Trial of Continuous or Interrupted Chest Compressions During CPR

Trial of Continuous or
The New England Journal Of Medicine vol. 373 no.23, 2015
Interrupted Chest Compressions

during CPR
Graham Nichol, M.D., M.P.H., Brian Leroux, Ph.D., Henry Wang, M.D., Clifton W.
Callaway, M.D., Ph.D., George Sopko, M.D., Myron Weisfeldt, M.D., Ian Stiell, M.D.,
Laurie J. Morrison, M.D., Tom P. Aufderheide, M.D., Sheldon Cheskes, M.D., Jim
Christenson, M.D., Peter Kudenchuk, M.D., Christian Vaillancourt, M.D., Thomas D. Rea,
M.D., Ahamed H. Idris, M.D., Riccardo Colella, D.O., M.P.H., Marshal Isaacs, M.D., Ron
Straight, Shannon Stephens, Joe Richardson, Joe Condle, Robert H. Schmicker, M.S.,
Debra Egan, M.P.H., B.S.N., Susanne May, Ph.D., and Joseph P. Ornato, M.D., for the
ROC Investigators*
Dinar Riny Novianty - 4151141477

• Standard cardiopulmonary resuscitation (CPR) consists
of manual chest compressions to maintain blood flow
and positive-pressure ventilation to maintain oxygenation
until spontaneous circulation is restored.
• Chest compressions are interrupted frequently by
ventilations given as rescue breathing during the
treatment of out-of-hospital cardiac arrest.
• These interruptions reduce blood flow and po- tentially
reduce the effectiveness of CPR.
• The interruption of chest compressions has been
associated with decreased survival in animals with
cardiac arrest.
BACKGROUND
• In nonasphyxial arrest, continuous compressions
were as effective as compressions that were
interrupted for ventilations of 4 seconds in
duration.
• Also, the use of continuous compressions resulted
in significantly better neurologic function.
• In contrast, in asphyxial arrest, ventilation improved
outcomes.
• This study tested whether continuous chest
compressions, as compared with chest
compressions interrupted for ventilationp affected
the rate of survival, neurologic function, or the rate
of adverse events.
BACKGROUND
• The trial was conducted by the Resuscitation Outcomes
Consortium (ROC) (includes 10 clinical sites in North
America that have experience conducting randomized
trials involving patients with out-of-hospital cardiac
arrest)
• The trial was sponsored by the National Heart, Lung, and
Blood Institute, the Canadian Institutes of Health
Research, and others
• The trial included adults with non–trauma-related out-of-
hospital cardiac arrest who received chest compressions
performed by providers from participating EMS agencies
who were dispatched to the scene.
METHODS
• The 114 participating EMS agencies across the eight
participating ROC sites were grouped into 47 clusters.
• Clusters of agencies were randomly assigned, in a 1:1 ratio,
to perform continuous chest compressions or interrupted
chest compressions during all the out-of-hospital cardiac
arrests to which they responded.
• Patients assigned to the group that received continuous
chest compressions were to receive continuous chest
compressions at a rate of 100 compressions per minute,
with asynchronous positive-pressure ventilations delivered
at a rate of 10 ventilations per minute.
• Patients assigned to the group that received interrupted
chest compressions were to receive compressions that
were interrupted for ventilations at a ratio of 30
compressions to two ventilations; ventilations were to be
given with positive pressure during a pause in
compressions of less than 5 seconds in duration.
METHODS
• The primary outcome was the rate of survival to
hospital discharge.
• Secondary outcomes included neurologic function at
discharge, which was measured with the use of the
modified Rankin scale on the basis of review of the
clinical record, and adverse events.
• Hospital-free survival was defined as the number of
days alive and permanently out of the hospital
during the first 30 days after the cardiac arrest.
METHODS
• During the active-enrollment phase, 1129 of 12,613
patients (9.0%) in the intervention group (which received
continuous chest compression) and 1072 of 11,035
(9.7%) in the control group (which received interrupted
chest compressions) survived to hospital discharge.
• Among patients with available data on neurologic status,
883 of 12,560 patients (7.0%) in the intervention group
and 844 of 10,995 (7.7%) in the control group survived
with a modified Rankin scale score of 3 or less.
• Patients in the intervention group were significantly less
likely than those in the control group to be transported to
the hospital or admitted to the hospital.
• Hospital-free survival was significantly shorter in the
intervention group than in the control group.
RESULTS
• A strategy of continuous manual chest compressions with
positive-pressure ventilation was not associated with a
significantly higher rate of survival to discharge or favorable
neurologic function than a strategy of manual chest compressions
with interruptions for ventilation performed by EMS providers.
• The group assigned to receive continuous chest compressions
had significantly lower rates of transport to the hospital and ad-
mission to the hospital, as well as shorter hospital-free survival,
than the group assigned to receive interrupted chest
compressions.
• Previous observational studies have shown large increases in
survival rates among patients with a shockable rhythm with the
implementation of continuous compressions.
• Among patients with a noncardiac cause of cardiac arrest who
were treated by lay-persons or those with a nonshockable rhythm
who were treated by EMS providers, continuous compressions
were not associated with a significant improvement in outcome.
DISCUSSION
Limitations of this study:
1.The mean difference in the ches compression fraction (the
proportion of each minute during which compressions were given)
between the treatment groups during the trial was small. Differences
in chest-compression fraction may be associated with outcome
2.There was some imbalance in the number of patients assigned to
each group in our trial owing to variation in the amount of time
during the first cluster period before cross- over, an uneven number
of cluster periods, and the suspension of a few EMS agencies by the
study monitoring committee.
3.The quality of postresuscitation care, including the use of targeted
temperature man- agement and early coronary angiography, is
associated with outcome after out-of-hospital cardiac arrest.
4.This study did not measure oxygenation or minutes of ventilation
delivered. High or low oxygenation and hyperventilation are
associated with poor outcome in humans with cardiac arrest.
DISCUSSION
Among patients with out-of-hospital cardiac arrest in
whom CPR was performed by EMS providers, a
strategy of continuous chest compressions with
positive-pressure ventilation did not result in
significantly higher rates of survival or favorable
neurologic status than the rates with a strategy of
chest compressions interrupted for ventilation.
CONCLUSION
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Trial of Continuous or Interrupted Chest Compressions During CPR

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Trial of Continuous or

The New England Journal Of Medicine vol. 373 no.23, 2015

Interrupted Chest Compressions

Dinar Riny Novianty - 4151141477

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