Bringing CPR to the Masses

Michael Pulia, MD FAAEM
Young Physicians Section Board of Directors

You stand ready, blade in one hand, tube in the other. To your right, two techs are ready to spring into action with chest compressions. To your left, a pair of RNs stand with needles drawn waiting to access even the most difficult to find vein. The doors swing open and in rush the medics with a lifeless body in tow. The flurry of activity in the next few moments resembles a pit crew trying desperately to get their driver back in the race. However, you are the leader of a team trying to bring someone back to life, and the stakes could not be higher. No other scenario in the ED commands this type of attention and resources. You run the algorithms, and despite everyone in the room giving it their all, this story does not have a happy ending. Aware of the grim odds, we know that too often this encounter ends with the words “time of death.” As you leave the room and try to grasp the magnitude of the decision to call the code, you wonder if there was anything else you could have done. With increasing frequency, it is apparent to me that the outcome was likely determined well before the patient rolled into the ED and that I was not present for the most critical moments of their medical crisis.

This all too familiar story probably began something like this: an at home sudden cardiac arrest (SCA), no CPR until EMS arrived 8 minutes later, worked on in the field for another 5 minutes, a 10 minute ambulance ride and the patient arrives in your ED 20+ minutes after their arrest with little hope of recovery. Examining several major metropolitan areas, researchers have found that the survival to discharge rate for SCA is less than 2%.^1,2 These dismal statistics are being challenged by new data from Europe and Seattle that suggest we can do much better. These locations saw survival to discharge rates improve to between 9-21% by implementing programs based on interventions in the first few moments following SCA, which are without question the most critical in determining the final outcome.^3,4 Improved outcomes from early defibrillation and bystander CPR are well established.^5-8 Despite efforts to educate the public about these benefits, bystander CPR rates remain at an unimpressive 30%.^9,10

It is with this exact dilemma in mind that the non-profit Ad Council, New York ad agency Gotham Inc., and the American Heart Association (AHA) have launched the massive new campaign entitled Hands-Only™ CPR. This program is based on the 2008 AHA science advisory published to amend and clarify the 2005 AHA Guidelines for CPR and Emergency Cardiovascular Care (ECC),¹¹ and it aims to dramatically change how bystander CPR is administered. The target audience is the majority of citizens who are either untrained or unwilling to participate in traditional CPR. As demonstrated by two large illustrations on the program’s homepage, http://handsonlycpr.org/, the message is crystal clear: 1 - Dial 911 and 2 - Press hard and fast in the center of the chest.¹² That’s it! So simple it’s genius. No ratios to remember, no mouth to mouth, no lengthy training courses and no fear of making a mistake. By eliminating the hurdles that bystanders often cite when asked why they did not perform CPR,¹⁰ the campaign hopes to make CPR more accessible than ever. For those who are trained and comfortable in providing the traditional 30:2 ratio CPR that includes mouth-to-mouth, the recommendation is to continue doing just that.

The 2008 advisory did not stem from the AHA giving up on this traditional CPR, but rather, new literature questioning the value of rescue breaths early after SCA and demonstrating that some CPR is better than no CPR. The origins of this paradigm shift can be traced back to the 2005 AHA Guidelines for CPR and ECC and its back to basics approach.¹³ Dr. Carl Ferraro, one of my mentors in residency, taught a simple but profound lesson about Basic Life Support (BLS); it is just doing for the patient what their body cannot. The 2005 guidelines took that same simplified approach; compressions were to be done before, after and in-between every intervention. Faster, more effective compressions with fewer interruptions would circulate the medications and improve chances for successful defibrillation. Shock-shock-shock was out and press-press-press was in. Since these guidelines were released, research continues to demonstrate the detrimental effects of any interruptions in compressions.¹⁴ Although chest compressions had been established as the corner-stone of all ECC, the exact role of early rescue breathing after SCA had yet to be elucidated.

Prior to 2005, only two human studies had demonstrated equivalent outcomes or no harm when comparing compressions only CPR (COCPR) versus traditional CPR.^15,16 The future role of rescue breaths in CPR became more clear in 2007, when several nonrandomized observational studies were published that, again, demonstrated no improved benefit when rescue breaths were added to COCPR.^9,17,18 One of these studies performed in Japan by Iwami et al. received significant media coverage in the U.S. The AHA took notice and made a statement saying it was not prepared to fully endorse COCPR for bystanders at that time. With the new Hands-Only™ CPR ad campaign featured prominently on the AHA homepage, www.americanheart.org/, it is safe to say they have now embraced COCPR as an alternative to traditional CPR that will improve outcomes in SCA by increasing bystander CPR rates.

According to media releases, the Hands-Only™ CPR campaign will employ a variety of ads, and the website features a bilingual video demonstration, real SCA success stories, links to free iPhone and Blackberry applications and a comprehensive FAQ page.¹² To complement the new simplified version of CPR, the AHA has also established short educational programs for those looking to be comfortable with CPR basics, such as the validated 22-minute CPR Anytime™ program. Data suggests these short, self-taught video courses can be widely disseminated and are often as effective as the traditional multi-hour instructor taught courses.¹⁹ While continued efforts to educate the public on early Automated External Defibrillator (AED) usage are important, the fact remains that most arrests occur in the home. COCPR can get family members involved early and buy patients time for EMS to arrive and defibrillate. As ED physicians, we can do our part to spread the word through community education, brief CPR updates to families of high-risk patients, or by simply referring people to the AHA or Hands-Only™ CPR websites

A potential unintended consequence of the increasing exposure to COCPR and an emphasis on the importance of uninterrupted compressions is renewed debate over the utility of advanced life support (ALS) for out-of-hospital SCA. The Ontario Prehospital Advanced Life Support (OPALS) study showed no improvement in survival to discharge rates when ALS was added to CPR and rapid defibrillation for SCA.²⁰ In light of this finding, the utility of any out-of-hospital intervention (advanced airway, IV access and medication delivery) should always be weighed against potential interruptions to or impaired quality of CPR. Running a code is challenging, even with a whole team performing assigned roles and switching out on compressions. One can imagine how difficult it is for two paramedics to run it alone while keeping up textbook CPR. Perhaps future revision to the AHA’s guidelines for health care providers will move further away from recommending ALS in the field for patients with a witnessed SCA or short down/transport times. Obviously, the type of arrest, timing of response and time to nearest ED will influence the optimal type of care provided. Quality studies are still needed to clarify the optimal protocols and shared responsibilities between EMS and the ED in order to improve outcomes in SCA.

Even as we attempt to bring COCPR to the masses, a recently proposed experimental CPR technique could replace chest compressions all together. Named “only rhythmic abdominal compression” (OAC) CPR, this technique was developed by a team out of Purdue that included the late, renowned bioengineer Dr. Leslie Geddes. Published in 2007, this technique showed incredible promise in a swine model. By compressing the abdomen evenly with a wooden board shaped to fit under the costal margin, researchers were able to not only achieve higher coronary perfusion pressures than with standard chest compressions, they were also able to partially ventilate the test animals.²¹ The basis for these effects is that 25% of our circulation volume resides in abdominal organs and that compression of the abdomen moves the diaphragm enough to provide air exchange. This is a significant advantage over standard chest compressions which have been shown to provide no adequate ventilation in humans.²² Applied to a human model, AOCPR could potentially be developed into a one person CPR technique that would take care of both breathing and circulation. This might revolutionize how CPR is provided by lay persons, EMS providers and hospital resuscitation teams. Regarding complications, no broken ribs or abdominal organ injuries were noted in the test animals. To date, this technique has not been validated, and given the unanswered questions about its ability to provide adequate cerebral perfusion and a potential for increased aspiration of gastric contents, it is likely some time away from human trials.²³

With these ongoing advances in resuscitation science and ad campaigns like Hands-Only™ CPR, it is exciting to consider how many more success stories we will see in the ED as SCA outcomes improve. These changes promise to transform CPR from what some view as a modern day dying ritual into a public health and modern medicine success story. Calling a code after an unexpected sudden death is one of the hardest things we do as EPs and any reduction in how often we do so will feel like a tremendous victory. To truly help our future patients and save thousands of lives each year, we need to make an impact in those first few moments after SCA when we cannot be physically present. One way to achieve this goal is for our specialty to lead the charge in educating the public about the technique and benefits of COCPR. Looking back on our past achievements in public health issues such as seatbelts, child abuse, helmets and domestic violence, I know we will respond to this challenge and begin writing a new chapter in the story of SCA.

1. Eckstein M, Stratton SJ, Chan LS. Cardiac Arrest Resuscitation Evaluation in Los Angeles: CARE-LA. Ann Emerg Med. 2005;45:504–509.
2. Dunne RB, Compton S, Zalenski RJ, et al. Outcomes from out-of-hospital cardiac arrest in Detroit. Resuscitation.2007;72:59–65.
3. Rea TD, Eisenberg MS, Culley LL, et al. Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest. Circulation. 2001;104:2513–2516.
4. Waalewijn RA, de Vos R, Koster RW. Out-of-hospital cardiac arrests in Amsterdam and its surrounding areas: results from the Amsterdam resuscitation study (ARREST) in “Utstein” style. Resuscitation. 1998;38:157–167.
5. Gallagher EJ, Lombardi G, Gennis P. Effectiveness of bystander cardiopulmonary resuscitation and survival following out-of-hospital cardiac arrest. JAMA. 1995;274:1922–1925.
6. Wik L, Steen PA, Bircher NG. Quality of bystander cardiopulmonary resuscitation influences outcome after prehospital cardiac arrest. Resuscitation. 1994;28:195–203.
7. White RD, Hankins DG, Bugliosi TF. Seven years’ experience with early defibrillation by police and paramedics in an emergency medical services system. Resuscitation. 1998;39:145-151.
8. Myerburg RJ, Fenster J, Velez M, et al. Impact of community-wide police car deployment of automated external defibrillators on survival from out-of-hospital cardiac arrest. Circulation. 2002; 106:1058-1064.
9. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. Lancet. 2007;369:920–926.
10. Swor R, Khan I, Domeier R, et al. CPR training and CPR performance: do CPR-trained bystanders perform CPR? Acad Emerg Med. 2006;13:596–601.
11. Sayre MR, Berg RA, Cave DM, et al. Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest. A Science Advisory for the Public From the AHA ECC Committee. Circulation. 2008;117:2162–2167.
12. AHA Hands-Only™ CPR Web site. Available at: <http://handsonlycpr.org/>. Accessed Nov. 3, 2009.
13. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005;112(24 Suppl):IV1–203.
14. Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation. 2009;120(13):1241-7.
15. Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. N Engl J Med. 2000;342:1546–1553.
16. Waalewijn RA, Tijssen JG, Koster RW. Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation Study (ARREST). Resuscitation. 2001;50: 273–279.
17. Iwami T, Kawamura T, Hiraide A, et al. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest. Circulation. 2007;116:2900-2907.
18. Bohm K, Rosenqvist M, Herlitz J, et al. Survival is similar after standard treatment and chest compression only in out-of hospital bystander cardiopulmonary resuscitation. Circulation. 2007;116:2908-2912.
19. Lynch B, Einspruch EL, Nichol G, et al. Effectiveness of a 30-min CPR self-instruction program for lay responders: a controlled randomized study. Resuscitation. 2005;67.
20. Steill IG, Wells GA, De Maio VJ, et al. Advanced cardiac life support in out-of-hospital cardiac arrest. N Eng J Med 351:647–656, 2004.
21. Geddes LA, Rundell A, Lottes A, et al. A new cardiopulmonary resuscitation method using only rhythmic abdominal compression: A preliminary report. Am J Emerg Med 2007; 25, 786–790.
22. Geddes LA, Rundell A, Otlewski M, et al. How much lung ventilation is obtained with only chest-compression CPR? Cardiovascular Engineering: An International Journal. 2008;8(3):145-8.
23. Tokuda AT, Ishimatsu S. A new cardiopulmonary resuscitation method using only rhythmic abdominal compression is hard. Am J Emerg Med. 2008;26(5):625.