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CPR First, Then Defibrillation?
March 18, 2003 - For a cardiac arrest victim, minutes count as the chances of survival dwindle with each passing moment before treatment. But a new study shows minutes may also matter when it comes to what type of treatment -- manual CPR (cardiopulmonary resuscitation) or electronic defibrillation to shock the heart back in sync -- emergency care personnel use for patients of cardiac arrest caused by irregular heartbeats.
According to researchers, the standard approach has been for emergency care personnel outside the hospital to use defibrillation immediately in treating patients with ventricular fibrillation -- irregular and rapid heartbeats that impairs the heart's pumping ability and frequently leads to cardiac arrest. In fact, the image of applying defibrillator paddles to the chest and delivering a life-saving shock to restore heart rhythm is a classic image repeated in film and television.
But researchers say the reality is that surviving an out-of-hospital cardiac arrest is rare. Despite frequent use of defibrillators, less than 5% of people survive a cardiac arrest that occurs outside a hospital, which suggests that new approaches in treating cardiac arrests caused by ventricular fibrillation might be needed.
In their study, published in the March 19 issue of TheJournal of the American Medical Association, researchers found that performing CPR before defibrillation can improve the survival chances of cardiac arrest victims who had to wait more than five minutes for an ambulance to receive treatment.
The study found that patients who endured longer ambulance response times, the hospital discharge and one-year survival rates were much higher if they received three minutes of CPR prior to defibrillation and then three-minute intervals of CPR (rather than the standard one minute) between defibrillation attempts. Patients who received this type of treatment were almost seven times more likely to be alive one year later than those who received standard care.
Researcher Lars Wik, MD, PhD, of the Institute for Experimental Medical Research of Ulleval University Hospital in Oslo, Norway, and colleagues say this finding confirms earlier studies that suggested CPR prior to defibrillation may provide a survival advantage when there has been a significant delay before delivering defibrillation. But this is the first randomized study to compare the two approaches directly.
The study compared the outcomes of 200 people who suffered a cardiac arrest caused by an irregular heartbeat outside of a hospital between 1998 and 2001 and received either immediate defibrillation or three minutes of CPR before defibrillation. Overall, researchers found no significant differences between the two treatments in improving hospital discharge or preventing deaths, except in patients who had ambulance response times of more than five minutes.
In an editorial that accompanies the study, Terence D. Valenzuela, MD, MPH, of the University of Arizona, says improving survival rates after out-of-hospital cardiac arrest is a major goal of public health campaigns to increase access to defibrillation. He says this study suggests that a new strategy using CPR prior to defibrillation may offer an attractive alternative for improving survival rates among people who must wait for treatment and merits further study.
SOURCE: The Journal of the American Medical Association, March 19, 2003.
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