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Senior Citizen Health & Medicine
Studies of Manual vs. Automated Chest Compression
for Cardiac Arrest Conflict
 June
14, 2006 Cardiac arrest that occur outside of hospitals claim hundreds
of thousands of lives every year, a large number of the victims being
senior citizens. Two new studies have come up with conflicting opinions
in trying to determine if an automated chest compression device works
better than manual chest compression. An editorial in the same issue of
the Journal of the American Medical Association tries to reconcile the
differences.
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Health & Medicine |
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Successful resuscitation depends on a coordinated
set of actions including early cardiopulmonary resuscitation (CPR),
according to background information in the article in the June 14 issue
of JAMA. Observations of rescue personnel during CPR indicate that
maintaining consistent chest compressions is a difficult task.
The desire to provide optimal chest compressions
led to the development of automated mechanical chest compression
devices.
The load-distributing band (LDB) is a
circumferential chest compression device with an electrically activated
constricting band on a short backboard and has been approved by the Food
and Drug Administration for use in attempted resuscitation of cardiac
arrest.
Compared with manual chest compression, an
automated LDB chest compression device produces greater blood flow to
vital organs and may improve outcomes.
Al Hallstrom, Ph.D., of the University of
Washington, Seattle, and colleagues conducted a study to compare LDB-CPR
with manual CPR during out-of-hospital cardiac arrest.
The multicenter, randomized trial included 1,071
patients who experienced out-of-hospital cardiac arrest in the United
States and Canada. Patients received either standard emergency medical
services (EMS) care for cardiac arrest with a LDB-CPR device (n = 554)
or manual CPR (n = 517). The primary outcome measure included survival
to 4 hours after the 911 call, with secondary measures being survival to
hospital discharge and neurological status among survivors.
There was no significant difference in survival at
4 hours after the 911 call between the manual CPR group and the
automated LDB-CPR group overall (29.5 percent vs. 28.5 percent) or among
the primary study population (24.7 percent vs. 26.4 percent).
Survival to hospital discharge was lower in the LDB-CPR
group among primary episodes (5.8 percent vs. 9.9 percent), as was
survival with intact neurological status.
As implemented in this study, the use of an
automated LDB-CPR device for resuscitation from out-of-hospital cardiac
arrest appeared to result in lower survival and worse neurological
outcomes than traditional manual CPR. Device design and implementation
strategies may need further preclinical evaluation," the authors state.
"The results of this study underscore the
complexity of resuscitation from out-of-hospital cardiac arrest. Further
work is required to understand the interaction of manual or assisted
chest compressions with other aspects of resuscitation such as the phase
of the arrest, drug choice and dose, timing of defibrillation, and
treatments such as hypothermia and coronary reperfusion, the authors
conclude.
Editor's Note: This study was sponsored by
Revivant Corporation, now part of the ZOLL Corporation. Co-author Dr.
Mosesso reported receiving equipment and supplies for the AED clinical
trial from the ZOLL Corporation.
Study Finds Better Patient Outcomes from
Automated Compression Device Compared To Manual Compression
In another study, researchers found that the rates
of return of spontaneous circulation and survival to hospital admission
were all significantly higher in the LDB-CPR phase, after adjustment for
differences in EMS response time intervals and EMS witnessed.
Marcus Eng Hock Ong, M.D., M.P.H., of Virginia
Commonwealth University, Richmond, Va., and colleagues compared
resuscitation outcomes before and after an urban EMS system switched
from manual CPR to LDB CPR. The study included an analysis of 783 adults
with out-of-hospital, nontraumatic cardiac arrest. A total of 499
patients were included in the manual CPR phase and 284 patients in the
LDB-CPR phase. Of these patients, the LDB device was applied in 210
patients.
Survival to hospital discharge was higher in the
LDB-CPR phase than in the manual CPR phase (9.7 percent vs. 2.9
percent), and was significantly higher after adjustment for differences
in EMS response time intervals, EMS witnessed, and postresuscitation
hypothermia, but there was no significant difference between the groups
in terms of neurologic outcomes among survivors.
In our study, OHCA clinical outcomes were improved
following the introduction of LDB into an urban EMS system. The benefit
was relatively robust across a range of patient subsets, especially for
those patients with ventricular fibrillation initially, bystander
witnessed events, and recipients of bystander CPR, the authors write.
Our results suggest that a resuscitation strategy
using the LDB CPR on rapidly responding EMS ambulances is associated
with improved outcomes, including survival to hospital discharge, in
adults with OHCA. These results suggest that the LDB device may be a
useful addition to current cardiac arrest treatment options, especially
when used early on patients with cardiac arrest who do not respond
immediately to a brief period of manual CPR, defibrillation or both.
However, further research (a large, adequately powered, prospective
randomized clinical trial that blinds the rescuers to the intervention
until they decide to initiate resuscitation) is needed to further define
the value of LDB in resuscitation, the researcher conclude.
Editorial: Manual Vs. Device-Assisted CPR -
Reconciling Apparently Contradictory Results
In an accompanying editorial, Roger J. Lewis, M.D.,
Ph.D., and James T. Niemann, M.D., of the Harbor-University of
California Los Angeles Medical Center, Los Angeles, discuss the
differences found in the studies comparing manual and automated chest
compression for cardiac arrest.
Can the differing conclusions of the 2 studies be
reconciled?
"Although it is not possible to reach definitive
conclusions until additional data are available, the best current
information suggests that the degree of benefit or harm associated with
use of the LDB-CPR device is influenced by the details of its
useperhaps including selection of the patient population with respect
to presenting rhythm, time from cardiac arrest to initiation of CPR, and
almost certainly time-to-deployment and the influence of deployment on
time-to-defibrillation, when appropriate.
"To shed light on these questions, future
comparative studies will need to pay particular attention to the
definition and consistency of the method of use of the device, to
measuring the multiple important time intervals with precision, and to
ensuring the quality of the manual CPR administered in both trial
groups.
Conducting high-quality clinical trials in
patients with out-of-hospital cardiac arrest is extremely difficult
because of the complexity of EMS systems, strong preconceived notions
regarding effective therapies, and the almost ubiquitous presence of
unmeasured confounding factors that profoundly influence outcomes for
individual patients and treatment effects.
"However, only by aggressively identifying and
rigorously testing promising new therapies will the outcomes improve for
patients who experience sudden cardiac death.
Editor's Note: Drs. Lewis and Niemann reported
receiving National Institutes of Health research funding for the study
of a manual CPR device.
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