Chest Compression Only Cardiopulmonary Resuscitation for Primary Cardiac Arrest
2016; Lippincott Williams & Wilkins; Volume: 134; Issue: 10 Linguagem: Inglês
10.1161/circulationaha.116.023017
ISSN1524-4539
Autores Tópico(s)Mechanical Circulatory Support Devices
ResumoHomeCirculationVol. 134, No. 10Chest Compression Only Cardiopulmonary Resuscitation for Primary Cardiac Arrest Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBChest Compression Only Cardiopulmonary Resuscitation for Primary Cardiac Arrest Gordon A. Ewy, MD Gordon A. EwyGordon A. Ewy From Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ. Originally published6 Sep 2016https://doi.org/10.1161/CIRCULATIONAHA.116.023017Circulation. 2016;134:695–697IntroductionCardiovascular disease continues to be the leading cause of death in most industrialized nations of the world. Unfortunately, the first sign of cardiovascular disease often is the last, because the first sign is frequently sudden cardiac arrest.Despite Standards in 1974, Standards and Guidelines in 1980, Guidelines in 1986, and Updates of Guidelines in 1992, 2000, and 2005, the survival rate of patients with out-of-hospital cardiac arrest (OHCA) in the United States averaged 7.6% and was unchanged from 1978 to 2008. Likewise, survival of patients with OHCA secondary to ventricular fibrillation (VF), those dramatically more likely to survive, also was unchanged for >2 decades, averaging 17.7%.A major reason for these previously low rates of survival was the lack of bystander cardiopulmonary resuscitation (CPR) because of the decades-old requirement of mouth-to-mouth ventilation as the first step. Most bystanders, including medical personnel, would call but then await the arrival of emergency medical services personnel. Such OHCA patients rarely survived.Our University of Arizona Sarver Heart Center Resuscitation Research Group found in animal models of ventricular fibrillation (VF) arrest that survival was better with continuous chest compressions than with no CPR until defibrillation at 10 minutes. As a result, since the early 1990s, we have recommended chest compression only CPR (CO-CPR) as the initial therapy for witnessed primary cardiac arrest, defined as, "An unexpected, seen or heard, collapse of a person who is not responsive and is not breathing normally."Not breathing normally is important, because the majority of subjects with primary VF arrest gasp for the first few minutes. The recognition of gasping as a sign of a recent primary cardiac arrest must be emphasized. Gasping has been reported in 55% of witnessed arrests by Clark and associates.1 We reported that 39% of patients with OHCA in Arizona who were gasping survived in comparison with only 9% of patients who were not gasping.Between 1993 and 2002 we published several studies, each showing no difference in survival of animals with VF-induced cardiac arrest receiving CO-CPR in comparison with those receiving the then guidelines CPR that recommended beginning and interrupting each set of 15 chest compressions with 2 mouth-to-mouth ventilations, interrupting each set of chest compressions by only 4-second time spans. Thus, we have long recommended CO-CPR for patients with primary cardiac arrest.A landmark observation was published in 2000 by researchers from England and our colleague Karl B. Kern, MD, on their analysis of videos of recently CPR-certified lay individuals, showing that they interrupted chest compressions for an average of 16 seconds to deliver the guidelines recommended "two quick breaths."2 Accordingly, we then compared survival in our resuscitation research laboratory between VF-arrested swine treated with CO-CPR or with realistic bystander CPR where each set of chest compressions was interrupted a realistic16 seconds for ventilations. Survival was 80% with CO-CPR and 13% with CPR that included 16-second interruptions for ventilations.A major concern of opponents of CO-CPR for primary cardiac arrest was, and evidently still is, that the lack of assisted ventilation results in low blood arterial oxygenation. In an experiment of VF arrest, arterial blood gasses were measured at baseline, twice during CO-CPR and passive oxygenation, and twice during assisted ventilation. In sinus rhythm, the arterial blood gas was 85 mm Hg (97% saturation), and fell to 70 mm Hg (93% saturation) after 9.5 minutes of untreated VF. The lack of a significant decrease in saturation was because the blood remaining in the arterial system following primary cardiac arrest was not circulating and therefore was still adequately saturated. However, after the initiation of CO-CPR, the arterial blood saturation decreased to 44 mm Hg (61% saturation) after 14 minutes, and then to 31 mm Hg (34% saturation) 16 minutes after primary cardiac arrest (Figure). Is an arterial saturation of 34% harmful? Insights into this question may be found in published research of individuals climbing Mount Everest. In such a report, 1 individual had an arterial saturation of 34%, showing that saturations as low as 34% for long periods of time are compatible with life in humans.3Download figureDownload PowerPointFigure. Arterial blood oxygen saturation in samples taken from a swine at baseline, before, during, and after CO-CPR resuscitation from primary ventricular fibrillation cardiac arrest. Samples were taken during sinus rhythm, at 9.5 minutes untreated arrest, at 14.25 minutes during chest compressions, at 16.5 minutes of chest compressions, and at 18.74 minutes postarrest during active ventilation. Samples obtained and photographed under the direction of Mathias Zuercher, MD, from Basal, Switzerland, who also is a member of the University of Arizona Sarver Heart Center Resuscitation Research Group. CO-CPR indicates chest compression only cardiopulmonary resuscitation; SR, sinus rhythm; and VF, ventricular fibrillation.The results of our extensive efforts to advocate and teach CO-CPR as part of cardiocerebral resuscitation for patients with primary cardiac arrest in the state of Arizona were published in 2010.4,5 The percentage of lay CPR providers who performed CO-CPR was 20% in 2006, ≈45% in 2007 and 2008, and ≈75% during 2008 and 2009. In all patients with OHCA, the survival rate was 7.8% in those receiving guidelines CPR and 13.3% for those who received CO-CPR. In the subset of patients with a witnessed cardiac arrest and a shockable rhythm, the survival rate was 17.7% in those receiving guidelines CPR and 34% in those patients receiving CO-CPR. Notably, the guidelines CPR survival rate of all patients with OHCA or those with a witnessed OHCA and a shockable rhythm was the same as that previously reported in the United States between 1978 and 2008, as described above.The American Heart Association's 2015 CPR guidelines for bystanders may still not be optimal because they continue to recommend the same approach (chest compressions interrupted for mouth-to-mouth ventilation) for 2 entirely different etiologies of cardiac arrest: primary cardiac arrest, including those from VF where the arterial blood is usually well saturated at the time of the arrest, and secondary cardiac arrest from respiratory failure, where severe arterial desaturation is the major cause of the arrest.It must also be emphasized that CO-CPR is not and was never recommended for respiratory arrests.ACKNOWLEDGMENTSThis article is a brief summary from the Hans Dahll Award; an invited lecture presented December 9, 2015, at the Citizens Emergency Cardiac Care National Meeting, San Diego, CA. The dedication and collaboration of the other members of the University of Arizona College of Medicine Resuscitation Research Group is gratefully acknowledged. The Hans Dahll Award, designated for a single individual, was therefore accepted on behalf of the University of Arizona Sarver Heart Center Resuscitation Group, which initially included my colleagues Dr Bob Berg, Dr Ben Bobrow, Lani Clark, Dr Karl B. Kern, Ron Hilwig, DVM, Dr Charles Otto, and Dr Mathias Zuercher.DISCLOSURESNone.FootnotesThe opinions in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at http://circ.ahajournals.org.Correspondence to: Gordon A. Ewy, MD, Emeritus, Professor of Medicine (Cardiology), University of Arizona College of Medicine, 932 W San Martin Dr, Tucson, AZ 85704-4423. E-mail [email protected]References1. Bobrow BJ, Zuercher M, Ewy GA, Clark L, Chikani V, Donahue D, Sanders AB, Hilwig RW, Berg RA, Kern KB. Gasping during cardiac arrest in humans is frequent and associated with improved survival.Circulation. 2008; 118:2550–2554. doi: 10.1161/CIRCULATIONAHA.108.799940.LinkGoogle Scholar2. Assar D, Chamberlain D, Colquhoun M, Donnelly P, Handley AJ, Leaves S, Kern KB. Randomised controlled trials of staged teaching for basic life support. 1. Skill acquisition at bronze stage.Resuscitation. 2000; 45:7–15.CrossrefMedlineGoogle Scholar3. Grocott MP, Martin DS, Levett DZ, McMorrow R, Windsor J, Montgomery HE; Caudwell Xtreme Everest Research Group. Arterial blood gases and oxygen content in climbers on Mount Everest.N Engl J Med. 2009; 360:140–149. doi: 10.1056/NEJMoa0801581.CrossrefMedlineGoogle Scholar4. Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.JAMA. 2008; 299:1158–1165. doi: 10.1001/jama.299.10.1158.CrossrefMedlineGoogle Scholar5. Ewy GA. Cardiocerebral resuscitation: the new cardiopulmonary resuscitation.Circulation. 2005; 111:2134–2142. doi: 10.1161/01.CIR.0000162503.57657.FA.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Jia T, Wang S, Luo C, Wang Z, Liu G, Shang Z, Lu X, Yang Q and Zhu C (2021) Levosimendan Ameliorates Post-resuscitation Acute Intestinal Microcirculation Dysfunction Partly Independent of its Effects on Systemic Circulation: A Pilot Study on Cardiac Arrest in a Rat Model, Shock, 10.1097/SHK.0000000000001771, 56:4, (639-646), Online publication date: 1-Oct-2021. (2020) Lay Responder Care for the Adult Victim of Out-of-Hospital Cardiac Arrest, New England Journal of Medicine, 10.1056/NEJMc2000808, 382:13, (e24), Online publication date: 26-Mar-2020. Chen H and Lin S (2017) Chest Compression-Only Cardiopulmonary Resuscitation Resuscitation Aspects, 10.5772/intechopen.70830 Ewy G (2017) Cardiocerebral and cardiopulmonary resuscitation - 2017 update, Acute Medicine & Surgery, 10.1002/ams2.281, 4:3, (227-234), Online publication date: 1-Jul-2017. Girianto P (2020) Pemberian Feedback pada Home Learning CPR untuk Meningkatkan Kemampuan Bystander CPR, Jurnal Ners dan Kebidanan (Journal of Ners and Midwifery), 10.26699/jnk.v7i1.ART.p030-036, 7:1, (030-036) Hopper K, Rezende M, Borchers A and Epstein S (2018) Efficacy of Manual Ventilation Techniques During Cardiopulmonary Resuscitation in Dogs, Frontiers in Veterinary Science, 10.3389/fvets.2018.00239, 5 Abebe T, Zeleke L, Assega M, Sefefe W and Gebremedhn E (2021) Health-Care Providers' Knowledge, Attitudes, and Practices Regarding Adult Cardiopulmonary Resuscitation at Debre Markos Referral Hospital, Gojjam, Northwest Ethiopia, Advances in Medical Education and Practice, 10.2147/AMEP.S293648, Volume 12, (647-654) September 6, 2016Vol 134, Issue 10 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.116.023017PMID: 27601556 Originally publishedSeptember 6, 2016 Keywordsheart arrestout-of-hospital cardiac arrestcardiopulmonary resuscitationbystander effectPDF download Advertisement SubjectsCardiopulmonary Resuscitation and Emergency Cardiac Care
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