Delaying Defibrillation to Give Basic Cardiopulmonary Resuscitation to Patients With Out-of-Hospital Ventricular Fibrillation: A Randomized Trial

University of Stavanger (UiS), Stavenger, Rogaland, Norway
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 04/2003; 289(11):1389-95. DOI: 10.1001/jama.289.11.1389
Source: PubMed


Defibrillation as soon as possible is standard treatment for patients with ventricular fibrillation. A nonrandomized study indicates that after a few minutes of ventricular fibrillation, delaying defibrillation to give cardiopulmonary resuscitation (CPR) first might improve the outcome.
To determine the effects of CPR before defibrillation on outcome in patients with ventricular fibrillation and with response times either up to or longer than 5 minutes.
Randomized trial of 200 patients with out-of-hospital ventricular fibrillation in Oslo, Norway, between June 1998 and May 2001. Patients received either standard care with immediate defibrillation (n = 96) or CPR first with 3 minutes of basic CPR by ambulance personnel prior to defibrillation (n = 104). If initial defibrillation was unsuccessful, the standard group received 1 minute of CPR before additional defibrillation attempts compared with 3 minutes in the CPR first group.
Primary end point was survival to hospital discharge. Secondary end points were hospital admission with return of spontaneous circulation (ROSC), 1-year survival, and neurological outcome. A prespecified analysis examined subgroups with response times either up to or longer than 5 minutes.
In the standard group, 14 (15%) of 96 patients survived to hospital discharge vs 23 (22%) of 104 in the CPR first group (P =.17). There were no differences in ROSC rates between the standard group (56% [58/104]) and the CPR first group (46% [44/96]; P =.16); or in 1-year survival (20% [21/104] and 15% [14/96], respectively; P =.30). In subgroup analysis for patients with ambulance response times of either up to 5 minutes or shorter, there were no differences in any outcome variables between the CPR first group (n = 40) and the standard group (n = 41). For patients with response intervals of longer than 5 minutes, more patients achieved ROSC in the CPR first group (58% [37/64]) compared with the standard group (38% [21/55]; odds ratio [OR], 2.22; 95% confidence interval [CI], 1.06-4.63; P =.04); survival to hospital discharge (22% [14/64] vs 4% [2/55]; OR, 7.42; 95% CI, 1.61-34.3; P =.006); and 1-year survival (20% [13/64] vs 4% [2/55]; OR, 6.76; 95% CI, 1.42-31.4; P =.01). Thirty-three (89%) of 37 patients who survived to hospital discharge had no or minor reductions in neurological status with no difference between the groups.
Compared with standard care for ventricular fibrillation, CPR first prior to defibrillation offered no advantage in improving outcomes for this entire study population or for patients with ambulance response times shorter than 5 minutes. However, the patients with ventricular fibrillation and ambulance response intervals longer than 5 minutes had better outcomes with CPR first before defibrillation was attempted. These results require confirmation in additional randomized trials.

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    • "Another study reported that life expectancy and quality of life were similar in patients who had survived OHCA-VF compared to a matched population [22]. Whereas early studies suggested a benefit of CPR before defibrillation [23] [24] [25] [26] [27], recent studies do not support these findings [28] [29] [30] [31] [32] [33]. Thus, current CPR guidelines do not recommend a specific CPR interval before defibrillation but highlight the importance of efficient and continuous chest compressions with as short as possible hands-off time until successful defibrillation [25] [34] [35]. "
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    ABSTRACT: Aim of the study Automated external defibrillation (AED) and public access defibrillation (PAD) have become cornerstones in the chain of survival in modern cardiopulmonary resuscitation. Most studies of AED and PAD have been performed in urban areas and evidence is scarce for sparsely populated rural areas. The aim of this review was to review the literature and discuss treatment strategies of out-of-hospital cardiac arrest in rural areas. Methods A Medline search was performed with the keywords “automated external defibrillation” (617 hits), “public access defibrillation” (256), “automated external defibrillator public” (542). Of these 1415 abstracts and additional articles found by manual searching references, 92 articles were included in this non-systematic review. Results Early defibrillation is crucial for survival with good neurological outcome after cardiac arrest. Rapid defibrillation can be a challenge in sparsely populated and remote areas, where the incidence of cardiac arrest is low and rescuer response times can be long. The few studies performed in rural areas showed that the introduction of AED programs based on a two-tier emergency medical system (EMS), consisting of a Basic Life Support (BLS) and Advanced Life Support (ALS) team, resulted in a decrease in collapse-to-defibrillation times and better survival of patients with out-of-hospital cardiac arrest. Conclusions In rural areas, introducing AED programs and a two-tier EMS may increase survival of out-of-hospital cardiac arrest patients. More studies on AED and PAD in rural areas are required.
    American Journal of Emergency Medicine 08/2014; 32(11). DOI:10.1016/j.ajem.2014.08.046 · 1.27 Impact Factor
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    • "After 10 minutes of VF, few patients are successfully resuscitated (2). However, after 5 minutes of VF, cardiopulmonary resuscitation (CPR) for 3 minutes prior to the first shock resulted in 22% survival to hospital discharge and 4% survival when the defibrillation shock was given before CPR (3). Thus, survival after more than 5 minutes of VF is possible. "
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    ABSTRACT: Aim To determine the role of repetitive endocardial focal activations and Purkinje fibers in the maintenance of long duration ventricular fibrillation (LDVF, VF>1 minute) in canine hearts in vivo. Methods The study was conducted in electrophysiological laboratory of Shanghai Ruijin hospital from July 2010 to August 2012. A 64-electrode basket was introduced through a carotid artery into the left ventricle (LV) of 11 beagle dogs for global endocardial electrical mapping. In the Lugol’s solution group (n = 5), the subendocardium was ablated by washing with Lugol’s solution. In the control group, (n = 6) saline was used for ablation. Before and after saline or Lugol ablation, we determined QRS duration and QT/QTc interval in sinus rhythm (SR). We also measured the activation rates in the first 2 seconds of each minute during 7 minutes of VF for each group. If VF terminated spontaneously in less than 7 minutes, the VF segments used in activation rate analysis were reduced accordingly. Results At the beginning of VF there was no difference between the groups in the activation rate. However, after 1 minute of LDVF the Lugol’s solution group had significantly slower activation rate than the control group. In the control group, all episodes of LDVF (6/6) were successfully sustained for 7 minutes, while in the Lugol’s solution group 4/5 episodes of LDVF spontaneously terminated before 7 minutes (4.8 ± 1.4 minutes) (P = 0.015). In the control group, at 5.1 ± 1.3 minutes of LDVF, a successive, highly organized focal LV endocardial activation pattern was observed. During this period, activations partly arose in PF and spread to the working ventricular myocardium. Mapping analysis showed that these events were consistent with repetitive endocardial focal activations. No evidence of similar focal activations was observed in the Lugol’s solution group. Conclusions Repetitive endocardial focal activations in the LV endocardium may be associated with activation of subendocardial PFs. This mechanism may play an important role in the maintenance of LDVF.
    Croatian Medical Journal 04/2014; 55(2):121-7. DOI:10.3325/cmj.2014.55.121 · 1.31 Impact Factor
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    • "Wik et al [2] were the first to randomize patients with VF OHCA to receive immediate RS delivery or 3 minutes of CPR prior to first RS. Because the sampling years were 1989 to 2001, the compression to ventilation ratio was 5:1 and initial shocks were delivered in triplet— as the guidelines recommended. "
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    ABSTRACT: Optimal resuscitation duration before the first rescue shock (RS) to maximize the probability of success after prolonged ventricular fibrillation (VF) cardiac arrest remains unknown. The purpose of this study was to determine the occurrence of return of spontaneous circulation (ROSC) and survival by RS attempt after 12 minutes of untreated VF. This was a secondary analysis of prospectively collected data from an institutional animal care and use committee-approved protocol. Fifty-three swine (30-35 kg) were instrumented under anesthesia. Ventricular fibrillation was electrically induced. After 12 minutes of untreated VF, cardiopulmonary resuscitation (CPR) was initiated (and continued as necessary (prn)) and a standard dose of epinephrine (0.01 mg/kg) was given (and repeated every 3 (q3) minutes prn). The first RS was delivered after 3 minutes of CPR (and q3 minutes thereafter prn). Each failed RS was followed (in series) by vasopressin (0.57 mg/kg), amiodarone (4.3 mg/kg), and sodium bicarbonate (1 mEq/kg) prn. Resuscitation continued until ROSC or 20-minute elapsed time. The primary outcomes were ROSC and 20-minute survival. Data were analyzed using descriptive statistics. After 3 minutes of resuscitation, 1 animal (1.9% [95% confidence interval {CI, 0.3-10.0]) achieved ROSC on RS1 and survived. After 6 minutes of resuscitation, 17 animals (32.1% [95% CI, 21.1-45.5]) achieved ROSC on RS2 and 15 (28.3% [95% CI, 18.0-41.6]) survived. Twelve additional animals had ROSC and survival with continued resuscitation. In 23 animals, ROSC was never achieved and efforts were terminated per protocol. Our data suggest that during the metabolic phase of VF, 3 minutes of CPR and 1 standard dose of epinephrine may be insufficient to achieve ROSC on the first RS attempt. A longer duration of CPR and/or additional vasopressors may increase the likelihood of successful defibrillation.
    The American journal of emergency medicine 03/2014; 32(6). DOI:10.1016/j.ajem.2014.02.035 · 1.27 Impact Factor
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