Hands-Only CPR

Now@NEJM just posted an article detailing the results of two new studies on Hands-Only or Compressions-Only CPR or Cardiocerebral Resuscitation (CCR). These studies[1,2] look very promising, in fact they showed no appreciable difference in overall survival-to-discharge for traditional CPR versus CCR. Moreover, when one of the studies, by Rea et al[1], compared using CCR to CPR survival-to-discharge of cardiac arrest victims of a primary cardiac etiology there was an increase from 12.3% to 15.5%, although it was not statistically significant. However, when comparing CCR to CPR to non-cardiac etiologies, there was a higher percentage of survivability in the CPR group (7.2% vs. 5.0%), although this as well was not statistically significant.

So what does this mean?

The researchers in Rea et al[1] note that while there was no statistically significant difference between the two, there was a clinically significant trend towards higher survival-to-discharge numbers using compressions alone. Additionally, 80.5% (n=981) of callers given compressions-only instructions began compressions versus 72.7% (n=960) given traditional CPR instructions. Overall 76.7% (n=1941) of callers began either CCR or CPR, which means 1 in 4 callers declined to perform some form of resuscitation.

Taking a closer look at the efficacy of the caller instructions, there is a nearly 8% increase in initiation of compressions under compressions-only instructions. Applying that increase to the CPR-instructions group would have meant nearly 75 more patients would have received compressions! Potentially another 9 people could have gone home from the hospital. Rea et al went as far as saying this was a clinically significant difference, but we all know how big of a difference it makes having just one more person walk home.

So what should we do?

I think progressive systems with tight integration between first responders, EMS, and dispatch need to get the Hands-Only word out to the public. Start using Hands-Only dispatch instructions along with an aggressive public information campaign. I feel in just a 60-90 second TV advertisement, Hands-Only CPR could be demonstrated to the public effectively. You could even throw in your favorite prime time TV cast to really capture those eyeballs.

I've not been in EMS very long, but my heart sinks every time I walk into a house and there has been no attempt at CPR. Our response times are often in the 8-9 minute range which means most of our attempts are futile. I understand the psychological barriers are high, but we need something to improve the rates of bystander CPR. If these studies have shown one thing, it is that Hands-Only CPR has a good chance of doing just that.

References
1. Rea TD, et al. CPR with Chest Compression Alone or With Rescue Breathing. N Engl J Med 2010; 363: 423-433. [at nejm.org]
Conclusions: Dispatcher instruction consisting of chest compression alone did not increase the survival rate overall, although there was a trend toward better outcomes in key clinical subgroups. The results support a strategy for CPR performed by laypersons that emphasizes chest compression and minimizes the role of rescue breathing.


2. Svensson L, et al. Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest. N Engl J Med 2010; 363: 434-442. [at nejm.org]
Conclusions: This prospective, randomized study showed no significant difference with respect to survival at 30 days between instructions given by an emergency medical dispatcher, before the arrival of EMS personnel, for compression-only CPR and instructions for standard CPR in patients with suspected, witnessed, out-of-hospital cardiac arrest.