V-Fib Lead II – Credit Glenlarson Wikipedia Commons
Some new studies out today indicate that longer CPR on patients who suffer an in-hospital cardiac arrest can result in improved survival rates.
In-hospital cardiac arrests are more likely to survive than out-of-hospital arrests simply because they are generally `witnessed arrests’ so CPR is initiated quicker, and the requisite `crash cart’ and medical personnel trained to use them are readily available.
Still, survival rates for in-hospital cardiac arrests are sobering, with a recent study (Trends in Survival after In-Hospital Cardiac Arrest) published in the NEJM finding that risk-adjusted rates of survival to discharge increased from 13.7% in 2000 to 22.3% in 2009.
This improvement also came with a reduction in neurological impairment in the survivors as well.
Another study, on a smaller cohort of pediatric (<18 years) patients experiencing in-hospital cardiac arrest found a tripling of survival rates between 2000 and 2009 (see Survival Trends in Pediatric In-Hospital Cardiac Arrests: An Analysis From Get With The Guidelines-Resuscitation Girotra S, Spertus JA, Li Y, et al.), again without higher rates of neurological disability among survivors.
One of the trends cited in both of these studies has been a dramatic increase in cardiac arrests due to non-shockable arrhythmias such as asystole (flat line) and PEA (Pulseless Electrical Activity) – what we used to call back in the stone age of EMS, electromechanical dissociation.
Neither of which respond to simple defibrillation.
Despite this trend, survivability of in-hospital cardiac arrests is improving (see Survivability Of Non-Shockable Rhythms With New CPR Guidelines).
Today, we look at a couple of studies that indicate that longer duration CPR for in-hospital arrests can result in better outcomes than previously believed. In the past, the belief has been that after 20 to 25 minutes, most resuscitation attempts become futile.
First a press release from Children's Hospital of Philadelphia (CHOP) describing these studies, then the links to the research.
CHOP experts are co-authors of 2 large studies of outcomes after in-hospital cardiac arrest
Experts from The Children's Hospital of Philadelphia were among the leaders of two large national studies showing that extending CPR longer than previously thought useful saves lives in both children and adults. The research teams analyzed impact of duration of cardiopulmonary resuscitation in patients who suffered cardiac arrest while hospitalized.
"These findings about the duration of CPR are game-changing, and we hope these results will rapidly affect hospital practice," said Robert A. Berg, M.D., chief of Critical Care Medicine at The Children's Hospital of Philadelphia. Berg is the chair of the Scientific Advisory Board of the American Heart Association's Get With Guidelines-Resuscitation program (GWTG-R). That quality improvement program is the only national registry that tracks and analyzes resuscitation of patients after in-hospital cardiac arrests.
The investigators reported data from the GWTG-Resuscitation registry of CPR outcomes in thousands of North American hospital patients in two landmark studies—one in children, published today, the other in adults, published in October 2012.
Berg was a co-author of the pediatric study, appearing online today in Circulation, which analyzed hospital records of 3,419 children in the U.S. and Canada from 2000 through 2009. This study, whose first author was Renee I. Matos, M.D., M.P.H., a mentored young investigator, found that among children who suffered in-hospital cardiac arrest, more children than expected survived after prolonged CPR—defined as CPR lasting longer than 35 minutes. Of those children who survived prolonged CPR, over 60 percent had good neurologic outcomes.
The conventional thinking has been that CPR is futile after 20 minutes, but Berg said these results challenge that assumption.
In addition to Berg, two other co-authors are critical care and resuscitation science specialists at The Children's Hospital of Philadelphia: Vinay M. Nadkarni, M.D., and Peter A. Meaney, M.D., M.P.H.
Nadkarni noted that illness categories affected outcomes, with children hospitalized for cardiac surgery having better survival and neurological outcomes than children in all other patient groups.
The overall pediatric results paralleled those found in the adult study of 64,000 patients with in-hospital cardiac arrests between 2000 and 2008. Berg also was a co-author of that GWTG-R study, published in The Lancet on Oct. 27, and led by Brahmajee K. Nallamothu, M.P.H., M.D., of the University of Michigan. Patients at hospitals in the top quartile of median CPR duration (25 minutes), had a 12 percent higher chance of surviving cardiac arrest, compared to patients at hospitals in the bottom quartile of median CPR duration (16 minutes). Survivors of prolonged CPR had similar neurological outcomes to those who survived after shorter CPR efforts.
The American Heart Association and American Stroke Association designated the adult study as the top finding of the year in heart disease and stroke research in its annual list of major advances. Next steps for CPR researchers are to identify important risk and predictive factors that determine which patients may benefit most from prolonged CPR, and when CPR efforts have become futile. "Taken together, the adult and pediatric results present a clear and hopeful message: persisting longer with CPR can offer better results than previously believed possible," concluded Berg.
The link to earlier Lancet report published online: 05 September 2012
Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study
Zachary D Goldberger MD, Paul S Chan MD, Prof Robert A Berg MD, Steven L Kronick MD, Colin R Cooke MD , Mingrui Lu MPH , Mousumi Banerjee PhD , Prof Rodney A Hayward MD, Prof Harlan M Krumholz MD , Dr Brahmajee K Nallamothu MD
And appearing today in Circulation.
Duration of Cardiopulmonary Resuscitation and Illness Category Impact Survival and Neurologic Outcomes for In-hospital Pediatric Cardiac Arrests
Renee I. Matos; R. Scott Watson; Vinay M. Nadkarni; Hsin-Hui Huang; Robert A. Berg; Peter A. Meaney; Christopher L. Carroll; Richard J. Berens; Amy Praestgaard; Lisa Weissfeld; Philip C. Spinella
Although these studies looked at in-hospital cardiac arrest, the use of AEDs (see Interactive Video: Using An AED For Sudden Cardiac Arrest (SCA)) in public venues, and the teaching of CPR Skills to the lay public, has had a substantial impact on the survivability of out-of-hospital cardiac arrests as well.
Luckily, today CPR is easier to do than ever.
Compression-only CPR is now the standard for laypeople, and so you don’t have to worry about doing mouth-to-mouth.
While it won’t take the place of an actual class, you can watch how it is done on in this brief instructional video from the American Heart Association.
A CPR class only takes a few hours, and it could end up helping you save the life of someone you love.
Of course, despite your best efforts, many SCA (sudden cardiac arrest) victims will not survive. But early and coordinated action taken by bystanders (calling 911, starting CPR, using AED if available) can substantially improve their chances.
For more on heart attacks, and CPR, you may wish to visit some of these earlier blogs.