Cournoyer et al. [1] assessed the association between bystander cardiopulmonary resuscitation (CPR), emergency medical service (EMS) response time, and out-of-hospital cardiac arrest (OHCA) patients' outcomes. This pre-pandemic cohort study was derived from the Resuscitation Outcomes Consortium (ROC) OHCA registry (ROC Epistry) Version 1 and 2 (December 1st, 2005 to April 1st, 2010) and 3 (April 1st, 2011 to June 30th, 2015), which included cases assessed by EMS in the out-of-hospital setting who: a) underwent either EMS-performed chest compressions or had a shock delivered by a bystander-applied automated external defibrillator; or b) were found pulseless by EMS personnel, but did not receive treatment [2]. Survival at hospital discharge was ascertained for all cases. They concluded that although bystander CPR is associated with an immediate increase in odds of survival and of good neurologic outcome for OHCA patients, it does not influence the negative association between longer EMS response time and survival and good neurologic outcome.
Using a Korean OHCA registry, Park and colleagues [3] analyzed OHCA patients whose arrest was not witnessed by EMS providers between 2017 and 2021. Because lack of hospital and survival information in 2021, the 2021 data were used only to identify the expected trend. They found that survival to discharge was 5019 (8.2%) in pre-COVID-19 set and 1457 (6.6%) in post-COVID-19 set. The proportion of bystander CPR was 59.0% in the pre-COVID-19 set and 61.0% in the post-COVID-19 set. The median (interquartile range) response time was 7 (5–9) minutes in the pre-COVID-19 set and 8 (6–10) minutes in the post-COVID-19 set. Response time and on-scene management of EMS showed the highest impact on decreased survival. A similar trend was also expected in the 2021. They concluded that an effort to create a more rapid response system for OHCA patients could have priority for the recovery of survival outcomes in OHCA patients in the post-COVID-19 period. Further studies to recover survival outcomes of OHCA are warranted.
However, the reasons for the lack of influence of bystander CPR on survival with good outcomes when EMS response times are prolonged are likely because sternal compression was performed highly ineffectively in 50% of all OHCA cases, time to first compression was significantly delayed and no efforts were made to prevent asphyxial cardiac arrest and facilitate unobstructed gasping, which are critical for increasing survival with good neurological outcomes.
I first called attention to the fact that sternal compressions are performed in a highly ineffective manner in 50% of all cases [4]. The 4-finger method of hand placement of the heel of the dominant bottom hand in contact with the sternum was proposed to avoid compression over the cranial side of the sternum and ensure maximally effective compression over the caudal half of the sternum adequately below the internipple line but safely above the xiphoid process (i.e., over the midpoint of the lower half of the sternum). I very recently proposed that in cases where a public access defibrillator is not readily available, eliminating instructions to remove clothing to bare the chest (see Fig. 1 ) and/or place the victim supine on the floor when the victim is found lying supine in bed, allows the 4-finger method of hand placement to be immediately applied with minimal delay and minimizes time to first compression [5]. In addition, based on strong evidence in patients [6,7], use of head rotation (or turning the head maximally to one side) was also advocated as a hands-free method of airway control to prevent asphyxial cardiac arrest and facilitate unobstructed gasping, which are critical for survival with good outcomes [8] (see Fig. 1).
Fig. 1.
When the head is maximally turned away from the bystander, the sternocleidomastoid muscle is very prominent. To achieve proper hand placement kneeling on victim's right side, place tip of left little finger just below the bulging sternocleidomastoid muscle and place the right heel 4 finger-widths of the left hand from the muscle aligned with it and centered on the sternum (if necessary, adjust the heel toward or away from oneself until a flat spot is felt). When kneeling on the arrest victim's left side, the bystander needs to do the opposite.
Arguably, only 10% of all adult OHCA victims would sustain unobstructed gasping without providing hands-free airway control (with or without providing chest compressions) prior to EMS arrival [9]. However, animal evidence suggests that arterial oxygenation and frequency of gasping during partially obstructed gasping with room air (likely occurring in 54% of arrest victims [9]) would likely be critically reduced, less effective, and shorter-lived [10,11]. Even the incidence of unobstructed gasping is greatly reduced when the duration of untreated ventricular fibrillation is greater than 3 min, only 8% of intubated animals are still gasping after 8 min or so (the average EMS response time) [11]. Head rotation is needed to significantly increase the incidence of unobstructed gasping upon EMS arrival, which as evidenced above, is between 6 and 10 min in the post-COVID-19 era. Chest compression using the 4-finger method of hand placement without baring the chest and/or without moving the victim to a hard flat surface or floor when found lying supine in bed, is needed to prolong and increase the frequency [12] of unobstructed gasping so that it is present upon EMS arrival. Oxygen promotes spontaneous gasping during experimental CPR [12].
CRediT authorship contribution statement
Eric M. Rottenberg: Writing – review & editing, Writing – original draft, Conceptualization.
Declaration of Competing Interest
I have no conflicts of interest to report.
References
- 1.Cournoyer A., Grunau B., Cheskes S., Vaillancourt C., Segal E., de Montigny L., et al. Clinical outcomes following out-of-hospital cardiac arrest: the minute-by-minute impact of bystander cardiopulmonary resuscitation. Resuscitation. 2023 Jan 13 doi: 10.1016/j.resuscitation.2023.109693. [DOI] [PubMed] [Google Scholar]
- 2.Morrison L.J., Nichol G., Rea T.D., Christenson J., Callaway C.W., Stephens S., et al. Rationale, development and implementation of the resuscitation outcomes consortium Epistry-cardiac arrest. Resuscitation. 2008;78:161–169. doi: 10.1016/j.resuscitation.2008.02.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Park J.H., Song K.J., Do Shin S., Hong K.J. The impact of COVID-19 pandemic on out-of-hospital cardiac arrest system-of-care: which survival chain factor contributed the most? Am J Emerg Med. 2023 Jan;63:61–68. doi: 10.1016/j.ajem.2022.10.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Rottenberg E.M. A simple method of performing maximally effective CPR chest compressions. Resuscitation. 2019 May;138:213–214. doi: 10.1016/j.resuscitation.2019.03.024. [DOI] [PubMed] [Google Scholar]
- 5.Rottenberg E.M. 4-finger method of hand placement and head rotation effectiveness in bystander CPR. Am J Emerg Med. 2022 Dec 12 doi: 10.1016/j.ajem.2022.12.011. S0735-6757(22)00749–5. [DOI] [PubMed] [Google Scholar]
- 6.Safiruddin F., Koutsourelakis I., de Vries N. Analysis of the influence of head rotation during drug-induced sleep endoscopy in obstructive sleep apnea. Laryngoscope. 2014;124:2195–2199. doi: 10.1002/lary.24598. [DOI] [PubMed] [Google Scholar]
- 7.Safiruddin F., Koutsourelakis I., de Vries N. Upper airway collapse during drug induced sleep endoscopy: head rotation in supine position compared with lateral head and trunk position. Eur Arch Otorhinolaryngol. 2015;272:485–488. doi: 10.1007/s00405-014-3215-z. [DOI] [PubMed] [Google Scholar]
- 8.Zhao L., Li C., Liu B., Wang M., Shao R., Fang Y. The association of gasping and outcome, in out of hospital cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2015;97:7–12. doi: 10.1016/j.resuscitation.2015.09.377. [DOI] [PubMed] [Google Scholar]
- 9.Safar P., Escarraga L.A., Chang F. Upper airway obstruction in the unconscious patient. J Appl Physiol. 1959 Sep;14:760–764. doi: 10.1152/jappl.1959.14.5.760. [DOI] [PubMed] [Google Scholar]
- 10.Fukui M., Weil M.H., Tang W., Yang L., Sun S. Airway protection during experimental CPR. Chest. 1995;108:1663–1667. doi: 10.1378/chest.108.6.1663. [DOI] [PubMed] [Google Scholar]
- 11.Menegazzi J.J., Check B.D. Spontaneous agonal respiration in a swine model of out-of-hospital cardiac arrest. Acad Emerg Med. 1995;2:1053–1056. doi: 10.1111/j.1553-2712.1995.tb03149.x. [DOI] [PubMed] [Google Scholar]
- 12.Fukui M., Weil M.H., Tang W., et al. Oxygen promotes spontaneous gasping during experimental CPR [abstract] J Invest Med. 1995;43(2):314A. [Google Scholar]