Wednesday, January 19, 2005

Simplified CPR technique is urged

"Patients should receive 'continuous, uninterrupted chest compressions,' or, at the very least, six times more chest compressions to breaths than guidelines currently call for, Ewy and Sanders suggested."
By Carla McClain ARIZONA DAILY STAR UA experts have issued a national plea to simplify CPR techniques after two new studies reveal that even well-trained doctors and paramedics often fail to perform CPR adequately, likely leading to lost lives. In short, they say, we no longer should require both mouth-to-mouth breathing and chest compressions, which the studies showed very few - even medical professionals - can do properly. Instead, everyone should be trained to do only fast and forceful chest compressions on people who collapse from sudden cardiac arrest, say two University of Arizona physicians, writing in today's Journal of the American Medical Association. "This is a real crisis," said Dr. Gordon Ewy, director of the UA's Sarver Heart Center. For more than a decade, Ewy has studied the dismal failure of current CPR techniques to save cardiac arrest victims. "If we keep following the present CPR guidelines, you end up compressing the chest only half the time you should, and people do not survive," he said. "If the American Heart Association does not make these changes this year, it will be a disaster." Tucson medical rescuers adopted the changes a year ago and the change appears to be saving lives, Ewy said. However, the rest of the world has not followed suit. The result is that even doctors, nurses and paramedics are not performing the more complicated, standard CPR adequately on stricken patients in the hospital or on the way there, according to the studies, also published in JAMA today. Among the problems commonly cited: Rescuers did not push hard enough or frequently enough on the victim's chest to restart the heart, and they breathed into the lungs too often, doing mouth-to-mouth or using breathing tubes. In one of the studies, involving 67 adult patients at the University of Chicago, doctors and nurses failed to follow at least one CPR guideline 80 percent of the time. Failure to follow several guidelines was common. "Patients who had it perfectly done were the distinct minority," said Dr. Benjamin Abella, one of the researchers. The other study involved 176 adults with out-of-hospital cardiac arrest treated by paramedics and nurse anesthetists in Stockholm, Sweden; Akershus, Norway; and London. Chest compressions were done only half the time, and most were too shallow. Sudden cardiac arrest deadly More than 600,000 people die each year from sudden cardiac arrest in North America and Europe. The heart suddenly stops beating, either from a heart attack or underlying heart disease. A combination heart monitor-defibrillator was used in the study to evaluate depth of chest compressions and other aspects of CPR. The monitor includes an automated voice that gives on-the-spot coaching, telling rescuers when chest compressions are not strong enough or frequent enough. But that feature was turned off in the studies. Both studies received funding from the Norwegian company that developed the device - Laerdal Medical Corp. - with Philips Medical Systems. The manufacturer is seeking permission from the U.S. Food and Drug Administration to sell the device in this country. The studies are the first using a monitor to evaluate "what's going on during real cardiac arrests and in real people," said American Heart Association spokesman Vinay Nadkarni. "It's outstanding information." He said the results will be taken up at a medical conference in Dallas next week that could lead to an update of the CPR guidelines, still followed and taught by the American Red Cross. CPR practiced for 50 years However, real change is unlikely to happen, Ewy said. "The word on the street is they may not make any changes," he said. "If they don't, that will be terrible, because, to make a long story short, they're wrong." The current guidelines call for 100 to 120 chest compressions performed every minute to restart a failed heart, with the compressions pushing the chest in 1 1/2 inches each time. In addition, mouth-to-mouth or tube ventilations must be done about 12 to 16 times a minute. The ambulance study found the average chest compression rate was half what was needed - 64 per minute - and most compressions were too shallow. "CPR has been around for 50 years, but until now, we haven't had a precise, reliable way to assess how well it's being done," said Dr. Lance Becker, director of the Emergency Resuscitation Research Center at the University of Chicago, who co-authored the hospital study. "Now we find out it's not being done very well." That alarming conclusion is what led the UA's Ewy and Dr. Arthur Sanders, a UA professor of emergency medicine, to call on the AHA to simplify the training and techniques for administering CPR. In an accompanying editorial in today's JAMA, they wrote: "The (current) guidelines are too complex, resulting in patients not receiving known benefits such as chest compressions for extended periods. It is time to simplify the CPR guidelines so that all patients who sustain cardiac arrest can receive optimal treatment. It is time to give rescuers and health care professionals the knowledge and skills that can be readily used in the real world. . . ." Patients should receive "continuous, uninterrupted chest compressions," or, at the very least, six times more chest compressions to breaths than guidelines currently call for, Ewy and Sanders suggested. UA medical students studied They cited a UA study of medical students recently trained in standard CPR, showing they delivered 43 chest compressions per minute - instead of the needed 120 - because of pauses for ventilations. Students who were taught the simplified chest-compression delivered 113 compressions per minute. Animal studies show this dramatically improves survival. One showed 100 percent of animals getting more than 80 chest compressions per minute were resuscitated, but only 10 percent of those getting less than 80 survived, Ewy and Sanders wrote. "It is time to focus on simplifying the technique," the editorial stated. Under current guidelines, "long and possibly lethal interruptions in chest compressions are the norm. The unintended consequences are . . . not enough survivors."

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