- Email: [email protected]
Progress in Improving Neurologically Intact Survival From Cardiac Arrest
EMERGENCY MEDICAL SERVICES/EDITORIAL
Progress in Improving Neurologically Intact Survival From Cardiac Arrest Arthur B. Sanders, MD, MHA
From the Department of Emergency Medicine, CPR Resuscitation Research Group, Sarver Heart Center, University of Arizona, Tucson, AZ.
0196-0644/$-see front matter Copyright © 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2008.04.018
SEE RELATED ARTICLE, P. 244. [Ann Emerg Med. 2008;52:253-255.] In 2002 to 2003, the University of Arizona Sarver Heart Center Resuscitation Research Group developed a novel approach to the treatment of patients in out-of-hospital cardiac arrest, cardiocerebral resuscitation. The development of cardiocerebral resuscitation was based on a concern that the American Heart Association 2000 guidelines were not optimal in 2002 and patients would be better served by a new protocol.1-6 Cardiocerebral resuscitation is a therapeutic approach to resuscitation, based in part on the 3-phase time-sensitive model of untreated ventricular fibrillation articulated by Weisfeldt and Becker7 in 2002. Cardiocerebral resuscitation recognizes that during the electrical phase of ventricular fibrillation arrest, eg, the first 4 or 5 minutes of ventricular fibrillation arrest, defibrillation is the therapy of choice. This explains why automatic external defibrillators are effective in locations in which early defibrillation is possible. However, most patients in out-of-hospital arrest are in the circulatory phase by the time the medics arrive, when perfusion is important before defibrillation.8-10 Cardiocerebral resuscitation has 3 major components. The first is that it encourages the expansion of bystander cardiopulmonary resuscitation (CPR) by teaching continuous chest compression with no active ventilation by witnesses of cardiac arrest. There is no evidence from clinical studies that ventilation, when added to chest compressions, improves the resuscitation of adults in sudden cardiac arrest. Although there are some theoretic concerns about not teaching rescue breathing for bystander CPR, human studies have reported equal or better survival when continuous chest compression CPR was compared to continuous chest compression with rescue breathing.11-16 The recent SOS-Kanto study reported on 4,068 patients who had outof-hospital cardiac arrest witnessed by bystanders. Although any form of bystander CPR was better than no CPR, patients in ventricular fibrillation arrest who received chest-compression-only CPR had better neurologic survival than patients who received standard CPR (19.4% versus 11.2%; P⬍.05).12 There is also evidence that many rescuers do not initiate CPR because they are hesitant to do mouth-to-mouth Volume , . : September
ventilation.17,18 The complexity of teaching and remembering the skill of rescue breathing represents a barrier to bystander CPR. Finally, the literature on the negative effects of interruptions of chest compressions for rescue breathing made a compelling case to promote continuous chest compression CPR.19-21 The need for continuous chest compressions to provide perfusion and the lack of evidence for the efficacy of adding ventilations led to the conclusion in 2003 that both laypersons and health care professionals need to deliver continuous chest compression CPR to adults in cardiac arrest. In April 2008, the American Heart Association issued a Science Advisory for the Public from the Emergency Cardiovascular Care Committee, advocating “hands-only (compression-only) cardiopulmonary resuscitation” as a call to action for bystander response to adults in cardiac arrest.11 Although the sample size from the Kellum et al22 study is not large enough to draw any definitive conclusions, we note in their Table 3 that survival in the project group who received bystander continuous chest compression was 8 of 16 (50%) compared with 12 of 22 (55%) for those who received standard CPR, again supporting the concept that continuous chest compression is as effective as CPR with rescue breathing.22 Studies in Europe and Arizona demonstrated that interruptions in chest compressions were a major problem, not just in layperson CPR but also in emergency medical services (EMS) systems.23,24 Medics were performing other tasks that our guidelines have assigned them (intubation, airway management, rhythm assessment, assisted ventilation, defibrillation, etc) and, as a result, the patients received chest compression less than 50% of the time during EMS treatment. The EMS protocol for cardiocerebral resuscitation focuses the medic on maximizing perfusion by delivering uninterrupted chest compressions preshock and postshock, delaying endotracheal intubation, minimizing positivepressure ventilation, and encouraging the early use of epinephrine.2-6,22,25,26 In this issue of Annals, Kellum et al22 report on 3 years of data before and after implementing cardiocerebral resuscitation. The protocol was instituted in 2004. The researchers compared the outcome of neurologically intact survivors with witnessed ventricular fibrillation arrest for patients during 2001 to 2003 Annals of Emergency Medicine 253
Neurologically Intact Survival From Cardiac Arrest with 2004 to 2007. Overall, there was a remarkable improvement in neurologically intact survival, from 15% of patients before the cardiocerebral resuscitation protocol to 39% after implementation of cardiocerebral resuscitation.22 This article was a follow-up analysis to a previous report by Kellum et al25 on the implementation of cardiocerebral resuscitation in 2 rural counties in Wisconsin. In their previous report, Kellum et al25 compare the outcome of neurologically intact survivors of witnessed ventricular fibrillation arrest for 3 years before and 1 year after cardiocerebral resuscitation was instituted in 2004. They found that overall ventricular fibrillation survival improved from 20% to 57% and neurologically intact survival increased from 15% to 48%. The present report of 3-year neurologically intact survival is important because it addresses the concern that the initial improvement in survival may have reflected the Hawthorne effect, in which the EMS providers tried harder and provided better resuscitation because they knew they were being assessed with the new cardiocerebral resuscitation protocol. In the 3-year study, we observed neurologically intact survival rates of 29% and 38% for the subsequent 2 years of observation when the enthusiasm for the new protocol should have waned.22 In another recent article, cardiocerebral resuscitation, reported as minimally interrupted cardiac resuscitation, was evaluated in a demonstration project by 2 fire departments in Arizona.26 Bobrow et al26 trained medics in cardiocerebral resuscitation and analyzed the effects of this training on survival to hospital discharge using a before-and-after intention-to-treat analysis. Overall survival increased from 1.8% (4/218) to 5.4% (36/668) after training. In patients with witnessed ventricular fibrillation arrest, survival improved from 4.7% (2/43) before training to 17.6% (23/131) after cardiocerebral resuscitation training. Bobrow et al26 also observed that only 62% of patients treated after training met all 4 compliance criteria. In a second analysis, Bobrow et al26 assessed survival in patients who actually met compliance criteria for cardiocerebral resuscitation in a database from 2,460 patients in multiple EMS systems. Survival was significantly better for those patients who received cardiocerebral resuscitation (9.1% versus 3.8%) and patients with witnessed ventricular fibrillation (28.4% versus 11.9%) compared with those who did not get cardiocerebral resuscitation. Thus, we now have 3 published reports from rural and urban EMS systems demonstrating improved survival with the implementation of cardiocerebral resuscitation. Cardiocerebral resuscitation was implemented in 2003, several years before the current American Heart Association guidelines were published in December 2005. The 2005 guidelines included many but not all the recommendations included in cardiocerebral resuscitation. The 2005 guidelines state that the medic may give 5 cycles of CPR before attempting defibrillation, 1 shock is recommended rather than stacked shocks, and CPR should be resumed immediately postshock.27 The 2005 guidelines do not encourage or provide instruction in continuous chest compression without rescue breathing for 254 Annals of Emergency Medicine
Sanders medics or laypersons. Thus, a major difference in 2005 guidelines recommendations and cardiocerebral resuscitation is the emphasis on the need for early ventilation and the concern about interruptions for rescue breathing. The studies by Kellum et al22,25 and Bobrow et al26 do not differentiate what components of cardiocerebral resuscitation might be most important in the achievement of improved survival. A number of important questions remain to be answered. The benefits demonstrated by these analyses of cardiocerebral resuscitation show that the primary benefit is for patients with witnessed ventricular fibrillation arrest. Is cardiocerebral resuscitation the best treatment for patients in cardiac arrest with an initial rhythm of asystole, pulseless electrical activity, or unwitnessed ventricular fibrillation arrest? Are all 4 elements of compliance (continuous chest compressions pre- and postshock, delayed intubation, early epinephrine) necessary for improving survival? Could better survival be obtained if the cardiocerebral resuscitation protocol were reinforced with periodic retraining sessions and feedback to medics about protocol compliance? Will the simplified continuous chest compression CPR encourage more bystanders to perform CPR? What are the take-home messages for clinicians and EMS medical directors from this new EMS protocol showing improvement in survival? First, it is vital that EMS systems measure the success of resuscitation efforts in the community. There are many system factors beyond the control of EMS medical directors that will affect survival. However, baseline data are key to understanding and developing strategies that can save lives. For most EMS systems, survival to hospital discharge is a reasonable standard to measure and follow so that changes can be compared over time. The ultimate goal is neurologically intact survival, and the report by Kellum et al22 is one of the few to document this outcome, justifying the descriptor “cardiocerebral resuscitation.” If survival from witnessed ventricular fibrillation is not optimal, we encourage the implementation of changes that have worked elsewhere and make sense in the community. The cardiocerebral resuscitation protocol is one option that EMS directors should consider. Assessment of the efficacy of the changes is essential by repeatedly measuring outcome success. Another lesson we can learn from the Kellum et al22 article is that waiting for official guideline recommendations every 5 years may not be the best strategy. Unless the science is clear, we should encourage innovative approaches such as cardiocerebral resuscitation to solve the difficult problems associated with treating victims of out-of-hospital cardiac arrest. The institution of Cardiocerebral Resuscitation by Kellum et al22 in Wisconsin and Bobrow et al26 in Arizona has already saved hundreds of lives. Supervising editor: Theodore R. Delbridge, MD, MPH Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author Volume , . : September
Sanders
Neurologically Intact Survival From Cardiac Arrest
has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Publication date: Available online May 19, 2008. Reprints not available from the author. Address for correspondence: Arthur B. Sanders, MD, MHA, PO Box 245057, Tucson, AZ 85724-5057; 520-626-5032, fax 520-626-2480; E-mail [email protected]. REFERENCES 1. American Heart Association, International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care: an international consensus on science. Part 3. Adult basic life support. Circulation. 2000; 102(suppl I):I-22-I-59. 2. Ewy GA. A new approach for out-of-hospital CPR: a bold step forward. Resuscitation. 2003;58:271-272. 3. Kern KB, Valenzuela TD, Clark LL, et al. An alternative approach to advancing resuscitation science. Resuscitation. 2005;64:261268. 4. Ewy GA. Cardiocerebral resuscitation: the new cardiopulmonary resuscitation. Circulation. 2005;111:2134-2142. 5. Ewy GA. Cardiac arrest: guideline changes urgently needed. Lancet. 2007;369:882-884. 6. Ewy GA, Kern KB, Sanders AB, et al. Cardiocerebral resuscitation for cardiac arrest. Am J Med. 2006;119:6-9. 7. Weisfeldt ML, Becker LB. Resuscitation after cardiac arrest: a 3-phase time-sensitive model. JAMA. 2002;288:3035-3038. 8. Wik L, Hansen TB, Fylling F, et al. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-ofhospital ventricular fibrillation: a randomized trial. JAMA. 2003; 289:1389-1395. 9. Cobb LA, Fahrenbruch CE, Walsh TR, et al. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA. 1999;281:11821188. 10. Valenzuela TD. Priming the pump— can delaying defibrillation improve survival after sudden cardiac death? JAMA. 2003;289: 1434-1436. 11. Sayre MR, Berg RA, Cave DM, et al. Hands-only (compressiononly) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest. Circulation. 2008;117:2162-2167. 12. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. Lancet. 2007;369:920-926.
13. Iwami T, Kawamura T, Hiraaide A, et al. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with outof-hospital cardiac arrest. Circulation. 2007;116:2900-2907. 14. Bohm K, Rosenqvist M, Herlitz J, et al. Survival is similar after standard treatment and chest compression only in out-of-hospital bystander cardiopulmonary resuscitation. Circulation. 2007;116: 2908-2912. 15. Hallstrom A, Cobb L, Johnson E, et al. Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. N Engl J Med. 2000;342:1546-1553. 16. Waalewijn RA, Tijssen JG, Koster RW. Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation Study (ARRESUST). Resuscitation. 2001;50:273-279. 17. Locke CJ, Berg RA, Sanders AB, et al. Bystander cardiopulmonary resuscitation: concerns about mouth-to-mouth contact. Arch Intern Med. 1995;155:938-943. 18. Ornato JP, Hallagan LF, McMahan SB, et al. Attitudes of ACLS instructors about mouth-to-mouth resuscitation during the AIDS epidemic. Ann Emerg Med. 1990;19:151-156. 19. Assar D, Chamberlain D, Colquhoun M, et al. Randomized controlled trials of staged teaching for basic life support, 1: skill acquisition at the bronze stage. Resuscitation. 2000;45:7-15. 20. Higdon TA, Heidenreich JW, Kern KB, et al. Single rescuer cardiopulmonary resuscitation: can anyone perform to the guidelines 2000 recommendations? Resuscitation. 2006;71:3439. 21. Heidenreich JW, Sanders AB, Higdon TA, et al. Uninterrupted chest compression CPR is easier to perform and remember than standard CPR. Resuscitation. 2004;63:123-130. 22. Kellum MJ, Kennedy KW, Barney R, et al. Cardiocerebral resuscitation improves neurologically intact survival with out-ofhospital cardiac arrest. Ann Emerg Med. 2008;52:244-252. 23. Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA. 2005;293:299-304. 24. Valenzuela TD, Kern KB, Clark LL, et al. Interruptions of chest compressions during emergency medical systems resuscitation. Circulation. 2005;112:1259-1265. 25. Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am J Med. 2006;119:335-340. 26. Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008;299:1158-1165. 27. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112(suppl):IV1-IV203.
Did you know? You can track the impact of your article with citation alerts that let you know when your article (or any article you’d like to track) has been cited by another Elsevier-published journal.
Visit www.annemergmed.com today to see what else is new online!
Volume , . : September
Annals of Emergency Medicine 255
Progress in Improving Neurologically Intact Survival From Cardiac Arrest Arthur B. Sanders, MD, MHA
From the Department of Emergency Medicine, CPR Resuscitation Research Group, Sarver Heart Center, University of Arizona, Tucson, AZ.
0196-0644/$-see front matter Copyright © 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2008.04.018
SEE RELATED ARTICLE, P. 244. [Ann Emerg Med. 2008;52:253-255.] In 2002 to 2003, the University of Arizona Sarver Heart Center Resuscitation Research Group developed a novel approach to the treatment of patients in out-of-hospital cardiac arrest, cardiocerebral resuscitation. The development of cardiocerebral resuscitation was based on a concern that the American Heart Association 2000 guidelines were not optimal in 2002 and patients would be better served by a new protocol.1-6 Cardiocerebral resuscitation is a therapeutic approach to resuscitation, based in part on the 3-phase time-sensitive model of untreated ventricular fibrillation articulated by Weisfeldt and Becker7 in 2002. Cardiocerebral resuscitation recognizes that during the electrical phase of ventricular fibrillation arrest, eg, the first 4 or 5 minutes of ventricular fibrillation arrest, defibrillation is the therapy of choice. This explains why automatic external defibrillators are effective in locations in which early defibrillation is possible. However, most patients in out-of-hospital arrest are in the circulatory phase by the time the medics arrive, when perfusion is important before defibrillation.8-10 Cardiocerebral resuscitation has 3 major components. The first is that it encourages the expansion of bystander cardiopulmonary resuscitation (CPR) by teaching continuous chest compression with no active ventilation by witnesses of cardiac arrest. There is no evidence from clinical studies that ventilation, when added to chest compressions, improves the resuscitation of adults in sudden cardiac arrest. Although there are some theoretic concerns about not teaching rescue breathing for bystander CPR, human studies have reported equal or better survival when continuous chest compression CPR was compared to continuous chest compression with rescue breathing.11-16 The recent SOS-Kanto study reported on 4,068 patients who had outof-hospital cardiac arrest witnessed by bystanders. Although any form of bystander CPR was better than no CPR, patients in ventricular fibrillation arrest who received chest-compression-only CPR had better neurologic survival than patients who received standard CPR (19.4% versus 11.2%; P⬍.05).12 There is also evidence that many rescuers do not initiate CPR because they are hesitant to do mouth-to-mouth Volume , . : September
ventilation.17,18 The complexity of teaching and remembering the skill of rescue breathing represents a barrier to bystander CPR. Finally, the literature on the negative effects of interruptions of chest compressions for rescue breathing made a compelling case to promote continuous chest compression CPR.19-21 The need for continuous chest compressions to provide perfusion and the lack of evidence for the efficacy of adding ventilations led to the conclusion in 2003 that both laypersons and health care professionals need to deliver continuous chest compression CPR to adults in cardiac arrest. In April 2008, the American Heart Association issued a Science Advisory for the Public from the Emergency Cardiovascular Care Committee, advocating “hands-only (compression-only) cardiopulmonary resuscitation” as a call to action for bystander response to adults in cardiac arrest.11 Although the sample size from the Kellum et al22 study is not large enough to draw any definitive conclusions, we note in their Table 3 that survival in the project group who received bystander continuous chest compression was 8 of 16 (50%) compared with 12 of 22 (55%) for those who received standard CPR, again supporting the concept that continuous chest compression is as effective as CPR with rescue breathing.22 Studies in Europe and Arizona demonstrated that interruptions in chest compressions were a major problem, not just in layperson CPR but also in emergency medical services (EMS) systems.23,24 Medics were performing other tasks that our guidelines have assigned them (intubation, airway management, rhythm assessment, assisted ventilation, defibrillation, etc) and, as a result, the patients received chest compression less than 50% of the time during EMS treatment. The EMS protocol for cardiocerebral resuscitation focuses the medic on maximizing perfusion by delivering uninterrupted chest compressions preshock and postshock, delaying endotracheal intubation, minimizing positivepressure ventilation, and encouraging the early use of epinephrine.2-6,22,25,26 In this issue of Annals, Kellum et al22 report on 3 years of data before and after implementing cardiocerebral resuscitation. The protocol was instituted in 2004. The researchers compared the outcome of neurologically intact survivors with witnessed ventricular fibrillation arrest for patients during 2001 to 2003 Annals of Emergency Medicine 253
Neurologically Intact Survival From Cardiac Arrest with 2004 to 2007. Overall, there was a remarkable improvement in neurologically intact survival, from 15% of patients before the cardiocerebral resuscitation protocol to 39% after implementation of cardiocerebral resuscitation.22 This article was a follow-up analysis to a previous report by Kellum et al25 on the implementation of cardiocerebral resuscitation in 2 rural counties in Wisconsin. In their previous report, Kellum et al25 compare the outcome of neurologically intact survivors of witnessed ventricular fibrillation arrest for 3 years before and 1 year after cardiocerebral resuscitation was instituted in 2004. They found that overall ventricular fibrillation survival improved from 20% to 57% and neurologically intact survival increased from 15% to 48%. The present report of 3-year neurologically intact survival is important because it addresses the concern that the initial improvement in survival may have reflected the Hawthorne effect, in which the EMS providers tried harder and provided better resuscitation because they knew they were being assessed with the new cardiocerebral resuscitation protocol. In the 3-year study, we observed neurologically intact survival rates of 29% and 38% for the subsequent 2 years of observation when the enthusiasm for the new protocol should have waned.22 In another recent article, cardiocerebral resuscitation, reported as minimally interrupted cardiac resuscitation, was evaluated in a demonstration project by 2 fire departments in Arizona.26 Bobrow et al26 trained medics in cardiocerebral resuscitation and analyzed the effects of this training on survival to hospital discharge using a before-and-after intention-to-treat analysis. Overall survival increased from 1.8% (4/218) to 5.4% (36/668) after training. In patients with witnessed ventricular fibrillation arrest, survival improved from 4.7% (2/43) before training to 17.6% (23/131) after cardiocerebral resuscitation training. Bobrow et al26 also observed that only 62% of patients treated after training met all 4 compliance criteria. In a second analysis, Bobrow et al26 assessed survival in patients who actually met compliance criteria for cardiocerebral resuscitation in a database from 2,460 patients in multiple EMS systems. Survival was significantly better for those patients who received cardiocerebral resuscitation (9.1% versus 3.8%) and patients with witnessed ventricular fibrillation (28.4% versus 11.9%) compared with those who did not get cardiocerebral resuscitation. Thus, we now have 3 published reports from rural and urban EMS systems demonstrating improved survival with the implementation of cardiocerebral resuscitation. Cardiocerebral resuscitation was implemented in 2003, several years before the current American Heart Association guidelines were published in December 2005. The 2005 guidelines included many but not all the recommendations included in cardiocerebral resuscitation. The 2005 guidelines state that the medic may give 5 cycles of CPR before attempting defibrillation, 1 shock is recommended rather than stacked shocks, and CPR should be resumed immediately postshock.27 The 2005 guidelines do not encourage or provide instruction in continuous chest compression without rescue breathing for 254 Annals of Emergency Medicine
Sanders medics or laypersons. Thus, a major difference in 2005 guidelines recommendations and cardiocerebral resuscitation is the emphasis on the need for early ventilation and the concern about interruptions for rescue breathing. The studies by Kellum et al22,25 and Bobrow et al26 do not differentiate what components of cardiocerebral resuscitation might be most important in the achievement of improved survival. A number of important questions remain to be answered. The benefits demonstrated by these analyses of cardiocerebral resuscitation show that the primary benefit is for patients with witnessed ventricular fibrillation arrest. Is cardiocerebral resuscitation the best treatment for patients in cardiac arrest with an initial rhythm of asystole, pulseless electrical activity, or unwitnessed ventricular fibrillation arrest? Are all 4 elements of compliance (continuous chest compressions pre- and postshock, delayed intubation, early epinephrine) necessary for improving survival? Could better survival be obtained if the cardiocerebral resuscitation protocol were reinforced with periodic retraining sessions and feedback to medics about protocol compliance? Will the simplified continuous chest compression CPR encourage more bystanders to perform CPR? What are the take-home messages for clinicians and EMS medical directors from this new EMS protocol showing improvement in survival? First, it is vital that EMS systems measure the success of resuscitation efforts in the community. There are many system factors beyond the control of EMS medical directors that will affect survival. However, baseline data are key to understanding and developing strategies that can save lives. For most EMS systems, survival to hospital discharge is a reasonable standard to measure and follow so that changes can be compared over time. The ultimate goal is neurologically intact survival, and the report by Kellum et al22 is one of the few to document this outcome, justifying the descriptor “cardiocerebral resuscitation.” If survival from witnessed ventricular fibrillation is not optimal, we encourage the implementation of changes that have worked elsewhere and make sense in the community. The cardiocerebral resuscitation protocol is one option that EMS directors should consider. Assessment of the efficacy of the changes is essential by repeatedly measuring outcome success. Another lesson we can learn from the Kellum et al22 article is that waiting for official guideline recommendations every 5 years may not be the best strategy. Unless the science is clear, we should encourage innovative approaches such as cardiocerebral resuscitation to solve the difficult problems associated with treating victims of out-of-hospital cardiac arrest. The institution of Cardiocerebral Resuscitation by Kellum et al22 in Wisconsin and Bobrow et al26 in Arizona has already saved hundreds of lives. Supervising editor: Theodore R. Delbridge, MD, MPH Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author Volume , . : September
Sanders
Neurologically Intact Survival From Cardiac Arrest
has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Publication date: Available online May 19, 2008. Reprints not available from the author. Address for correspondence: Arthur B. Sanders, MD, MHA, PO Box 245057, Tucson, AZ 85724-5057; 520-626-5032, fax 520-626-2480; E-mail [email protected]. REFERENCES 1. American Heart Association, International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care: an international consensus on science. Part 3. Adult basic life support. Circulation. 2000; 102(suppl I):I-22-I-59. 2. Ewy GA. A new approach for out-of-hospital CPR: a bold step forward. Resuscitation. 2003;58:271-272. 3. Kern KB, Valenzuela TD, Clark LL, et al. An alternative approach to advancing resuscitation science. Resuscitation. 2005;64:261268. 4. Ewy GA. Cardiocerebral resuscitation: the new cardiopulmonary resuscitation. Circulation. 2005;111:2134-2142. 5. Ewy GA. Cardiac arrest: guideline changes urgently needed. Lancet. 2007;369:882-884. 6. Ewy GA, Kern KB, Sanders AB, et al. Cardiocerebral resuscitation for cardiac arrest. Am J Med. 2006;119:6-9. 7. Weisfeldt ML, Becker LB. Resuscitation after cardiac arrest: a 3-phase time-sensitive model. JAMA. 2002;288:3035-3038. 8. Wik L, Hansen TB, Fylling F, et al. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-ofhospital ventricular fibrillation: a randomized trial. JAMA. 2003; 289:1389-1395. 9. Cobb LA, Fahrenbruch CE, Walsh TR, et al. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA. 1999;281:11821188. 10. Valenzuela TD. Priming the pump— can delaying defibrillation improve survival after sudden cardiac death? JAMA. 2003;289: 1434-1436. 11. Sayre MR, Berg RA, Cave DM, et al. Hands-only (compressiononly) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest. Circulation. 2008;117:2162-2167. 12. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. Lancet. 2007;369:920-926.
13. Iwami T, Kawamura T, Hiraaide A, et al. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with outof-hospital cardiac arrest. Circulation. 2007;116:2900-2907. 14. Bohm K, Rosenqvist M, Herlitz J, et al. Survival is similar after standard treatment and chest compression only in out-of-hospital bystander cardiopulmonary resuscitation. Circulation. 2007;116: 2908-2912. 15. Hallstrom A, Cobb L, Johnson E, et al. Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. N Engl J Med. 2000;342:1546-1553. 16. Waalewijn RA, Tijssen JG, Koster RW. Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation Study (ARRESUST). Resuscitation. 2001;50:273-279. 17. Locke CJ, Berg RA, Sanders AB, et al. Bystander cardiopulmonary resuscitation: concerns about mouth-to-mouth contact. Arch Intern Med. 1995;155:938-943. 18. Ornato JP, Hallagan LF, McMahan SB, et al. Attitudes of ACLS instructors about mouth-to-mouth resuscitation during the AIDS epidemic. Ann Emerg Med. 1990;19:151-156. 19. Assar D, Chamberlain D, Colquhoun M, et al. Randomized controlled trials of staged teaching for basic life support, 1: skill acquisition at the bronze stage. Resuscitation. 2000;45:7-15. 20. Higdon TA, Heidenreich JW, Kern KB, et al. Single rescuer cardiopulmonary resuscitation: can anyone perform to the guidelines 2000 recommendations? Resuscitation. 2006;71:3439. 21. Heidenreich JW, Sanders AB, Higdon TA, et al. Uninterrupted chest compression CPR is easier to perform and remember than standard CPR. Resuscitation. 2004;63:123-130. 22. Kellum MJ, Kennedy KW, Barney R, et al. Cardiocerebral resuscitation improves neurologically intact survival with out-ofhospital cardiac arrest. Ann Emerg Med. 2008;52:244-252. 23. Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA. 2005;293:299-304. 24. Valenzuela TD, Kern KB, Clark LL, et al. Interruptions of chest compressions during emergency medical systems resuscitation. Circulation. 2005;112:1259-1265. 25. Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am J Med. 2006;119:335-340. 26. Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008;299:1158-1165. 27. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112(suppl):IV1-IV203.
Did you know? You can track the impact of your article with citation alerts that let you know when your article (or any article you’d like to track) has been cited by another Elsevier-published journal.
Visit www.annemergmed.com today to see what else is new online!
Volume , . : September
Annals of Emergency Medicine 255