Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device

doi:10.1016/j.resuscitation.2013.05.002

Resuscitation

Volume 84, Issue 9, September 2013, Pages 1214-1222

https://doi.org/10.1016/j.resuscitation.2013.05.002 Get rights and content

Abstract

Background

A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD + ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD + ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology.

Methods

This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score ≤ 3).

Results

Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR = 1335; ACD + ITD = 1403). Survival to HD with favorable neurologic function was greater with ACD + ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p = 0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p = 0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups.

Conclusions

Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD + ITD resulted in a significant increase in survival to hospital discharge with favorable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD + ITD, regardless of the etiology of the cardiac arrest.

Introduction

Use of active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD + ICD) has been shown in animal studies to increase myocardial and cerebral perfusion and to improve neurological outcome.¹ A recent clinical trial called the ResQTrial demonstrated that ACD + ITD improved survival to hospital discharge with favorable neurologic function for subjects with an OHCA of presumed cardiac etiology by 53%, compared with S-CPR.² This study focused on cardiac arrest of presumed cardiac etiology. After resuscitation efforts were completed, many patients in that trial were found to have had one or more exclusionary criteria, such as a cardiac arrest of non-cardiac etiology.

Given the need to start CPR as soon as possible to optimize chances for survival, widespread implementation of ACD + ITD would require immediate application of this intervention to a wide spectrum of patients with cardiac arrest, often before the cause of the cardiac arrest is known. One of the primary reasons for performing the analysis described in this manuscript was to determine whether rescue personnel should know the etiology of the cardiac arrest before providing ACD + ITD therapy. We know that it is difficult in many cases and impossible in others to know the etiology prior to starting CPR. Thus, the primary objective of this secondary analysis of the ResQTrial study population was to determine whether treatment with ACD + ITD is more effective in returning patients to their baseline neurological function than S-CPR in all randomized study subjects, regardless of the cause of the arrest. The primary outcome measure was survival to hospital discharge with favorable neurological function, as determined by the Modified Rankin Scale.

Section snippets

Methods

The ResQTrial was performed by investigators in seven distinct geographic locations in the United States (US), including 46 emergency medical services (EMS) agencies, encompassing a total population of 2.3 million. The study was conducted under the US Code of Federal Regulations (21 CFR 50.24): Exception from Informed Consent under Emergency Circumstances. Informed consent was required for continued participation in the study, which consisted of medical records review and in-person follow-up

Results

From October 2005 to July 2009, a total of 2738 patients were prospectively enrolled and randomized to treatment with ACD + ITD (N = 1403) or S-CPR (N = 1335) (Fig. 1). Among all survivors to hospital discharge, consent for ongoing participation in the study was obtained in 86.0% (257/299). Known survival outcomes to one year were available for 2669 (97.5%) patients. Baseline demographics and a summary of resuscitation efforts are shown in Table 1. Baseline characteristics were similar and enrollment

Discussion

When EMS providers arrive at the scene of a cardiac arrest, they generally cannot distinguish between non-cardiac and cardiac etiology prior to initiating CPR. Given this limitation, the intent of this analysis was to determine if the observations from patients in cardiac arrest from a presumed cardiac etiology could be generalized to all non-traumatic cardiac arrest patients in need of CPR, regardless of the cause of the arrest. This study demonstrated that survival to HD with favorable

Conclusions

The expanded analysis with 2738 subjects represents one of the largest prospective interventional CPR trials to date evaluating one year survival and neurologic outcomes after non-traumatic cardiac arrest. Patients treated with ACD + ITD had a relative 38% increase in survival to hospital discharge with favorable neurologic function (MRS ≤ 3), compared with S-CPR, regardless of the etiology of their cardiac arrest. Survival to one year with favorable neurological function was also increased by a

Conflicts of interest statement

TPA, RJF, MAW, BDM, RAS, RMD, and MLO all received grant funds to their respective institutions for services related to patient enrollment, follow-up and data management for this clinical study; Outside the present study, TPA has board membership for Take Heart America and Citizen CPR Foundation, has consulted for JoLife Medical and Medtronic, Inc., and has received grants/grants pending from the NIH Immediate Trial, NIH Resuscitation Outcomes Consortium, the NIH Neurological Emergency

Funding

US National Institutes of Health grant R44-HL065851-03 Advanced Circulatory Systems, Inc. The investigational plan was approved by the NIH, and a representative of the NIH participated as a member of the Data and Safety Monitoring Board. The study sponsor, Advanced Circulatory Systems, Inc., assisted with designing the study, obtaining government funding, interpreting the data, and in preparing the manuscript. The sponsor was not involved with patient care or assessment of patient neurologic

Acknowledgements

We thank the many first responders, firefighters, emergency medical technicians, and paramedics at all study sites, without whom survival from cardiac arrest would not be possible.

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Citation Excerpt :
ACD + ITD CPR is performed with intermittent PPV and not COI. This device combination has been shown to improve hemodynamics, and neurologically-sound survival after cardiac arrest in patients [18–20]. The purpose of this study was to perform in vivo testing of COI using the B-card in a swine model of cardiac arrest.
The purpose of this study was to examine continuous oxygen insufflation (COI) in a swine model of cardiac arrest. The primary hypothesis was COI during standard CPR (S-CPR) should result in higher intrathoracic pressure (ITP) during chest compression and lower ITP during decompression versus S-CPR alone. These changes with COI were hypothesized to improve hemodynamics. The second hypothesis was that changes in ITP with S-CPR + COI would result in superior hemodynamics compared with active compression decompression (ACD) + impedance threshold device (ITD) CPR, as this method primarily lowers ITP during chest decompression.
After 6 min of untreated ventricular fibrillation, S-CPR was initiated in 8 female swine for 4 min, then 3 min of S-CPR + COI, then 3 min of ACD + ITD CPR, then 3 min of S-CPR + COI. ITP and hemodynamics were continuously monitored.
During S-CPR + COI, ITP was always positive during the CPR compression and decompression phases. ITP compression values with S-CPR + COI versus S-CPR alone were 5.5 ± 3 versus 0.2 ± 2 (p < 0.001) and decompression values were 2.8 ± 2 versus −1.3 ± 2 (p < 0.001), respectively. With S-CPR + COI versus ACD + ITD the ITP compression values were 5.5 ± 3 versus 1.5 ± 2 (p < 0.01) and decompression values were 2.8 ± 2 versus −4.7 ± 3 (p < 0.001), respectively.
COI during S-CPR created a continuous positive pressure in the airway during both the compression and decompression phase of CPR. At no point in time did COI generate a negative intrathoracic pressures during CPR in this swine model of cardiac arrest.
Long-Term Prognostic Value of Gasping During Out-of-Hospital Cardiac Arrest
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Citation Excerpt :
Prospectively gathered data from a multicenter, randomized, controlled, National Institutes of Health–funded clinical trial that compared standard CPR versus the combination of active compression decompression CPR plus an impedance threshold device for patients in cardiac arrest in subjects with OHCA were used for these analyses (11,12).
Gasping is a natural reflex that enhances oxygenation and circulation during cardiopulmonary resuscitation (CPR).
This study sought to assess the relationship between gasping during out-of-hospital cardiac arrest and 1-year survival with favorable neurological outcomes.
The authors prospectively collected incidence of gasping on all evaluable subjects in a multicenter, randomized, controlled, National Institutes of Health–funded out-of-hospital cardiac arrest clinical trial from August 2007 to July 2009. The association between gasping and 1-year survival with favorable neurological function, defined as a Cerebral Performance Category (CPC) score ≤2 was estimated using multivariable logistic regression.
The rates of 1-year survival with a CPC score of ≤2 were 5.4% (98 of 1,827) overall, and 20% (36 of 177) and 3.7% (61 of 1,643) for individuals with and without spontaneous gasping or agonal respiration during CPR, respectively. In multivariable analysis, 1-year survival with CPC ≤2 was independently associated with younger age (odds ratio [OR] for 1 SD increment 0.57; 95% confidence interval [CI]: 0.43 to 0.76), gasping during CPR (OR: 3.94; 95% CI: 2.09 to 7.44), shockable initial recorded rhythm (OR: 16.50; 95% CI: 7.40 to 36.81), shorter CPR duration (OR: 0.31; 95% CI: 0.19 to 0.51), lower epinephrine dosage (OR: 0.47; 95% CI: 0.25 to 0.87), and pulmonary edema (OR: 3.41; 95% CI: 1.53 to 7.60). Gasping combined with a shockable initial recorded rhythm had a 57-fold higher OR (95% CI: 23.49 to 136.92) of 1-year survival with CPC ≤2 versus no gasping and no shockable rhythm.
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Coronary Artery Disease in Patients With Out-of-Hospital Refractory Ventricular Fibrillation Cardiac Arrest
2017, Journal of the American College of Cardiology
The prevalence of coronary artery disease (CAD) among patients with refractory out-of-hospital (OH) ventricular fibrillation (VF)/ventricular tachycardia (VT) cardiac arrest is unknown.
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Complex but treatable CAD was prevalent in patients with refractory OH VF/VT cardiac arrest who also met criteria for continuing resuscitation in the CCL. A systems approach using ECLS and reperfusion seemed to improve functionally favorable survival.

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^☆: A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.05.002

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Clinical paperTreatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device☆

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Conflicts of interest statement

Funding

Acknowledgements

Lancet

Lancet

Resuscitation

Resuscitation

Improved cerebral perfusion pressures and 24-h neurological survival in a porcine model of cardiac arrest with active compression-decompression cardiopulmonary resuscitation and augmentation of negative intrathoracic pressure

Crit Care Med

American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care

Circulation

Interobserver agreement for the assessment of handicap in stroke patients

Stroke

The Cognitive Abilities Screening Instrument (CASI): a practical test for cross-cultural epidemiological studies of dementia

Int Psychogeriatr

Clinical paper
Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device☆