The importance of chest compressions as the cornerstone of resuscitation has been confirmed by research in both animal and human subjects.(1-15) Indeed, in the absence of effective chest compressions, it appears most resuscitation efforts will be futile. Interruptions in compressions as brief as 10–20 seconds dramatically decrease the efficacy of defibrillation and, consequently, the probability of return of spontaneous circulation (ROSC).(9,15-18) In the early or electrical phase of resuscitation, evidence suggests that compressions and defibrillation may be the only interventions required, leading many to encourage compression-only CPR for bystanders.(7,9,10,19) The evidence is so compelling, others have adopted a compression-only approach during the initial EMS response, creating a focus on circulation and defibrillation rather than on such time-consuming events as intubation.(4,7,9,10,14-16,19-25)
The challenge now before the EMS community is ensuring the science translates into reliable resuscitation for our patients. The fact that compressions are of paramount importance is confirmed, but we know from years of experience and research that: 1) the "time off the chest" can easily exceed 20 seconds in the absence of consistent oversight, 2) rescuers experience fatigue and 3) the focus on compressions can often be diverted to what were once considered more important interventions, such as intubation.(8,11,15,18,20,21) In many of these situations, there is no time allowed for effective chest recoil, and/or the compressions become too weak or infrequent to provide adequate coronary or cerebral perfusion pressure.(26-32) The most elaborate protocols with eloquent descriptions of resuscitation are useless if the actual circulation needed from adequate compressions is lacking.
Responsibility Lies in the Field
It may seem obvious to many of us in EMS, but the broader medical community, and certainly the community at large, may not fully understand where the responsibility for resuscitation lies. This isn’t simply an academic or abstract argument; as in many other endeavors in life, if everyone is responsible then no one is accountable and important interventions can be overlooked.
If the community and its EMS providers believe EMS plays only a role in resuscitation but is not ultimately responsible for achieving ROSC or determining futility of resuscitation, many lives may be lost due to the interruption in compressions and other resuscitation techniques that inevitably occur during transfer of the patient from the location of the arrest to the ambulance, during transport to the hospital, and/or at the time of hospital transfer.
On the other hand, if there are insufficient EMS resources to ensure quality compressions without fatigue and to otherwise provide an adequate resuscitation attempt in the field, transfer to a hospital during resuscitation may be the best option. Each community is unique, but in the overwhelming majority of cases the responsibility for determining how the prehospital resuscitation effort will be conducted lies with the EMS system and not with hospitals, medical societies, national organizations or other entities. Once this is recognized, resource and system-design issues should be considered in order to optimize resuscitation.
To meet this responsibility, EMS providers, administrators and medical directors should address three issues:
- Where will resuscitations be conducted in my community?
- What resource and system-design issues are present in my system that can be leveraged to improve the delivery of compressions during resuscitation?
- Are there unique patients who will require a more specialized approach regarding their resuscitation?
Where and how we run our codes can have an impact on cardiac compressions and successful resuscitations.
Dispatch sufficient EMS resources to conduct complete resuscitations in the field: A viable option for reliable resuscitation is to plan to complete resuscitations in the field to either ROSC or termination. The benefits of this approach are numerous.
First, avoiding movement of the patient during resuscitation decreases the probability of interruptions in compressions, particularly if manual compressions are being provided. Additionally, the inherent dangers of ongoing resuscitative efforts in a moving ambulance can be minimized. Finally, resuscitations that declare themselves as obviously futile can be terminated in the home.
Evidence clearly suggests there are a group of patients for whom futility can be reliably declared, allaying fears related to terminating a potentially viable patient in the field. Evidence also suggests the vast majority of families are more satisfied with EMS in-field termination of futile cases than they are with transport of the patient to the hospital.(34,35)
Several system components must be in place for this resuscitative plan to generate optimal outcomes, and three are of highest importance. First, policies and procedures must be in place to deal with grieving families, death certificates and local requirements as they relate to the requirements of the medical examiner. Second, education of the EMS providers must include the art of grief notification and family interactions. Finally, and most importantly, a plan must be in place to ensure quality compressions during the entire resuscitation process, whether delivered by manual or mechanical means. (For more on compression devices, read "Through the Years", and also go to www.jems.com/effectiveCPR.)
Dispatch sufficient resources to begin resuscitation in the field and transport ongoing resuscitations: A second viable option is to complete the initial or electrical and mechanical phases of resuscitation at the site of the cardiac arrest and then routinely transfer the majority of ongoing resuscitations to the emergency department. The benefits of this approach include a reduction in the number of resources that need to be dispatched, a reduction in the length of time the dispatched resources will be committed to the scene, and avoidance of the issues related to death notification and medical examiner interaction. These issues may be particularly relevant in communities where EMS resources are severely limited and/or educational time for EMS personnel is limited.
This approach has the potential to lead to suboptimal resuscitation outcomes, however, if particular attention is not devoted to the avoidance of interruptions of chest compressions during the transfer processes. With the realization that seconds of chest compression interruption have a profoundly negative impact on patient outcome, the choreography of transfer must be precise and reproducible.
Transport all cardiac arrests as quickly as possible to the hospital: This is the least recommended option, and the most likely to result in ineffective compressions and failed resuscitations.(36,37) A period of resuscitative effort is required immediately at the location of the arrest, particularly during the electrical and mechanical phases when resuscitations are most likely to occur. It is simply not an option to defer resuscitation to the hospital; EMS systems are obligated to formulate a plan to provide on-scene resuscitation that is reliable, evidence-based and reproducible. The most important component of this effort is chest compressions—the challenge is to find the best method for an individual community to ensure the adequate provision of these compressions.
The responsibility for resuscitation lies with EMS. Once this ownership is established, communities must determine where arrests will be worked to completion. The current evidence suggests that performing manual compressions in the moving ambulance is the least desirable method for resuscitation, particularly in the absence of real-time feedback regarding rate and depth of compressions as well as ventilatory rates.
It appears the ideal resuscitation will involve a combination of adequate on-scene personnel, simple feedback techniques and checklists, technological feedback from the cardiac monitor/defibrillator, and/or use of mechanical compression devices. Current evidence is insufficient to recommend one technique over another. Each community should employ a resuscitation plan based on the cost/benefit analysis in the context of their overall EMS funding, goals and objectives.
Disclosure: The author has reported no conflicts of interest with the sponsor of this supplement
- ECC Committee, Subcommittees and Task Forces of the American Heart Association: "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care." Circulation. 112(24 Suppl):1–88, 2005.
- ECC Committee, Subcommittees and Task Forces of the American Heart Association: "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care." Circulation. 112(24 Suppl):58–66, 2005.
- Becker LB, Ostrander MP, Barrett J, et al: "Outcome of CPR in a large metropolitan area: Where are the survivors?" Annals of Emergency Medicine. 20(4):355–361, 1991.
- Bobrow BJ, Clark LL, Ewy GA, et al: "Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest." JAMA. 299(10):1158–1165, 2008.
- Davis B: "Many lives are lost across USA because emergency medical services systems fail." USA Today. May 21, 2005.
- Davis B: "Fewer paramedics mean more lives saved." USA Today. May 21, 2006.
- Ewy GA: "Cardiocerebral resuscitation should replace cardiopulmonary resuscitation for out-of-hospital cardiac arrest." Current Opinion in Critical Care. 12(3):189–192, 2006.
- Ewy GA: "Cardiac arrest: Guideline changes urgently needed." Lancet. 369(9565):882–884, 2007.
- Ewy GA: "Continuous-chest-compression cardiopulmonary resuscitation for cardiac arrest." Circulation. 116(25):2894–2896, 2007.
- Ewy GA, Kellum MJ, Bobrow BJ: "Cardiocerebral resuscitation: Improving cardiac arrest survival with a new technique." JEMS. 34(7):58–69, 2009.
- Fries M, Tang W: "How does interruption of cardiopulmonary resuscitation affect survival from cardiac arrest?" Current Opinion in Critical Care. 11(3):200–203, 2005.
- Hazinski MF, Nadkarni VM, Hickey RW, et al: "Major changes in the 2005 AHA Guidelines for CPR and ECC: Reaching the tipping point for change." Circulation. 112(24 Suppl):IV206–211, 2005.
- Kellum MJ, Kennedy KW, Ewy GA: "Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest." American Journal of Medicine. 119(4):335–340, 2006.
- 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 American Heart Association Emergency Cardiovascular Care Committee." Circulation. 117(16):2162–2167, 2008.
- Valenzuela TD, Kern KB, Clark LL, et al: "Interruptions of chest compressions during emergency medical systems resuscitation." Circulation. 112(9):1259–1265, 2005.
- Eftestøl T, Sunde K, Steen PA: "Effects of interrupting precordial compressions on the calculated probability of defibrillation success during out-of-hospital cardiac arrest." Circulation. 105(19):2270–2273, 2002.
- Wik L: "Rediscovering the importance of chest compressions to improve the outcome from cardiac arrest." Resuscitation. 58(3):267–269, 2003.
- Yu T, Weil MH, Tang W, et al: "Adverse outcomes of interrupted precordial compression during automated defibrillation." Circulation. 106(3):368–372, 2002.
- "Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): An observational study." Lancet. 369(9565):920–926. 2007.
- Aufderheide TP, Lurie KG: "Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation." Critical Care Medicine. 32(9 Suppl):S345–351, 2004.
- Aufderheide TP, Sigurdsson G, Pirrallo RG, et al: "Hyperventilation-induced hypotension during cardiopulmonary resuscitation." Circulation. 109(16):1960–1965, 2004.
- Pepe PE, Raedler C, Lurie KG, et al: "Emergency ventilatory management in hemorrhagic states: Elemental or detrimental?" Journal of Trauma. 54(6):1048–1055; discussion 1055–1057, 2003.
- Pepe PE, Roppolo LP, Fowler RL: "The detrimental effects of ventilation during low-blood-flow states." Current Opinion in Critical Care. 11(3):212–218, 2005.
- Stiell IG, Wells GA, Field B, et al: "Advanced cardiac life support in out-of-hospital cardiac arrest." New England Journal of Medicine. 351(7):647–656, 2004.
- Wigginton JG, Benitez FL, Pepe PE: "Endotracheal intubation in the field: con position." Hospital Medicine. 66(2):91–94, 2005.
- Aufderheide TP, Pirrallo RG, Yannopoulos D, et al: "Incomplete chest wall decompression: a clinical evaluation of CPR performance by trained laypersons and an assessment of alternative manual chest compression-decompression techniques." Resuscitation. 71(3):341–351, 2006.
- Lurie K, Zielinski T, McKnite S, et al: "Improving the efficiency of cardiopulmonary resuscitation with an inspiratory impedance threshold valve." Critical Care Medicine. 28(11 Suppl):N207–209, 2000.
- Lurie KG, Voelckel WG, Zielinski T, et al: "Improving standard cardiopulmonary resuscitation with an inspiratory impedance threshold valve in a porcine model of cardiac arrest." Anesthesia and Analgesia. 93(3):649–655, 2001.
- Lurie KG, Zielinski T, McKnite S, et al: "Use of an inspiratory impedance valve improves neurologically intact survival in a porcine model of ventricular fibrillation." Circulation. 105(1):124–129, 2002.
- Yannopoulos D, Aufderheide TP, Gabrielli A, et al: "Clinical and hemodynamic comparison of 15:2 and 30:2 compression-to-ventilation ratios for cardiopulmonary resuscitation." Critical Care Medicine. 34(5):1444–1449, 2006.
- Yannopoulos D, Sigurdsson G, McKnite S, et al: "Reducing ventilation frequency combined with an inspiratory impedance device improves CPR efficiency in swine model of cardiac arrest." Resuscitation. 61(1):75–82, 2004.
- Yannopoulos D, Tang W, Roussos C, et al: "Reducing ventilation frequency during cardiopulmonary resuscitation in a porcine model of cardiac arrest." Respiratory Care. 50(5):628–635, 2005.
- Pepe PE, Swor RA, Ornato JP, et al: "Resuscitation in the out-of-hospital setting: Medical futility criteria for on-scene pronouncement of death." Prehospital Emergency Care. 5(1):79–87, 2001.
- Edwardsen EA, Chiumento S, Davis E. "Family perspective of medical care and grief support after field termination by emergency medical services personnel: A preliminary report." Prehospital Emergency Care. 6(4):440–444, 2002.
- Tsai E. "Should family members be present during cardiopulmonary resuscitation?" New England Journal of Medicine. 346(13):1019–1021, 2002.
- Haque IU, Udassi JP, Udassi S, et al: "Chest compression quality and rescuer fatigue with increased compression to ventilation ratio during single rescuer pediatric CPR." Resuscitation. 79(1):82–89, 2008.
- Olasveengen TM, Wik L, Steen PA. "Quality of cardiopulmonary resuscitation before and during transport in out-of-hospital cardiac arrest." Resuscitation. 76(2):185–190, 2008.