-to-treat analysis, 30 day survival was similar in the LUCAS-2 group (104 6% of 1652 patients) and in the manual CPR group (193 7% of 2819 patients; adjusted odds ratio OR 0·86, 95% CI 0·64–1·15). No serious adverse events were noted. Seven clinical adverse events were reported in the LUCAS-2 group (three patients with chest bruising, two with chest lacerations, and two with blood in mouth). 15 device incidents occurred during operational use. No adverse or serious adverse events were reported in the manual group. Interpretation We noted no evidence of improvement in 30 day survival with LUCAS-2 compared with manual compressions. On the basis of ours and other recent randomised trials, widespread adoption of mechanical CPR devices for routine use does not improve survival. Funding National Institute for Health Research HTA – 07/37/69.
Mechanical chest compression devices may help to maintain high-quality cardiopulmonary resuscitation (CPR), but little evidence exists for their effectiveness. We evaluated whether or not the ...introduction of Lund University Cardiopulmonary Assistance System-2 (LUCAS-2; Jolife AB, Lund, Sweden) mechanical CPR into front-line emergency response vehicles would improve survival from out-of-hospital cardiac arrest (OHCA).
Evaluation of the LUCAS-2 device as a routine ambulance service treatment for OHCA.
Pragmatic, cluster randomised trial including adults with non-traumatic OHCA. Ambulance dispatch staff and those collecting the primary outcome were blind to treatment allocation. Blinding of the ambulance staff who delivered the interventions and reported initial response to treatment was not possible. We also conducted a health economic evaluation and a systematic review of all trials of out-of-hospital mechanical chest compression.
Four UK ambulance services (West Midlands, North East England, Wales and South Central), comprising 91 urban and semiurban ambulance stations. Clusters were ambulance service vehicles, which were randomly assigned (approximately 1 : 2) to the LUCAS-2 device or manual CPR.
Patients were included if they were in cardiac arrest in the out-of-hospital environment. Exclusions were patients with cardiac arrest as a result of trauma, with known or clinically apparent pregnancy, or aged < 18 years.
Patients received LUCAS-2 mechanical chest compression or manual chest compressions according to the first trial vehicle to arrive on scene.
Survival at 30 days following cardiac arrest; survival without significant neurological impairment Cerebral Performance Category (CPC) score of 1 or 2.
We enrolled 4471 eligible patients (1652 assigned to the LUCAS-2 device and 2819 assigned to control) between 15 April 2010 and 10 June 2013. A total of 985 (60%) patients in the LUCAS-2 group received mechanical chest compression and 11 (< 1%) patients in the control group received LUCAS-2. In the intention-to-treat analysis, 30-day survival was similar in the LUCAS-2 (104/1652, 6.3%) and manual CPR groups 193/2819, 6.8%; adjusted odds ratio (OR) 0.86, 95% confidence interval (CI) 0.64 to 1.15. Survival with a CPC score of 1 or 2 may have been worse in the LUCAS-2 group (adjusted OR 0.72, 95% CI 0.52 to 0.99). No serious adverse events were noted. The systematic review found no evidence of a survival advantage if mechanical chest compression was used. The health economic analysis showed that LUCAS-2 was dominated by manual chest compression.
There was substantial non-compliance in the LUCAS-2 arm. For 272 out of 1652 patients (16.5%), mechanical chest compression was not used for reasons that would not occur in clinical practice. We addressed this issue by using complier average causal effect analyses. We attempted to measure CPR quality during the resuscitation attempts of trial participants, but were unable to do so.
There was no evidence of improvement in 30-day survival with LUCAS-2 compared with manual compressions. Our systematic review of recent randomised trials did not suggest that survival or survival without significant disability may be improved by the use of mechanical chest compression.
The use of mechanical chest compression for in-hospital cardiac arrest, and in specific circumstances (e.g. transport), has not yet been evaluated.
Current Controlled Trials ISRCTN08233942.
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in
; Vol. 21, No. 11. See the NIHR Journals Library website for further project information.
Abstract Introduction International guidelines for basic life support and defibrillation are identical for lay people and healthcare professionals. In 2002, a small meeting hosted by the ...Resuscitation Council (UK) debated recent advances in resuscitation science, along with the possibility of more demanding procedures for treating out of hospital cardiac arrest (OHCA) that could take advantage of the expertise available with professional use. The resulting algorithm known as Protocol C could not be tested in a randomized trial for reasons relating to consent, but was introduced by one ambulance service as an observational study. Results from a 2-year period from one city within the service area are presented, using the Utstein style of reporting to show the recommended ‘comparator’ group whilst also providing epidemiological data on the frequency of cardiac arrest within the community and the outcome of all resuscitation attempts. Methods Manual methods were used to collect data from 2009 and 2010 for cases of cardiac arrest treated by crews from the two ambulance stations within the city of Brighton and Hove. All transported patients were tracked individually through the hospital because no official method of data linkage is available. Outcome data were obtained for survival to hospital discharge, or to 30 days for the few who remained in hospital care for that duration. Results In the epidemiological analysis, 454 patients with OHCA were treated over 2 years, of whom 151 (33%) had sustained return of spontaneous circulation (ROSC) at hospital handover and 59 (13%) survived to discharge or for 30 days. Within the ‘comparator’ group of 79 patients, 47 (59%) achieved sustained ROSC to hospital handover and 24 (30%) survived. Conclusion The use of Protocol C has been associated with rates of sustained ROSC to hospital and of survival to discharge that have reached the range of international best practice. The improvement noted in this observational study cannot be ascribed to the new protocol alone; any wider use should await randomized trials to test the impact of this single variable. Meanwhile, wider adoption of the Utstein system to compare results for treatment of OHCA will provide a potent stimulus for emergency services to seek ways of improving outcome.
This prospective study evaluated the acquisition and retention of skills in cardio-pulmonary resuscitation (CPR) and the use of the automated external defibrillator (AED) by lay volunteers involved ...in the Department of Health, England National Defibrillator Programme. One hundred and twelve trainees were tested immediately before and after an initial 4-h class; 76 were similarly reassessed at refresher training 6 months later. A standardised test scenario that required assessment of the casualty, CPR and the use of an AED was evaluated using recording manikin data and video recordings. Before training only 44% of subjects delivered a shock. Afterwards, all did so and the average delay to first shock was reduced by 57
s. All trainees placed the defibrillator electrodes in an ‘acceptable’ position after training, but very few did so in the recommended ‘ideal’ position. After refresher training 80% of subjects used the correct sequence for CPR and shock delivery, yet a third failed to perform adequate safety checks before all shocks. The trainees self-assessed AED competence score was 86 (scale 0–100) after the initial class and their confidence that they would act in a real emergency was rated at a similar level. Initial training improved performance of all CPR skills, although all except compression rate had deteriorated after 6 months. The proportion of subjects able to correctly perform most CPR skills was higher following refresher training than after the initial class. Although this course was judged to be effective in teaching delivery of counter-shocks, the need was identified for more emphasis on positioning of electrodes, pre-shock safety checks, airway opening, ventilation volume, checking for signs of a circulation, hand positioning, and depth and rate of chest compressions.
Este estudo prospectivo avaliou a aquisição e retenção de capacidade em ressuscitação cardiopulmonar (CPR) e no uso de desfrilhador automático externo (AED) por reanimadores leigos envolvidos no Departamento de Saúde do England National Defrillator Programme. Foram testados 112 candidatos imediatamente antes e após um aula inicial de 4 horas; 76 foram igualmente reavaliados em treino repetido 6 meses depois. Foi avaliado o desempenho num cenário de teste normalizado que requeria avaliação da vı́tima, CPR e utilização de um AED, através de informação gravada pelos manequins e gravação vı́deo. Antes do treino apenas 44% dos candidatos efectuaram um choque. Após o treino todos o fizeram e o tempo médio para o 1° choque foi reduzido em 57 segundos. Todos os candidatos colocaram os eléctrodos do desfrilhador numa posição “aceitável” após o treino mas muito poucos o fizeram na posição “ideal” recomendada. Após treino repetido 80% dos candidatos usaram a sequência correcta para CPR e aplicação do choque, no entanto 1/3 falhou na verificação adequada da segurança antes de todos os choques. O score de competência em AED por auto-avaliação dos candidatos foi 86 (escala 0–100) após a aula inicial e a sua confiança de que actuariam numa emergência real foi avaliada num nı́vel similar. O treino inicial melhorou a performance de todas as capacidades para CPR, embora todas tenham deteriorado após 6 meses, excepto a frequência das compressões. A avaliação da proporção de candidatos capazes de realizar correctamente a maioria das competências para CPR foi maior após o treino repetido do que após a aula inicial. Embora este curso tenha sido avaliado como eficaz no ensino da administração dos choques, foi identificada a necessidade de maior ênfase no posicionamento dos eléctrodos, nas avaliações de segurança pré-choque, na permeabilização da via aérea, no volume de ventilação, na avaliação dos sinais de circulação, no posicionamento das mãos, na profundidade e na frequência das compressões torácicas.
Este estudio prospectivo evaluó la adquisición y retención de destrezas en reanimación cardiopulmonar (CPR) y el uso de desfibriladores automáticos externos (AED) por voluntarios legos involucrados en el departamento de salud, en el Programa Nacional de Desfibrilación de Inglaterra. Ciento once alumnos fueron examinados inmediatamente antes y después de una clase inicial de 4 hrs; 76 fueron reevaluados de forma similar durante un curso de reentrenamiento seis meses después. Se evaluó un escenario estandarizado que requerı́a evaluación de la vı́ctima, CPR y el uso de un AED usando datos del registro de un maniquı́ y registros en cintas de video. Antes del entrenamiento solamente 44% de los sujetos entregaron una descarga. Después, todos lo hicieron y la demora promedio a la primera descarga fue reducida en 57
s. Todos los alumnos ubicaron los electrodos de desfibrilación en una posición ’aceptable’ después del entrenamiento, pero muy pocos lo hicieron en la posición ’ideal’ recomendada. Después del reentrenamiento el 80% de los sujetos usaron la secuencia correcta de CPR y entrega de descarga eléctrica, pero aún un tercio fracasó en garantizar seguridad antes de todas las descargas entregadas. Los alumnos se evaluaron a si mismos en competencia en uso del AED con un puntaje de 86 (escala de 0–100) después de la clase inicial y su confianza de que actuarı́an bien en una emergencia real fue evaluada en un nivel similar. El entrenamiento inicial mejoró el desempeño de todas las destrezas de CPR, aunque todas, salvo la frecuencia de compresiones, se deterioraron después de 6 meses. La proporción de sujetos capaces de realizar correctamente la mayorı́a de las destrezas de CPR evaluadas fue mayor después de el curso de reentrenamiento que después de la clase inicial. Aunque este curso fue juzgado como efectivo en la enseñanza de entrega de descargas eléctricas, se identificó la necesidad de mayor énfasis en el posicionamiento de los electrodos, las evaluaciones de seguridad antes de entregar las descargas, apertura de vı́a aérea, volumen ventilatorio, evaluación de signos de circulación, posición de las manos, y profundidad y frecuencia de las compresiones torácicas.
Survival after out-of-hospital cardiac arrest is closely linked to the quality of CPR, but in real life, resuscitation during prehospital care and ambulance transport is often suboptimal. Mechanical ...chest compression devices deliver consistent chest compressions, are not prone to fatigue and could potentially overcome some of the limitations of manual chest compression. However, there is no high-quality evidence that they improve clinical outcomes, or that they are cost effective. The Prehospital Randomised Assessment of a Mechanical Compression Device In Cardiac Arrest (PARAMEDIC) trial is a pragmatic cluster randomised study of the LUCAS-2 device in adult patients with non-traumatic out-of-hospital cardiac arrest.
The primary objective of this trial is to evaluate the effect of chest compression using LUCAS-2 on mortality at 30 days post out-of-hospital cardiac arrest, compared with manual chest compression. Secondary objectives of the study are to evaluate the effects of LUCAS-2 on survival to 12 months, cognitive and quality of life outcomes and cost-effectiveness.
Ambulance service vehicles will be randomised to either manual compression (control) or LUCAS arms. Adult patients in out-of-hospital cardiac arrest, attended by a trial vehicle will be eligible for inclusion. Patients with traumatic cardiac arrest or who are pregnant will be excluded. The trial will recruit approximately 4000 patients from England, Wales and Scotland. A waiver of initial consent has been approved by the Research Ethics Committees. Consent will be sought from survivors for participation in the follow-up phase.
The trial will assess the clinical and cost effectiveness of the LUCAS-2 mechanical chest compression device.
The trial is registered on the International Standard Randomised Controlled Trial Number Registry (ISRCTN08233942).
This study compares the retention of basic life support (BLS) skills after 6 and 12 months by lay persons trained either in a conventional manner, or using a staged approach. Three classes, each of 2
...h, were offered to volunteers over a period of 4 months. For the conventional group, the second and third classes consisted of review of skills. Those in the staged group were first taught chest compression alone; chest compression with ventilation in a ratio of 50:5 was introduced at the second class; full standard CPR was taught at the third class. A total of 495 volunteers entered the study, 262 being randomly allocated to conventional training, and 233 to staged training. More of those who received staged training attended a second (78 volunteers) and third class (41 volunteers), compared with those who received conventional training (36 and 17, respectively). The objective of this study, however, was to compare the
strategies of the different training methods. A total of 291 volunteers (167 conventional and 124 staged training) were available for unannounced home testing of full conventional CPR 6 months after initial training, and 260 volunteers (135 conventional and 125 staged training) were tested at 12 months. At 6 months, those taught by the staged method were significantly better at time to first compression (
P<0.0001), compression rate (
P=0.024), and hand position (
P=0.0001). At 12 months, those taught by the staged method were significantly better at shouting for help (
P=0.005), time to first compression (
P<0.0001), and compression depth (
P=0.003). Those taught conventionally were significantly better at checking for a carotid pulse at both 6 and 12 months (
P<0.0001). These results suggest that training lay persons in basic life support skills using a staged approach leads to overall better skill retention at 6 and 12 months, and has other advantages including a greater willingness to re-attend follow-up classes.
Este estudo compara a capacidade de retenção de competência em Suporte Básico de Vida (SBV) após 6 e 12 meses por leigos treinados de forma convencional ou utilizando um treino faseado. Foram realizadas três sessões para voluntários, cada uma de 2 horas, durante um perı́odo de 4 meses. Para o grupo convencional, a segunda e terceiras lições consistem em revisão das competências. Ao grupo de treino faseado primeiro foi ensinado apenas compressão torácica; na segunda lição foi ensinada compressão com ventilação numa taxa de 50:2. A reanimação Cardio-pulmonar completa standard só foi ensinada na terceira lição. Entraram no estudo um total de 495 voluntários, destes 262 foram aleatorizados para treino convencional, e 233 para um treino faseado. A adesão dos voluntários à segunda (78 voluntários) e terceira lição (41 voluntários) foi maior nos que receberam treino faseado do que nos que receberam treino convencional (36 e 17, respectivamente). Contudo, o objectivo deste estudo foi comparar as estratégias de diferentes métodos de treino. Um total de 291 voluntários (167 do treino convencional e 124 do treino faseado) estavam disponı́veis para teste de CPR completa convencional no domicı́lio, sem aviso prévio, 6 meses após o treino inicial; e 260 voluntários (135 do treino convencional e 125 faseado) foram testados aos 12 meses. Aos 6 meses, aqueles que foram ensinados pelo método faseado, foram significativamente melhores no tempo para a primeira compressão (
P < 0.0001), na taxa de compressão (
P = 0.024) e na posição das mãos (
P = 0.0001). Aos 12 meses, aqueles ensinados pelo método faseado foram significativamente melhores no pedido de ajuda (
P = 0.005), tempo para a primeira compressão (
P < 0.0001), e profundidade da compressão (
P = 0.003). Aqueles ensinados pelo método convencional foram significativamente melhores na pesquisa do pulso carotı́deo, quer aos 6 quer aos 12 meses (
P < 0.0001). Estes resultados sugerem que o treino dos leigos em suporte básico de vida utilizando um método de ensino faseado leva a melhor retenção das competências, tanto aos 6 como aos 12 meses, e tem outras vantagens incluindo a vontade de voltar a frequentar lições de seguimento.
Este estudio compara la retención de destrezas de soporte vital básico (BLS) después de 6 y 12 meses por parte de personas legas, entrenadas en forma convencional o usando una aproximación por etapas. Se ofrecieron aun grupo de voluntarios tres clases, de 2 hrs cada una, en un lapso de 4 meses. Para el grupo con entrenamiento convencional, la segunda y tercera clase consistieron en revisión de las destrezas. Aquellos en el grupo por etapas, primero se les enseñó solo compresión torácica; en la segunda etapa se les enseñó compresión con ventilación en una frecuencia de 50:2 ; y en la tercera se enseñó reanimación estándar completa. En este estudio participaron 495 voluntarios, siendo colocados aleatoriamente 262 a entrenamiento convencional, y 233 designados a entrenamiento en etapas. De aquellos que recibieron entrenamiento en etapas hubo mas que asistieron a la segunda (78 voluntarios) y tercera clase (41 voluntarios), comparados con aquellos que recibieron entrenamiento convencional (36 y 17 respectivamente). El objetivo de este estudio, sin embargo, fue comparar las estrategias de los diferentes métodos de entrenamiento. Hubo un total de 291 voluntarios (167 convencional, 124 por etapas) disponibles para evaluación en domicilio sin previo aviso, en CPR convencional completo seis meses después de el entrenamiento inicial, y 260 voluntarios (135 convencionales y 125 por etapas) fueron evaluados a los 12 meses. A los 6 meses, aquellos entrenados con método por etapas fueron significativamente mejores en el tiempo a la primera compresión (
P < 0.0001), frecuencia de compresiones (
P = 0.024), y en posición de manos (
P = 0.0001). A los 12 meses, aquellos entrenados por etapas fueron significativamente mejores en gritar por ayuda (
P = 0.005), tiempo a la primera compresión (
P < 0.0001), y profundidad de las compresiones (
P = 0.003). Aquellos entrenados en forma convencional fueron significativamente mejor en buscar pulso carotı́deo tanto a los 6 como a los 12 meses (
P < 0.0001). Estos resultados sugieren que el entrenamiento de personas legas en destrezas de soporte vital básico usando una aproximación por etapas lleva a una mejor retención global de las destrezas a los 6 y 12 meses, y tiene otras ventajas que incluyen mayor disposición para asistir nuevamente a las clases de refuerzo y seguimiento.
Summary
Cricothyroidotomy can be performed using three techniques. This literature review seeks to determine which is more appropriate for use in prehospital can't intubate/can't ventilate scenarios ...where laryngeal mask airways prove ineffective. The common approach of inserting a 14‐gauge cannula and using low‐pressure ventilation via intermittent occlusion of an opening in oxygen tubing (15 l.min−1 flow) results in ineffective ventilation within 60 s or less, depending on the degree of airway obstruction. In the absence of a high degree of upper airway obstruction, ventilation can be effective if the cannula is attached to a high pressure (45 psi) jet ventilator, but such devices are rare in UK prehospital practice. A self‐inflating bag used with a cuffed tube inserted through a horizontal scalpel incision provides sustained adequate ventilation, has a relatively low complication rate compared to needle cricothyroidotomy and is a skill that can be easily taught to paramedics, nurses and doctors.
To determine the optimal refresher training interval for lay volunteer responders in the English National Defibrillator Programme who had previously undertaken a conventional 4-h initial class and a ...first refresher class at 6 months.
Subjects were randomised to receive either two additional refresher classes at intervals of 7 and 12 months or one additional refresher class after 12 months.
Greater skill loss had occurred when the second refresher class was undertaken at 12 compared with 7 months. Skill retention however, was higher in the former group, ultimately resulting in no significant difference in final skill performance. There was no significant difference in performance between subjects attending two versus three refresher classes.
On completion of refresher training all subjects were able to deliver countershocks, time to first shock decreased by 17
s in both groups, and the proportion of subjects able to perform most skills increased. The execution of several important interventions remained poor, regardless of the total number of classes attended or the interval between them. These included CPR skills, defibrillation pad placement, and pre-shock safety checks. Refresher classes held more frequently and at shorter intervals increased subjects’ self-assessed confidence, possibly indicating greater preparedness to use an AED in a real emergency.
This study shows that the ability to deliver countershocks is maintained whether the second refresher class is held at seven or 12 months after the first. To limit skill deterioration between classes, however, refresher training intervals should not exceed 7 months. The quality of instruction given should be monitored carefully. Learning and teaching strategies require review to improve skill acquisition and maintenance.
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