1. A Cochrane review found that for untrained bystanders, continuous chest compressions without rescue breathing improved survival to hospital discharge compared to interrupted CPR. For trained professionals, interrupted CPR had slightly better outcomes. 2. The AHA recommends that untrained lay rescuers provide continuous chest compressions with or without dispatcher assistance for adults in cardiac arrest. For trained lay rescuers, compression-only CPR is recommended. 3. A study found no difference in outcomes between continuous compressions with asynchronous ventilations and 30:2 CPR. 30:2 CPR was associated with better outcomes than 15:2 CPR. It may be reasonable for EMS to use 10 breaths per

1. CPR
What’s new?
Dr. Anoop James
Assistant professor
Emergency Medicine
JMMC & RI

2. Continuous or Interrupted Chest Compressions for OHCA?
Zhan L, Yang LJ, Huang Y, He Q, Liu GJ.Continuous chest compression versus interrupted chest compression for cardiopulmonary
resuscitation of non-asphyxial out-of-hospital cardiac arrest.Cochrane Database of Systematic Reviews 2017, Issue 3.

3. Continuous or Interrupted Chest Compressions for OHCA?
Zhan L, Yang LJ, Huang Y, He Q, Liu GJ.Continuous chest compression versus interrupted chest compression for cardiopulmonary
resuscitation of non-asphyxial out-of-hospital cardiac arrest.Cochrane Database of Systematic Reviews 2017, Issue 3.
Untrained bystander-administered CPR:
“Continuous chest compression CPR without rescue breathing
improved participants’ survival to hospital discharge compared with
interrupted CPR (14% versus 11.6%)”
There were no data available for survival at one year, quality of life, return
of spontaneous circulation or adverse effects.

4. Continuous or Interrupted Chest Compressions for OHCA?
Zhan L, Yang LJ, Huang Y, He Q, Liu GJ.Continuous chest compression versus interrupted chest compression for cardiopulmonary
resuscitation of non-asphyxial out-of-hospital cardiac arrest.Cochrane Database of Systematic Reviews 2017, Issue 3.
CPR administered by a trained professional
“Survival to hospital – Higher with interrupted CPR (9.7% vs 9.0% )”
Survival to hospital admission – Higher with interrupted CPR
Return of spontaneous circulation - Higher with interrupted CPR
Neurological outcome – Little or no difference between two groups
Rates of adverse events – Higher with interrupted CPR

5. Continuous or Interrupted Chest Compressions for OHCA?
AHA 2017 UPDATE - For Adults in OHCA
1. Untrained lay rescuers should provide chest compression–only CPR with or
without dispatcher assistance.
2. For lay rescuers trained in chest compression–only CPR, we recommend
that they provide chest compression–only CPR for adults in OHCA.
3. For lay rescuers trained in CPR using chest compressions and ventilation
(rescue breaths), it is reasonable to provide ventilation (rescue breaths) in
addition to chest compressions for the adult in OHCA.

6. CPR with Asynchronous Ventilation or 30:2 Ventilation?
Nikolla, D. A., & Carlson, J. N. (2018). Which Compression-to-Ventilation Ratio Yields Better Cardiac Arrest Outcomes? Annals of Emergency
Medicine, 71(4), 485–486.

7. Asynchronous
ventilation or
30:2
ventilation?

8. Asynchronous ventilation or 30:2 ventilation?
Conclusions:
1. There was no difference between continuous-compression CPR
with asynchronous ventilations and 30:2 CPR for favorable
neurologic outcomes and survival to hospital discharge
2. CPR at 30:2 was associated with greater favorable neurologic
outcomes than 15:2 in adults.
3. In pediatric patients, 30:2 or 15:2 CPR resulted in improved rates
of favorable neurologic outcomes

9. Asynchronous ventilation or 30:2 ventilation?
“It may be reasonable for EMS providers to use a rate of 10 breaths per
minute (1 breath every 6 seconds) to provide asynchronous
ventilation during continuous chest compressions before placement
of an advanced airway.”

10. Early Intubation In CPR Improves Survival – Yes or No?
Result: “Early intubation at any given time during
first 15 min of initiating CPR was associated with
decreased survival to hospital discharge, reduced
ROSC and reduced functional outcomes”
Andersen LW, Granfeldt A, Callaway CW, et al. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and
Survival. JAMA. 2017;317(5):494-506.

11. 1. No evidence of benefit with the use of mechanical devices for chest
compressions.
2. Manual chest compressions remain the standard of care for the treatment of
cardiac arrest.
3. Mechanical devices may be used as alternative to conventional CPR in specific
settings (e.g. limited rescuers available, prolonged CPR, CPR during hypothermic
cardiac arrest, CPR in a moving ambulance, CPR in the angiography suite, CPR
during preparation for ECPR).
AHA 2015 Update:
Mechanical vs Manual CPR?

12. Mechanical vs Manual CPR?
Result: The ability to achieve ROSC with mechanical
device was inferior to manual chest compression and
cannot be recommended as a replacement for manual CPR

13. E-CPR vs Conventional CPR?
“ECPR may be considered among select cardiac arrest patients who have
not responded to initial conventional CPR, in settings where it can be
rapidly implemented.”
AHA 2015 Update……

14. E-CPR vs Conventional CPR?
“Efficacy of extracorporeal cardiopulmonary
resuscitation compared to conventional cardiopulmonary
resuscitation for adult cardiac arrest patients: a
systematic review and meta-analysis”
Meta-analysis by Ahn C et.
Al - 2016
Result: ECPR showed similar survival rates and neurologic
outcomes to CCPR in out-of-hospital cardiac arrest patients.
However, ECPR was associated with significantly better survival
rates and neurologic outcomes than CCPR in IHCA.
Ahn, C. et al. Efficacy of extracorporeal cardiopulmonary resuscitation compared to conventional cardiopulmonary resuscitation for adult cardiac
arrest patients: a systematic review and meta-analysis. Sci. Rep. 6, 34208

15. E-CPR vs Conventional CPR?
“Comparison of extracorporeal and conventional
cardiopulmonary resuscitation: A meta-analysis of
2 260 patients with cardiac arrest ”
Meta-analysis by Wang G
et. Al - 2017
Result: ECPR showed a beneficial effect on survival rate to discharge
and long-term neurological outcome over CCPR in adult patients with
CA.
There was a significant difference in survival to discharge favoring ECPR
over CCPR group in OHCA patients
No significant difference was found in IHCA patients
Wang GN, Chen XF, Qiao L, et al. Comparison of extracorporeal and conventional cardiopulmonary resuscitation: A meta-analysis of 2 260 patients with
cardiac arrest. World J Emerg Med. 2017;8(1):5-11.

16. Is PEA a Reason to Refuse ECPR?
Result: Survival to discharge in patients with PEA as initial rhythm at the time of
decision for ECPR is 23.8% while no patients with asystole as initial rhythm survived
discharge. Patients with PEA should be carefully considered for ECPR
• Most current recommendations for ECPR do not include patients
with a non-shockable rhythm such as PEA and asystole.
• Retrospective single-center study of adults who underwent
ECPR for in-hospital cardiac arrest
• 3 patient groups separated by initial rhythm : asystole, PEA and
shockable rhythm.
Pabst D, Brehm CE. Is pulseless electrical activity a reason to refuse cardiopulmonary resuscitation with ECMO support? Am J Emerg Med. 2018
Apr;36(4):637-640.

17. Procainamide or Amiodarone For Managing Stable WCT?
Ortiz M, Martín A, Arribas F, Coll-Vinent B, Del Arco C, Peinado R, Almendral J; PROCAMIO Study Investigators. Randomized comparison of intravenous
procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2017 May
1;38(17):1329-1335.
Result: Procainamide therapy was associated with less
major cardiac adverse events and a higher proportion of
tachycardia termination within 40 min.
PROCAMIO
Trial

18. Epinephrine for OHCA – Yes or No?
Result: Epinephrine group – higher rates of 30-day survival; no
significant difference in neurological outcomes.
More survivors had severe neurologic impairment in the
epinephrine group
Paramedic 2
Trial
Perkins GD et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. NEJM 2018.

19. T-CPR?????
 Telephone CPR (T-CPR)
 Telecommunicators are the true, first responders and a critical link in the
cardiac arrest chain of survival
 Every emergency dispatch center in the nation should be aware of the following:
• The provision of T-CPR instruction for virtually all cardiac arrests is a standard of care.
• Meeting this standard requires training, ongoing training, and continuous quality
improvement.
• Meeting this standard saves lives.
• Not meeting this standard results in deaths that are preventable.

20. T-CPR?????

21. Thank You