Active compression-decompression cardiopulmonary resuscitation does not improve survival in patients with prehospital cardiac arrest in a physician-manned emergency medical system. The United Kingdom pre-hospital study of active compression-decompression resuscitation. Active compression-decompression cardiopulmonary resuscitation: a population-based, prospective randomised clinical trial in out-of-hospital cardiac arrest. The Ontario trial of active compression-decompression cardiopulmonary resuscitation for in-hospital and prehospital cardiac arrest. Effectiveness of mechanical versus manual chest compressions in out-of-hospital cardiac arrest resuscitation: a pilot study. A randomized clinical trial of active compression-decompression CPR vs standard CPR in out-of-hospital cardiac arrest in two cities. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. Active compression-decompression resuscitation: a prospective, randomized study in a two-tiered EMS system with physicians in the field. Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial.
To examine the efficacy of a new method of cardiac resuscitation, active compression-decompression cardiopulmonary resuscitation (ACD CPR), in prehospital cardiac arrest.
                Prospective, randomized, controlled trial.
                Physician-manned Mobile Intensive Care Unit (MICU) of a university hospital, serving a population of 200,000.
                Adult patients with prehospital nontraumatic cardiac arrest treated by the MICU.
                Patients were randomized to standard chest compression according to American Heart Association (AHA) recommendations (group 1, 30 patients) or to the new technique (group 2, 26 patients). ACD was performed by use of a hand-held suction device. In both groups, advanced life support was performed as recommended by the AHA.
                Rate of patients regaining a spontaneous circulation (ROSC), hospital discharge rate, and mean carbon dioxide content during resuscitation were recorded. ROSC rates in groups 1 and 2 were 40% and 38.5%, respectively. Four patients (13.3%) in group 1 and three patients (11.5%) in group 2 were discharged (group 1 v group 2: n.s.). Anatomic conditions precluded the application of ACD CPR in 5 patients. The new technique was found to impose greater physical efforts than STD CPR. Capnography was performed in 23 patients (mean value: STD CPR: 11.9 +/- 4.7 mmHg, ACD CPR: 13.7 +/- 4.9 mmHg [n.s.]).
                ACD CPR did not improve, outcome and practical performance was complicated. Therefore, this technique should not be performed routinely, or without strict supervision in prehospital cardiac arrest. This prospective, controlled trial with crossover group design compares the effectiveness of active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) and standard CPR on the outcomes of victims of prehospital cardiac arrest. In three UK cities, victims of non-traumatic, out of hospital cardiac arrest, over the age of 8 years received either standard or ACD-CPR on arrival of ambulance personnel. Main outcome measures were return of spontaneous circulation, survival to be admitted to the intensive care unit, survival to hospital discharge, and neurological outcome. A total of 576 patients (STD-CPR, n=309; ACD-CPR, n=267) were analysed. The treatment groups were similar with respect to age, gender, proportion of witnessed arrests, initial cardiac rhythm, and call to advanced life support interval. The proportion of patients receiving bystander CPR was higher in the ACD group (37.1% vs. 28.5%; P=0.028). The interval between collapse and defibrillation was longer in the ACD group (12.3 min vs. 10.4 min; P=0.028). There was no difference between the STD-CPR and ACD-CPR groups in survival to admission to the intensive care unit (13.6% vs. 13.8%; P=0.93) or hospital discharge (4.8% vs. 6.0%; P=0.67). There was no difference between the groups with respect to the neurological outcome of those patients surviving to hospital discharge. Analysis of important subgroups also showed no benefit for ACD-CPR. We conclude that there was no improvement in outcome with ACD-CPR when used by ambulance personnel in Cardiff and Portsmouth. Different mechanical devices have been developed to improve cardiopulmonary resuscitation (CPR). The aim of this study was to evaluate active compression-decompression (ACD) CPR applied by Emergency Medical Service (EMS) in a defined population. The Trondheim region EMS (population 154,000) employs simultaneous paramedic and physician response. Upon decision to treat, patients with cardiac arrest of presumed cardiac origin were allocated to ACD CPR (CardioPump) or standard CPR by drawing a random number tag. Outcome in each patient was determined on a 5 point ordinal scale (no clinical improvement = 1, survival to discharge = 5). In 4 years, CPR was attempted in a total of 431 cardiac arrests, 54 patients (13%) survived to discharge; 302 patients with similar baseline characteristics were randomised. The prevalence of bystander CPR was 57% and the median call-arrival interval 9 min. By intention to treat, the mean score in the standard CPR group was 2.51 and 17/145 patients (12%) survived. The mean score in the ACD CPR group was 2.53 (P = 0.9) and 20/157 patients (13%) survived. Cerebral outcome was similar in the two groups. Among the 145 ACD patients, the technique was successfully applied in 110, found inapplicable in 35 and in seven patients chest compressions were unnecessary. This is the largest, single-centre, randomised, population based study of ACD CPR in out-of-hospital cardiac arrest to date. Even when considering a wider outcome spectrum than crude survival, we found no evidence of clinical benefit. In a quarter of cases ACD CPR was inapplicable, further limiting its potential usefulness. To compare the impact of active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) and standard CPR on the outcomes of in-hospital and prehospital victims of cardiac arrest.
                Randomized controlled trial with blinding of allocation using a sealed container.
                (1) Emergency departments, wards, and intensive care units of 5 university hospitals and (2) all locations outside hospitals in 2 midsized cities.
                A total of 1784 adults who had cardiac arrest.
                Patients received either standard or ACD CPR throughout resuscitation.
                Survival for 1 hour and to hospital discharge and the modified Mini-Mental State Examination (MMSE).
                All characteristics were similar in the standard and ACD CPR groups for the 773 in-hospital patients and the 1011 prehospital patients. For in-hospital patients, there were no significant differences between the standard (n = 368) and ACD (n = 405) CPR groups in survival for 1 hour (35.1% vs 34.6%; P = .89), in survival until hospital discharge (11.4% vs 10.4%; P = .64), or in the median MMSE score of survivors (37 in both groups). For patients who collapsed outside the hospital, there were also no significant differences between the standard (n = 510) and ACD (n = 501) CPR groups in survival for 1 hour (16.5% vs 18.2%; P = .48), in survival to hospital discharge (3.7% vs 4.6%; P = .49), or in the median MMSE score of survivors (35 in both groups). Exploration of clinically important subgroups failed to identify any patients who appeared to benefit from ACD CPR.
                ACD CPR did not improve survival or neurologic outcomes in any group of patients with cardiac arrest. A prospective, randomized effectiveness trial was undertaken to compare mechanical versus manual chest compressions as measured by end-tidal CO2 (ETCO2) in out-of-hospital cardiac arrest patients receiving advanced cardiac life support (ACLS) resuscitation from a municipal third-service, emergency medical services (EMS) agency. The EMS agency responds to approximately 6,700 emergencies annually, 79 of which were cardiac arrests in 1994, the study year. Following endotracheal intubation, all cardiac arrest patients were placed on 100% oxygen via the ventilator circuit of the mechanical cardiopulmonary resuscitation (CPR) device. Patients were randomized to receive mechanical CPR (TCPR) or human/manual CPR (HCPR) based on an odd/even day basis, with TCPR being performed on odd days. ETCO2 readings were obtained 5 minutes after the initiation of either TCPR or HCPR and again at the initiation of patient transport to the hospital. All patients received standard ACLS pharmacotherapy during the monitoring interval with the exception of sodium bicarbonate. CPR was continued until the patient was delivered to the hospital emergency department. Age, call response interval, initial electrocardiogram (ECG) rhythm, scene time, ETCO2 measurements, and arrest outcome were identified for all patients. Twenty patients were entered into the study, with 10 in each treatment group. Three patients in the TCPR group were excluded. Measurements in the HCPR group revealed a decreasing ETCO2 during the resuscitation in 8 of 10 patients (80%) and an increasing ETCO2 in the remaining 2 patients. No decrease in ETCO2 was noted in the TCPR group, with 4 of 7 patients (57%) actually showing an increased reading and 3 of 7 patients (43%) showing a constant ETCO2 reading. The differences in the ETCO2 measurements between TCPR and HCPR groups were statistically significant. Both groups were similar with regards to call response intervals, patient ages, scene times, and initial ECG rhythms. One patient in the TCPR group was admitted to the hospital but later died, leaving no survivors in the study. TCPR appears to be superior to standard HCPR as measured by ETCO2 in maintaining cardiac output during ACLS resuscitation of out-of-hospital cardiac arrest patients. To compare the effectiveness of active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) with a handheld suction device vs standard manual CPR in victims of out-of-hospital cardiopulmonary arrest.
                Prospective randomized clinical trial with crossover group design.
                Emergency medical services (EMS) of a large (San Francisco) and medium-sized (Fresno) city in California.
                All normothermic adult victims of out-of-hospital, nontraumatic cardiac arrest on whom CPR was performed by first responders.
                Patients were randomized to receive either standard manual CPR according to American Heart Association guidelines or ACD CPR, on first-responder contact.
                Return of spontaneous circulation, admission to the intensive care unit, survival to hospital discharge, and neurological function at hospital discharge.
                The ACD group (n = 117 in Fresno; n = 297 in San Francisco) and standard group (n = 136 in Fresno; n = 310 in San Francisco) were similar with regard to demographic and prognostic variables, such as age, witnessed arrest and bystander CPR frequency, and initial cardiac rhythm. Average interval from 911 call activation to EMS responder arrival was 6.4 minutes in Fresno and 4.0 minutes in San Francisco. In Fresno, there was no difference between the ACD group and standard CPR group in return of spontaneous circulation (17% vs 20%; P = .68), hospital admission (16% vs 20%; P = .56), hospital discharge (5% vs 7%; P = .64), or cerebral performance category score at discharge (1.5 vs 1.6; P = .90). Similarly, in San Francisco there was no difference between the ACD group and standard CPR group in return of spontaneous circulation (19% vs 21%; P = .65), hospital admission (13.5% vs 14.5%; P = .79), hospital discharge (4.7% vs 5.5%; P = .80), or cerebral performance category score at discharge (2.2 vs 2.6; P = .31). There was no increase in significant complications associated with the use of ACD CPR.
                There was no improvement in outcome with ACD CPR in out-of-hospital cardiac arrest in these two cities. Differences in study design, demographics, EMS systems, response intervals, training, and technique performance may contribute to the lack of improvement in initial resuscitation with ACD CPR compared with previous studies. Future research needs to control these variables to determine the reason for these differences in outcome. Endotracheal intubation (ETI) is widely used for airway management of children in the out-of-hospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome.
                To compare the survival and neurological outcomes of pediatric patients treated with bag-valve-mask ventilation (BVM) with those of patients treated with BVM followed by ETI.
                Controlled clinical trial, in which patients were assigned to interventions by calendar day from March 15, 1994, through January 1, 1997.
                Two large, urban, rapid-transport emergency medical services (EMS) systems.
                A total of 830 consecutive patients aged 12 years or younger or estimated to weigh less than 40 kg who required airway management; 820 were available for follow-up.
                Patients were assigned to receive either BVM (odd days; n = 410) or BVM followed by ETI (even days; n = 420).
                Survival to hospital discharge and neurological status at discharge from an acute care hospital compared by treatment group.
                There was no significant difference in survival between the BVM group (123/404 [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.11) or in the rate of achieving a good neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22).
                These results indicate that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system. Improved cardiopulmonary circulation with active compression-decompression cardiopulmonary resuscitation (ACD-CPR) has been demonstrated in studies using different animal models and a small number of humans in cardiac arrest (CA). However, prehospital studies have shown both positive and no extra benefit of ACD-CPR on return of spontaneous circulation (ROSC), hospital admission and discharge rates. The aim of our prospective study was to compare standard manual CPR (S-CPR) with ACD-CPR as the initial technique of resuscitating patients with out-of-hospital CA, with respect to survival rates and neurological outcome. Patients with out-of-hospital CA treated by emergency medical services (EMS) personnel were randomly assigned to one of two groups (ACD-CPR versus S-CPR). Time intervals to key measures were documented by means of on-line tape-recording. Neurological outcome was assessed using standard scoring systems (cerebral and overall performance categories (CPC and OPC)). A total of 220 patients (S-CPR, n = 114: ACD-CPR, n = 106) were included in the study in a random order. The treatment groups were similar with respect to age, sex, time interval from collapse to CPR, defibrillation and first adrenaline medication. There was no difference between the ACD group and the standard CPR group in terms of ROSC (50.9% vs. 59.6%), hospital admission (33% vs. 33.3%), hospital discharge (16% vs. 14%), or CPC and OPC (1.82 vs. 2.13 and 2.06 vs. 2.25, respectively). Concerning complications of CPR, there was no difference between the groups. In our two-tiered EMS system with physician-staffed ambulances, ACD-CPR neither improved nor impaired survival rates and neurological prognosis in patients with out-of-hospital cardiac arrest. The new CPR technique did not increase the complications associated with the resuscitation effort. High-quality cardiopulmonary resuscitation (CPR) may improve both cardiac and brain resuscitation following cardiac arrest. Compared with manual chest compression, an automated load-distributing band (LDB) chest compression device produces greater blood flow to vital organs and may improve resuscitation outcomes.
                To compare resuscitation outcomes following out-of-hospital cardiac arrest when an automated LDB-CPR device was added to standard emergency medical services (EMS) care with manual CPR.
                Multicenter, randomized trial of patients experiencing out-of-hospital cardiac arrest in the United States and Canada. The a priori primary population was patients with cardiac arrest that was presumed to be of cardiac origin and that had occurred prior to the arrival of EMS personnel. Initial study enrollment varied by site, ranging from late July to mid November 2004; all sites halted study enrollment on March 31, 2005.
                Standard EMS care for cardiac arrest with an LDB-CPR device (n = 554) or manual CPR (n = 517).
                The primary end point was survival to 4 hours after the 911 call. Secondary end points were survival to hospital discharge and neurological status among survivors.
                Following the first planned interim monitoring conducted by an independent data and safety monitoring board, study enrollment was terminated. No difference existed in the primary end point of survival to 4 hours between the manual CPR group and the LDB-CPR group overall (N = 1071; 29.5% vs 28.5%; P = .74) or among the primary study population (n = 767; 24.7% vs 26.4%, respectively; P = .62). However, among the primary population, survival to hospital discharge was 9.9% in the manual CPR group and 5.8% in the LDB-CPR group (P = .06, adjusted for covariates and clustering). A cerebral performance category of 1 or 2 at hospital discharge was recorded in 7.5% of patients in the manual CPR group and in 3.1% of the LDB-CPR group (P = .006).
                Use of an automated LDB-CPR device as implemented in this study was associated with worse neurological outcomes and a trend toward worse survival than manual CPR. Device design or implementation strategies require further evaluation.
                clinicaltrials.gov Identifier: NCT00120965.
The efficacy of emergency intubation as currently practised has not been rigorously studied. The skill level of the operator may be key in determining efficacy. In non-traumatic cardiac arrest, it is unlikely that intubation carries the same life saving benefit as early defibrillation and bystander cardiopulmonary resuscitation (CPR). In trauma and paediatric patients, the current evidence base provides no imperative to extend the practice of prehospital intubation in urban systems. It would be ethical and pertinent to initiate a large, high quality randomised trial comparing the efficacy of competently practised emergency intubation with basic bag-valve-mask manoeuvres (BVM) in urban adult out-of-hospital non-traumatic cardiac arrest.