That concept has been around for a while, there is even a study that discusses doing BOTH chest and abdominal compressions.

The problem with past and even (partially) current AHA (American Heart Association) recommended CPR is that there is too much “hands off chest” time. Watch CPR done by even the most experienced rescuers and you will notice that a significant amount of time is spent without compressions being done. The higher the level of care, the more time spent sans compressions (time spent for other procedures like intubation) even using defibrillators can significantly reduce compression time.

The most recent changes AHA has made to CPR and ACLS (advanced cardiac life support) has started to address these issues by recommending 30:2 compression to ventilation ratios, 5 cycles of compression PRIOR to defibrillation in not witnessed cardiac arrest (non-traumatic).

Before I get ahead of myself, a lot of talk has been about save percentages. Numbers in the high teens, twenties and thirties are optimistic statistics. In the past when you have seen these numbers they represent the percent of patients of ANY cardiac arrest not just Sudden Cardiac Arrest (SCA) most studies don't include traumatic arrest. What is the difference? Let’s use a patient from a few weeks ago as an example, awake and alert when we arrive… late 20’s alcoholic who is having periods of “not breathing” according to his relatives. We already have the patient on the monitor and an IV established when he codes, monitor shows a fatal rhythm (TdP for you medical guys out there). Good compressions (if you aren’t sweating you aren’t doing them right) are begun immediately and the patients converts back in to a perfusing rhythm after some medication is administered prior to defibrillating the patient. We continue care and at the hospital the patient still has a pulse and lives to get drunk and have his family call us numerous times since. Now, you take all the patients like this that experience cardiac arrest in front of a health care provider or team of providers you will see save percentages in the upper 90’s (that is our average) if you just look at ROSC (return of spontaneous circulation). You start looking at survival to discharge from the hospital with similar function prior to cardiac arrest those numbers drop into the high 50’s. Those are still exceptional percentages if you look at them alone but are a complete misrepresentation of overall survival rates and their inclusion in the effectiveness of CPR percentages skew the actually percentage.

When looking at the effectiveness of CPR, using just those patients who experience SCA in the prehospital setting will give you a much more accurate number. SCA is the leading cause of death in America, on average 42 adults experience SCA an hour (over 400,000 annually). In 2003 USA Today did a comprehensive study and even though almost half of the 50 largest cities had almost 0% survival to discharge rates the national average was 2-5% with the large city average of 1-2%! Similar studies have showed nearly identical results.

These numbers have been unchanged since the early 1990’s, the question was why. A few issues surfaced; first while bystander CPR on SCA patients was in the 40-60% range in the 1980s, it is currently under 10%. There is no obvious solution to this issue, however 911 operators instructing callers on how to do JUST compressions have improved numbers in those areas and “layperson” CPR removing ventilations have also improved bystander CPR rates (a move that makes sense, but we will cover that later).

A second issue was brought to light by a study in Seattle (who has the highest SCA save percentages) brought to light another interesting fact; patients who initially received BLS (basic life support) WITHOUT defibrillators had higher survival rates than those who initially received BLS or ALS (advanced life support) WTH defibrillators. When they looked at why, they noticed that good quality CPR was done by the BLS crews without defibrillation prior to a unit arriving with a defibrillator (this is also thought to be why the nationwide survival rate was higher than urban survival rates). The solution, add a period of CPR prior to defibrillation on not witnessed SCA with no GOOD bystander CPR performed prior to arrival and survival rates improved dramatically.

While we know that defibrillators make a huge difference in survival rates, statistics from airports and casinos where there is a proliferation of public access AEDs proves their effectiveness. The problem with these statistics is the patient receives their first shock from a defibrillator most often in the first 3 minutes AND good CPR is performed prior to an AED being applied to the patient.

While we have always treated cardiac arrest patients the same, we realize now that patients need to be treated differently giving how long they have been down. That difference is simply providing good quality compressions early in the event prior using a defibrillator UNLESS the patient actually codes in front of you and you have the defibrillator in your hand. We also discover that the old 15:2 compression to ventilation ratio assured that the patient never maintained a perfusable pressure. So by increasing the ratio to 30:2 (or even higher as some areas are currently doing) and providing 5 cycles at a rate of 100 compressions a minute PRIOR to applying the defibrillator (or doing any other interventions like advanced airways) in the unwitnessed/no good bystander CPR prior to arrival patients we can increase survival percentages significantly (from 2-3% to 10-11% in recent studies). In AZ (and other areas) we have started to use what we call CCR (Cardio-cerebral resuscitation) also called Continuous Compressions Resuscitation by the providers. CCR completely removes the ventilations for the first 6 minutes of patient care and dramatically increased the “hands on chest” time (and to not make this post any longer than it already is) improving survival rates (from 3% to 17% in a few months for a local agency) by allowing the heart to return to the initial phase of cardiac arrest where it is more susceptible to being “shocked” into a perfusing rhythm. This protocol requires cycles of 200 uninterrupted compressions at 100 compressions per minute… we call them “gorilla compressions” because you have to push hard, deep and fast. And it does kick the crap out of providers. This is the way AHA is going with their recommendations in the future.

In the end the solution is simple, better education… for the laypeople and the providers!

Edited to add: Glock-A-Roo makes a great point about docs and the quality of the CPR they provide