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...EMERGENCY MEDICINE

Compression-only CPR: Bystanders can still save lives

Timothy W. Ferrarotti, DHSc, PA-C

Timothy Ferrarotti is an adjunct member of the PA program faculty at Quinnipiac University, Hamden, Connecticut, and practices emergency medicine in northwest Connecticut. He has indicated no relationships to disclose relating to the content of this article.

The American Heart Association (AHA) now supports the use of compression-only cardiopulmonary resuscitation (CPR) by untrained bystanders of witnessed cardiac arrest. The Emergency Cardiovascular Care Committee of the AHA authored a science advisory on March 31, 2008, that addresses the provision of CPR by bystanders in the out-of- hospital setting. This advisory was an update and clarification of the 2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care.

EASIER CPR MORE LIKELY TO BE PERFORMED

This change is considered an improvement for many reasons. First, it is easier for emergency dispatchers to instruct callers in how to perform compression-only CPR until emergency medical services (EMS) arrives. Second, it gives bystanders permission to avoid mouth-to-mouth contact with a potential stranger but still provide potentially lifesaving help. Those who are unwilling to risk infection by performing mouth-to-mouth resuscitation may be more willing to perform chest compressions alone. Third, compression-only CPR is much easier for those whose CPR skills are stale, as the provider does not have to think how many compressions to ventilations should be performed, how long to allow between each breath, and how many cycles to perform. Fourth, compression-only CPR allows for more frequent compressions compared to traditional CPR, as there are no pauses for provision of breaths. Finally, it is easier to educate more laypersons about compression-only CPR, potentially increasing the number of bystanders who could intervene in an arrest.

PRIMARY CARE PAs CAN TEACH COMPRESSION-ONLY CPR

Primary care PAs should be aware of the recommendation for compression-only CPR for a number of reasons. Some PAs may not have taken a CPR renewal course for a long period of time; they may be just as confused about the ratios and timing as other providers who have not refreshed recently. PAs are just as likely as other persons to come across a cardiac arrest outside of the office setting; those who are unprepared, with no barrier-type mask or ready access to an automated external defibrillator (AED), may be willing to provide compression-only CPR to a stranger. Primary care PAs are in an excellent position to teach compression-only CPR to patients and their relatives. Push hard and push fast can be taught during a brief office visit. Some primary care PAs volunteer for service agencies where this new basic form of CPR can be taught. With regards to laypersons’ knowledge of CPR, there is a large area for improvement. According to Sayre and colleagues, “the reported prevalence of bystander CPR remains low in most cities, about 27% to 33%.”¹ The dissemination of information on such an easier form of CPR may increase these numbers.

Over the past few years, compression-only CPR has become increasingly accepted. The International Liaison Committee on Resuscitation noted in 2005 that “Rescuers should be encouraged to do compression-only CPR if they are unwilling to do airway and breathing manoeuvres or if they are not trained in CPR or are uncertain how to do CPR.”² Sayre and colleagues note that as long as 10 years ago, the AHA evaluated whether the guidelines on performing rescue breathing should be changed.¹

Primary care PAs should understand that all health care providers should maintain CPR skills and recertify regularly. Traditional CPR that includes rescue breathing is preferred when properly trained and equipped providers are available. But when health care providers find themselves without proper barrier devices and witness a cardiac arrest, they may deliver compression-only CPR. At the same time, the EMS system or in-hospital emergency response system should be activated and an AED summoned. It is better to perform compressions alone than to do nothing while awaiting proper equipment.

SOME PATIENTS CAN STILL BENEFIT FROM TRADITIONAL CPR

All PAs should understand the basic message of this new advisory. The message is not that all rescue breathing should be abandoned, nor is it to imply that health care providers should provide compressions only. In fact, the advisor notes that many patient populations may benefit from rescue breathing alone or the combination of rescue breathing and compressions performed in traditional CPR. Pediatric patients, those whose arrest is prolonged, and those who have asphyxiation, airway obstruction, or primary apnea are among those who likely will benefit more from traditional CPR.

During a prolonged arrest, the decrease in the oxygen saturation of the blood is likely to be greater with compression-only CPR compared to CPR that incorporates ventilation. Thus, compression-only CPR by bystanders should probably be followed by traditional CPR performed by trained providers (in addition to the application of an AED and advanced cardiac life support).

The primary care PA must also be aware of the reality of cardiac arrest. Contrary to what is depicted on prime time television, the majority of patients who suffer cardiac arrest have a dismal prognosis. The seven studies reviewed by Sayre and colleagues in the science advisory depict dismal outcomes regardless of the type of CPR performed. Though the measured outcome varies between studies, the range of positive outcomes for no bystander CPR is 2% to 6%; for compression-only CPR, it is 4% to 15%; and for traditional CPR, it is 4% to 16%. Clearly, the majority of arrest patients do not survive long-term. Though among the study populations the absolute increase in survival from CPR ranged from only 1% to 10%, a number of individual patients appear to have had a 100% increase in survival as a result of CPR.

The advisory authors stressed the influence of three studies published in 2007 on their recommendation to support compression-only CPR.¹ In a study of all-cause adult cardiac arrests, Nagao and colleagues found that a neurologically favorable 1-month survival occurred in 2% of patients who got no bystander CPR, 4% of patients who got traditional CPR by bystanders, and 6% of those who received compression-only CPR.³ The benefit of compression-only CPR was greatest among those who suffered a witnessed ventricular fibrillation arrest.³ Bohm and colleagues studied a similar group and found that 1-month survival was equal (7%) no matter which type of CPR was performed.⁴ Iwami and colleagues studied neurologically favorable 1-year survival in adult victims of witnessed cardiac arrest from a presumed cardiac cause.⁵ They found no difference between the two methods; 3% achieved the outcome despite receiving no CPR, while 4% of patients who received compressions only and 4% of those who received traditional CPR reached the outcome. Thus, the evidence is mixed but appears to show that there is no benefit to rescue breathing by bystanders of witnessed cardiac arrest and there may even be harm. These conclusions should not be extrapolated to other situations where arrest is unwitnessed or may be due to noncardiac causes. JAAPA

Sarah Zarbock, PA-C, department editor

REFERENCES

	1.	Sayre MR, Berg RA, Cave DM, et al. Hands-only (compression-only) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest: A science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee. Circulation. 2008;117:2162-2167.
	2.	International Liaison Committee on Resuscitation, European Resuscitation Council, and American Heart Association. Part 2: Adult basic life support. Resuscitation. 2005;67:187-201.
	3.	SOS-KANTO Study Group. Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. Lancet. 2007;369:920-926.
	4.	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.
	5.	Iwami T, Kawamura T, Hiraide A, et al. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest. Circulation. 2007;116:2900-2907.

What’s New in….

Our readership surveys routinely tell us that the PAs who read JAAPA are particularly interested in content that can help them keep up with advances in medicine. We also believe that the Journal should provide a forum for PAs working in subspecialties to educate colleagues outside the specialty about significant developments in their field. What’s New in…, debuting in this issue, provides a quick, concise way to meet both these needs. This new department will answer questions about what’s new, why the new development is significant, and what PAs need to know about it. For both authors and the readers, the bottom line remains the same—how this change will affect patients.