Posted on 12/16/2013

Bystander-initiated cardiopulmonary resuscitation (CPR) has poor neurological outcome, and this is true even when the bystanders are family members, which suggests deficits in public CPR training.

A recent Japanese study of CPR initiated out of hospital by family versus non-family showed that significantly fewer family members initiated CPR (P<0.001) and significantly fewer patients requiring resuscitation had 1-month survival (P=0.049) or neurologically favorable survival (P=0.016) when treated by a family member, according to research from Keiko Fujie, MD, of the University of Tsukuba in Ibaraki, Japan, and colleagues, which was published online by Resuscitation.

"I think that the important points the study raises are that we are deficient in our CPR training -- dispatchers can certainly help bystanders perform adequate CPR. However, we must do more to train our citizens," noted Kevin Campbell, MD, of University of North Carolina Health Care in Chapel Hill.

To complicate matters further, rates of ventricular fibrillation have declined in recent years, while rates of the more-serious pulseless electrical activity and asystole have remained the same, according to Douglas Zipes, MD, of the Indiana University School of Medicine in Indianapolis.

In cases where bystanders are the first responders, it is paramount that laypersons on site have the best instruction and clear instruction on best practices in resuscitating a patient experiencing out-of-hospital cardiopulmonary arrest (OHCA), said Zipes.

What To Tell Bystanders

Once a bystander witnesses a patient going into cardiac arrest, the most effective treatment is to shock the patient with an automated external defibrillator (AED) and try to get their heart going.

"If there is an AED available, bystanders should employ it -- even if they are not trained to do so," Campbell said. "If an AED is deployed, it may make the difference between life and death." 

A time-to-shock of 3 to 4 minutes is ideal in preventing brain damage.

"If a bystander uses an AED within 3 or 4 minutes for those with VF/VT (shockable rhythm), survival is at least 50% to 60% with a good neurologic outcome," said Myron Weisfeldt, MD, of Johns Hopkins Medical Institution, who added that "If there is no bystander AED available and shock must wait for emergency medical services (EMS) to arrive, then survival is related to the time it takes to call 911 and the time it takes for EMS to get there."

Weisfeldt noted that survival with EMS shock ranges from 30% to 40% when the time from call to EMS arrival of is 6 to 7 minutes, a window that can be difficult to achieve in rural areas where a patient may not be as easily reached by an ambulance.

In the absence of an AED or if shocks fail, the next option is to initiate hands-only CPR, according to updated guidelines from the American Heart Association.

"Bystanders doing CPR improve survival about 20%. If more is done when dispatchers instruct, that will lead to 20% or so improvement in survival," Weisfeldt said.

Also, based on the outcomes in the study by Fujie and colleagues, "dispatchers should instruct non-family if possible -- as opposed to family bystanders -- to perform high quality CPR, with minimal pauses, and without any rescue breathing to increase the chances for survival," noted Robert Glatter, MD, Lenox Hill Hospital in New York, N.Y.

Neurological Outcomes

Campbell explained that "negative neurological outcomes are directly related to the amount of time that a patient is being resuscitated," meaning that a longer wait before they are in arrest "without an effective heart beat, the more likely brain death or significant neurologic damage will occur."

However, even with properly performed bystander CPR, adverse neurological outcomes are still common, Glatter warned. "Survival to hospital discharge neurologically intact has been quite low in the bulk of large case series," he added.

Challenges

One of the biggest challenges dispatchers and emergency medicine personnel face is that "too often people stand by and do nothing because they feel uncomfortable or they are not trained formally in CPR," according to Anne Curtis, MD, of the University at Buffalo in New York, who added that "effective chest compressions can keep a patient alive until trained personnel arrive."

"The most important aspect of CPR that bystanders should know is that chest compressions are good enough to help save the life of a patient who has had a cardiac arrest. It's not essential to do mouth-to-mouth resuscitation," she said.

Campbell echoed Curtis' sentiments, noting that much of the population has no formal CPR training. However, he noted that "CPR training is widely available in the U.S. and we, as healthcare providers, must promote awareness and advocate for training others in our communities."

Both Campbell and Zipes also warned that AEDS are still lacking in many settings. The devices should be "deployed in all schools, public buildings, concert and sporting event venues, and churches," said Campbell.

Zipes remarked that "AEDs should be as common as fire extinguishers," and that they are more common than they used to be, but not at all common in households, where many cardiac arrests occur.

"I think that home AEDS are somewhat controversial in that not all people might feel comfortable or confident operating them," Glatter commented, adding that, "with proper education and training, it is conceivable that a select group may truly benefit from their introduction into the home setting ... Knowing that the devices may be life-saving may prompt a change in outlook regarding their potential use in people's homes in the future."

Glatter emphasized the importance of delivery of high-quality chest compressions "reinforced by the use of simulation-based models," and use of video taping those who receive CPR training to compare before-and-after effects of training progression. This addition to formal training "may help to improve quality of compressions and increase neurologically favorable outcomes," he said, adding that the research from Fujie, et al. "highlights the importance of the public being engaged, invested, and committed to CPR programs in their communities not only to save lives -- but to improve neurologic outcomes."

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SOURCE: MedPageToday

 

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