Abstract
The aim of this study was to evaluate whether there is a difference in the return of spontaneous circulation (ROSC) and survival with sequel-free recovery rates between the patients who underwent cardiopulmonary resuscitation (CPR) according to 2005 and 2010 guidelines. This study was conducted in the Bakırköy Dr. Sadi Konuk and Kartal Lütfi Kırdar Training and Research Hospital between dates of October 2010 and 28 February 2011 after approval of Ethics Committee. In the first months of the study, CPR was performed according to AHA 2005 ACLS guidelines (Group-1), while CPR was performed according to AHA 2010 ACLS guidelines after November 2010 (Group-2). Patients were assessed for neurological deficit with Cerebral Performance Categories Scale. Mean age was found as 69.01±13.05 (minimum: 21, maximum: 92) in 86 patients included. Of the 33 patients underwent CPR in the Group 1, ROSC was achieved in 51.5%; and 6.1% of these patients were discharged. Of the 53 patients underwent CPR in the Group 2, ROSC was achieved in 37.7%; and 9.4% of these patients were discharged. Although the number of living patients in Group 2 was higher than Group 1, the difference was not found statistically significant (5 versus 2), (P>0.05). But, neurological outcomes were found better with 2010 compared to 2005 guidelines (3/7 versus 0/2 good cerebral performance). It was found that the 2005 CPR guidelines practices in ED were more successful than the 2010 CPR guidelines practices in ROSC, but less successful in the rate of discharge from hospital and neurological sequel-free discharge rate.
Keywords: Cardiac arrest, cardiopulmonary resuscitation, CPR, 2005-2010 AHA guidelines, CPS, cerebral performance scale
Introduction
Despite all advanced techniques outcome of cardiopulmonary resuscitation (CPR) has not improved much over the last decades [1]. In USA, more than 460,000 patients die annually from sudden cardiac death on account of unexpected cardiac arrests [2]. Treatment of cardiac arrest is aimed to achieve return of spontaneous circulation (ROSC) by early cardiopulmonary resuscitation (CPR), rapid defibrillation and effective advanced life support [3,4]. While closed chest cardiac massage and monophasic defibrillation were documented in 1960 and in 1962, first CPR guideline was developed by American Heart Association (AHA) in 1966 [5-7]. Thereafter, first international CPR guidelines were published in 2000. AHA and ERC (European Resuscitation Council) 2005 resuscitation model was re-updated later and published last version in 2010 [3,4,8-13].
There have been several important differences between 2005 and 2010 ACLS.
Guidelines as listed below [3].
Lay rescuers begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim’s pulse. “Look, listen and feel for breathing” has been removed from the algorithm.
Compression rate should be at least 100/min (rather than ‘approximately 100/minute’).
There has been a change in the recommended sequence for the lone rescuer to initiate chest compressions before giving rescue breaths-C-A-B-(Chest compressions, Airway, Breathing) rather than-A-B-C-(Airway, Breathing, Chest compressions).
A compression depth of 1.5-2 inches is no longer used for adults, and the absolute depth specified for children and infants is deeper than 2005 AHA guidelines for CPR (at least 2 inches in adults).
It has been found that, among all cardiac arrest cases, approximately 1.4-36% of patients who survived after CPR recover without neurological deficit, despite all advances in resuscitation and emergency medicine care [14,15].
Various methods are used to assess neurological outcome after arrest. Cerebral Performance Categories Scale (CPC) is one of those methods [16,17]. (CPC 1: Good cerebral performance; CPC 2: Moderate cerebral disability; CPC 3: Severe cerebral disability; CPC 4: Coma or vegetative state; CPC 5: Brain death).
In the pre-hospital, emergency department and intensive care, the number of studies related to cardiac arrest is very scarce. Also, there are only a few studies comparing 2005 advanced cardiac life support (ACLS) and 2010 ACLS guidelines [10-13,18-20].
The aim of this study is to assess whether there is a difference regarding ROSC and survival with sequel-free recovery rates between patients receiving CPR according to 2005 and 2010 guidelines.
Materials and methods
Study design
The cohort study was designed as prospective and observational.
Study population
This study was conducted in patients who were presented with cardiac arrest or experienced in-hospital cardiac arrest and underwent CPR in the Bakirkoy Dr. Sadi Konuk (9 patients) and Kartal Lutfi Kirdar (79 patients) Training and Research Hospital between 1 October 2010 and 28 February 2011 after approval of Ethics Committee and Helsinki Decleration 2008. Patients younger than 15 years of age, those with trauma or cancer, or those considered as dead at the arrival were excluded.
Study protocol
The study was conducted at two distinct time periods, on two different patient groups for two distinct practices. In the first month of the study, CPR according to AHA 2005 ACLS guidelines was performed in patients presented with cardiac arrest (Group-1), while CPR was performed according to AHA 2010 new ACLS guidelines in patients presented with cardiac arrest after November, 2010 (Group-2). When new ACLS guidelines were published in November 2010, the first period was ceased. After November 2010 all CPR procedures were reorganized and performed according to AHA 2010 new ACLS guidelines.
Age, gender, underlying disease, antecedents to cardiac arrest type of arrival to ED, duration between cardiac arrest and initiation of CPR, first monitored rhythms, duration of CPR and defibrillation, setting that CPR and defibrillation performed, CPR duration, length of intensive care stay, time of death, setting of death, Glasgow Coma Scale (GCS) and CPC scores at ED, intensive care unit (ICU) were recorded.
CPR outcomes and ROSC were compared in patients underwent CPR according to AHA 2005 and AHA 2010.
Patients who underwent CPR and discharged were re-assessed for neurological deficit (GCS and CPC) after one month.
CPR practice and management were performed by Emergency Physicians and Senior Emergency Residents in Emergency Departments and by Anesthesiology or Cardiology Physicians or Senior Residents of Anesthesiology and Cardiology in ICU.
Statistical analysis
Statistical analysis was performed by using SPSS for Windows 19.0. Kolmogorov-Smirnov test was used to assess data distribution. Parametric, interrupted data were analyzed by t-test, while non-parametric data were analyzed by Kruskall-Wallis and Mann Whitney U test. Chi-square and Fischer’s exact test were used in proportional data. P<0.05 was considered as significant.
Results
In the study 86 patients (43 women and 43 men) were evaluated. The mean age was found as 69.01±13.05 years (minimum: 21, maximum: 92).
Thirty three patients (Group 1) underwent CPR according to 2005 AHA guidelines, while 53 patients (Group 2) according to 2010 AHA guideline.
Of the cardiac arrests, 54.6% occurred in the ED. There was no significant difference between Group 1 and 2 regarding places (in scene, in ambulance and in ED) that cardiac arrest occurred (P>0.05) (Table 1).
Table 1.
Compared to CPR results in Group 2005 AHA and Group 2010 AHA with arrest localization
| Group-1 n=33 | Group-2 n=53 | p | |||
|---|---|---|---|---|---|
| Age (Mean ± SD) | 68.1±14.0 | 69.6±12.5 | 0.597 | ||
| n | n | P | |||
| Sex | Female | 19 | 24 | 0.578 | |
| Male | 14 | 29 | |||
| Arrest localization | In scene | Dead | 14 | 15 | 1.000 |
| Living | 2 | 1 | |||
| In ambulance | Dead | 2 | 5 | ||
| In ED | Dead | 15 | 28 | 0.291 | |
| Living | - | 4 | |||
| Result | Dead | In ED | 16 | 34 | 0.268 |
| In ICU* | 7 | 2 | |||
| In ICU** | 8 | 12 | |||
| Total | 31 | 48 | |||
| Living | 2 | 5 | |||
Between 0 and 24 hours;
After 24 hours.
In the present study, 16 of 33 patients, who underwent CPR in ED according to 2005 AHA guidelines, were unresponsive to CPR; ROSC was achieved in 51.5% of the patients. Of the patients, 21.2% survived less than 24 hours, whereas 24.2% survived more than 24 hours. Six point one percent of the patients survived with management according to AHA 2005 guideline were discharged.
Thirty three out of 53 patients who underwent CPR in ED according to AHA 2010 guidelines were unresponsive to CPR; ROSC was achieved in 37.7% of the patients. Of the patients, 3.7% survived less than 24 hours, whereas 22.6% survived more than 24 hours. Of the patients survived with management according to AHA 2010 guideline, 9.4% were discharged.
Although the number of living patients in Group 2 was higher than Group 1, the difference was not found statistically significant (5 versus 2), (P=0.578).
For the Groups 1 and 2, rhythms on monitor before CPR and after CPR are shown in Tables 2 and 3.
Table 2.
The initial ECG rhythms in Groups before CPR
| Initial ECG Rhythms Before CPR | |||||
|---|---|---|---|---|---|
|
| |||||
| N | |||||
|
| |||||
| Asystole | PEA | Pulseless VT | VF | ||
| Group-1 2005 AHA | Dead in ED | 13 | 2 | 1 | - |
| Dead in ICU* | 5 | 2 | - | - | |
| Dead in ICU** | 5 | 3 | - | - | |
| Total Dead | 23 | 7 | 1 | - | |
| Living | 2 | - | - | - | |
| Group-2 2010 AHA | Dead in ED | 22 | 6 | - | 6 |
| Dead in ICU* | 1 | - | - | 1 | |
| Dead in ICU** | 11 | - | 1 | - | |
| Total Dead | 34 | 6 | 1 | 7 | |
| Living | 3 | 2 | - | - | |
| All groups | Total | 62 | 15 | 2 | 7 |
Between 0 and 24 hours;
After 24 hours.
Table 3.
The returned ECG rhythms in Groups after CPR
| Returned ECG Rhythms After CPR | ||||||
|---|---|---|---|---|---|---|
|
| ||||||
| N | ||||||
|
| ||||||
| Asystole | Pulseless VT | AF | MI | NSR | ||
| Group-1 2005 AHA | Dead In ED | 16 | - | - | - | - |
| Dead In ICU* | - | - | - | 1 | 7 | |
| Dead In ICU** | - | - | - | - | 7 | |
| Total Dead | 16 | - | - | 1 | 14 | |
| Living | - | - | 1 | - | 1 | |
| Group-2 2010 AHA | Dead In ED | 33 | - | - | - | 1 |
| Dead In ICU* | - | - | - | - | 2 | |
| Dead In ICU** | - | 3 | - | - | 9 | |
| Total Dead | 33 | 3 | - | - | 12 | |
| Living | - | - | - | - | 5 | |
| All groups | Total | 49 | 3 | 1 | 1 | 32 |
Between 0 and 24 hours;
After 24 hours.
Overall initial rhythm on monitor was asystole in 72.09% (group 1: 75.75%; group 2: 69.81%) of patients, pulseless electrical activity (PEA) in 17.44% (group 1: 21.21%; group 2: 15.09%) and pulseless ventricular tachycardia (VT) in 2.32% (group 1: 3.03%; group 2: 1.88%) and ventricular fibrillation (VF) in 8.13% (group 1: 0%; group 2: 13.20%) of patients of both groups.
Overall return rhythm on monitor was asystole in 56.97% of patients, atrial fibrillation (AF) in 1.16%, myocardial infarction (MI) in 1.16% and as Normal Sinus Rhythm (NSR) in 37.20% and as pulseless VT in 3.48% of patients of both groups.
In group 1, 92% of patients with initial rhythms of asystole (n=25), 100% of patients with pulseless VT (n=1) and 100% of patients with PEA (n=7) died in Group 1. In group 2, 91.89% of patients with asystole (n=37), 100% of patients with pulseless VT (n=1), 100% of patients with VF (n=7) and 75% of patients with PEA (n=8) of initial rhythms died.
One patient returned with NSR and one patient with AF after CPR survived in Group 1, whereas five patients returned with NSR after CPR survived in Group 2.
Return rhythm on monitor was asystole in 48.48% of patients, AF in 3.03% of patients, myocardial infarction (MI) in 3.03% of patients and NSR in 45.45% of patients in Group 1. Also, return rhythm on monitor was asystole in 62.26% of patients, pulseless VT in 5.66% of patients and NSR in 32.07% of patients of Group 2.
While 100% of patients with asystole (n=16), 100% with MI (n=1) and 93.33% with NSR (n=14) of return rhythms died in Group 1; 100% of patients with asystole (n=33), 100% of patients with pulseless VT (n=3) and 70.58% of patients with NSR (n=17) of return rhythms died in Group 2.
For the Groups 1 and 2, means of pre-hospital periods, CPR periods, arrest to CPR durations, stay in ICU durations, GCS and CPC between dead and living patients are shown in Table 4.
Table 4.
Comparison of duration of prehospital, CPR, arrest to CPR and stay in ICU of Dead and Living Patients in Group 1 and Group 2
| Group-1 (2005 AHA, n=33) | Group-2 (2010 AHA, n=53) | |||||
|---|---|---|---|---|---|---|
|
| ||||||
| Dead n=31 | Living n=2 | P | Dead n=48 | Living =5 | P | |
|
|
|
|||||
| Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | |||
| Prehospital duration | 10.1±4.7 | 10.0±0.0 | 0.909 | 9.3±3.2 | 9.6±0.9 | 0.825 |
| CPR duration | 31.7±17.8 | 12.5±3.5 | 0.341 | 31.0±17.3 | 6.8±5.6 | 0.007 |
| Arrest to CPR duration | 4.8±6.2 | 10.0±0.0 | 0.187 | 4.2±6.0 | 4.0±8.9 | 0.505 |
| Stay in ICU duration | 4.8±6.2 | 10.0±0.0 | 0.216 | 4.2±6.0 | 4.0±8.9 | 0.151 |
| GCS | 5.8±4.3 | 3.0±0.0 | 0.322 | 6.1±5.0 | 11.2±5.5 | 0.029 |
| CPC | 3.4±0.8 | 4.0±0.0 | 0.319 | 3.4±0.9 | 2.4±1.5 | 0.079 |
Mann-Whitney U Test, %95 CI, P<0.05.
While there was a significant difference in means of CPR duration between patients survived and those died in Group 2 (P=0.007), there was no significant difference in other means between patients survived and those died (P>0.05).
Also, for the Groups 1 and 2, there was no significant difference in underlying diseases, duration between cardiac arrest and initiation of CPR and defibrillation, setting that CPR and defibrillation performed and between dead and living patients (P>0.05).
Characteristics of living patients after CPR and discharged are shown in Table 5.
Table 5.
The characteristics of living patients after CPR
| Patients | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
|---|---|---|---|---|---|---|---|
| CPR guidelines | 2005 | 2005 | 2010 | 2010 | 2010 | 2010 | 2010 |
| Age | 62 | 83 | 64 | 62 | 83 | 73 | 69 |
| Sex | Female | Male | Male | Female | Male | Female | Male |
| Transport types | Private vehicle | 112 | 112 | Private vehicle | Private vehicle | Private vehicle | Private vehicle |
| Arrival time to ED | 21.00 | 13.00 | 11.00 | 23.00 | 08.00 | 03.00 | 23.00 |
| Initial rhythms | Asystole | Asystole | PEA | Asystole | PEA | Asystole | Asystole |
| Return ECG rhythm | AF | NSR | NSR | NSR | NSR | NSR | NSR |
| Arrest to CPR duration (minutes) | 10 | 10 | - | - | - | 20 | - |
| Total CPR duration (minutes) | 15 | 10 | 4 | 2 | 2 | 10 | 15 |
| Stay in ICU duration (day) | 44 | 11 | 29 | 13 | 9 | 32 | 1 |
| Initial GCS (just after CPR) | 3 | 3 | 15 | 15 | 8 | 3 | 15 |
| Discharge GCS | 15 | 15 | 8 | 15 | 15 | 15 | 15 |
| One month later GCS | 15 | 15 | 8 | 15 | 15 | 15 | 15 |
| Initial CPC (just after CPR) | 4 | 4 | 2 | 1 | 2 | 1 | 1 |
| Discharge CPC | 3 | 3 | 4 | 1 | 2 | 1 | 1 |
| One month later CPC | 3 | 3 | 4 | 1 | 2 | 1 | 1 |
In the Group 1, no significant difference was found in between GCS and CPC values at presentation to ED of patients survived and those died (P>0.05). Also, no significant difference was found in CPC values at presentation to ED between patients survived and those died in Group 2 (P>0.05), while GCS value at presentation to ED was found to be significantly higher in patients survived than those died (P<0.05).
In this study, 42.85% of patients had a Good cerebral performance (CPC: 1); 14.28% of patients had a Moderate cerebral disability (CPC: 2); 28.71% had a Severe cerebral disability (CPC: 3); and 14.28% had a vegetative state (CPC: 4) who survived with CPR after discharge and one month later (Table 5).
Discussion
In a study by Deasy et al., it was emphasized that outcomes from out-of-hospital cardiac arrest have improved since introduction of the 2005 CPR guidelines, but this improvement may not be due to implementation of the 2005 resuscitation guidelines [10]. In a meta-analysis study by Salmen et al., it was emphasized that AHA/ERC 2005 resuscitation guidelines improved out-of-hospital cardiac arrest outcomes compared to older guidelines [13]. Short-term survival was observed in 19.9% of cases and 5.3% of patients survived was discharged [21]. In a study on 383 cases by Khan et al., ROSC was achieved in 72% of the cases; 42% survived more than 24 hours; and, of the patients survived 19% were discharged [22]. In a study on elderly patients, ROSC was achieved in 32.6% of patients and 8.4% survived to discharge from hospital [15]. In a study from Turkey, by Pembeci et al., it was found that ratio of immediate survival, survival at 24 hours and survival to discharge as 49.3%, 28.5% and 13.4%, respectively [23].
In this study, practices for 2005 CPR guidelines were more successful in achieving ROSC (51.5% versus 37.7%) than 2010 CPR guidelines, whereas that of 2010 CPR guidelines were found to be more successful in terms of discharge (9.4% versus 6.1%) after survival. But the difference was not found statistically significant.
In a study by Khan et al., it was emphasized that factors such as age, gender, comorbidity or time of arrest had no effect on survival rate [22]. In other studies, it was suggested that age positively affects prognosis [24-26]. In this study, it was found that age, gender or time of arrest had no effect on survival rate.
In a study by Ebell, it was found that survival rate was higher in cases with witnessed cardiac arrest at presentation or during follow-up in case of an underlying cardiac disorder, when compared to others [25]. In this study, coronary artery disease existed in all patients survived in both groups. It was seen that underlying cardiac disorders positively affected survival rates regardless of being witnessed arrest or not.
In a study by Khan, it was found that first monitored rhythms of VF or pulseless VT were associated with better results compared to other rhythms; however, difference was not statistically significant [22]. In the study by Cooper et al., the difference was considered as significant [26]. In contrast to study by Amer, asystole was the most commonly encountered (85.1%) of first monitored rhythm in both groups in this study [15]. Moreover in this study, while the most commonly first monitored rhythm in both groups was found as asystole, the most commonly return monitored rhythm in both groups was found as asystole.
In this study, initial rhythm was found as asystole (71.4%) and PEA (28.6%) of living patients. None of the patients with first monitored rhythm of VF or pulseless VT survived in both groups.
In the studies, CPR duration, time of cardiac arrest, time of CPR, time of defibrillation and location of cardiac arrest are determined as key predictors of survival [15,21-23]. Similarly, it was found that CPR duration was 10 minutes or shorter in 85.7% of the patients who survived in the present study. In the present study, there was no difference in CPR duration between patients survived or those died in Group 1; however, CPR duration was significantly shorter in patients survived than those died in Group 2 (31.0±17.3 vs. 6.8±5.6 minutes).
Early intervention, early CPR and early ROSC are known to affect patient prognosis. It has been found that early ROSC has improved the sequel-free quality of life in arrest patients [4]. In the studies, it was found that emergency medical service (EMS) response within eight minutes isn’t associated to survival regardless of disease severity. However, it was found that EMS response within four minutes positively affects survival in moderate-high risk group [27]. In the present study, no significant difference was detected in survival between patients who arrived to ED by ambulance or by their own vehicle.
According to the studies, any single clinical neurological finding doesn’t predict adverse outcome within first 24 hours after cardiac arrest [28]. Baseline neurological status after ROSC is accepted as a marker which reflects diffuse ischemia during circulatory arrest. GCS was accepted as the measure of neurological status and correlated to discharge [29]. In the present study, among the patients who underwent CPR according to 2010 AHA guidelines, baseline GCSs were significantly higher in patients who survived than those died. We believe that there is a correlation between this significantly higher GCS and good neurological outcome.
In recent studies, approximately 3-8% of patients who survived after CPR have recovered without neurological deficit among all cardiac arrest cases, despite all advances in resuscitation and emergency medicine care [14]. In a retrospective cohort study by Phelps et al., it was reported that CPC predicted better long-term prognosis after cardiac arrest. They found 62% of patients had a CPC of 1; 23% a CPC of 2; 10% a CPC of 3; and 5% a CPC of 4 [30]. In this study, it was found that 2010 guideline had better neurological outcome than 2005 guideline. Neurological deficit was detected in 100% and 60% of patients who survived after CPR according to 2005 and 2010 guidelines respectively.
Due to inadequate sample size and not having available/possible earlier publications so our study will be considered as a pilot study.
Conclusion
The present study showed that practices of 2005 CPR guidelines in emergency medicine department are more successful than 2010 CPR guidelines practices regarding ROSC; however, less successful regarding capability to discharge from hospital and discharge without neurological sequel. Also we found that CPC can also be used in long-term follow up of survivors after arrest.
Study limitation
The study is a master thesis in the department of emergency medicine. The duration of the study was kept as short due to lack of time. We were unable to guess the publication time of the 2010 guideline. Therefore study sample was small.
Acknowledgements
I would like to thank all Emergency Department staff in Bakirkoy Dr. Sadi Konuk and Kartal Lutfi Kırdar Training and Research Hospital.
Disclosure of conflict of interest
None.
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