I’m skeptical about … CPR.

In 1996, an article appeared in the New England Journal of Medicine noting the success of CPR after cardiac arrest as depicted on the TV shows “ER,” “Chicago Hope” and “Rescue 911” was 75%. Pretty impressive, especially when you consider that the actual survival rate of cardiac arrest in the mid-90s was on the order of 5%. Despite accurately depicting the process, the shows widely missed the mark on the outcome of that process—namely, that dead people typically stay dead. Which is not to say that we shouldn’t try. There are big saves. In the hospital, if a patient arrests in front of me, more often than not, I can get him back—at least temporarily. In the field, it’s another matter. Outside of the ER, I have witnessed only one cardiac arrest; a middle-aged man who seized and then promptly arrested at the gym where I was working out. Despite immediate CPR, prompt paramedic arrival, and rapid transport to the hospital, he didn’t survive. Most don’t. Nearly everyone has read about the miraculous recovery of someone who “dropped dead” and walked out of the hospital neurologically intact a few days later. But that’s the exception, not the rule. Of the 300,000 or so patients who suffer an out-of-hospital cardiac arrest each year in this country, the overall survival rate is between 8-9%, but only 2-4% leave the hospital neurologically intact. When deprived of oxygen, the brain begins to die in as little as 5 minutes; so in the case of cardiac arrest, time isn’t just life but more importantly quality of life. And that’s where CPR comes in; it buys time.

What got me thinking about all this was having to re-certify in BLS (Basic Life Support), ACLS (Advanced Cardiac Life Support), and PALS (Pediatric Advanced Life Support). This is a biannual requirement of my hospital (but paid for by me). Administrators look at these certificates like the Boy Scouts do merit badges—not particularly useful, but required nonetheless. According to online AHA (American Heart Association) financial statements, the organization took in more than $863 million in revenue for fiscal year 2015-16, $152 million of which came from “program fees” and the sale of “educational materials.” Big Pharma chipped in another $179 million in the form of “corporate support” and “contributed income,” making the AHA the 20th most lucrative “charity” in the nation. According to Forbes Magazine, the highest salary at the organization tops out at more than $1.4 million. Sorry, but it’s silly to think of any organization that pays million dollar salaries to its executives and accepts hundreds of millions in corporate “contributions” as a charity. I was charged nearly $500 to re-take the same warmed-over AHA courses that I have taken multiple times in the past and am more than qualified to teach. But considering that we’re truly talking about matters of life or death, this might be okay if what the AHA was peddling was based solely on evidence. The truth is that only a few of the recommendations have solid evidence supporting them, while others represent a consensus opinion, and still others actually run counter to the prevailing evidence.

 

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None of the drugs recommended in the myriad AHA guidelines have ever been shown to save lives. That’s right, you heard me—not one! And we’ve known this for a long time. A 1998 trial, published in the Annals of Emergency Medicine, concluded that none of the drugs in the AHA guidelines, including epinephrine (adrenaline), lidocaine, atropine, bicarb, and calcium, were helpful in keeping people alive long enough to be discharged from the hospital after a cardiac arrest. In fact, while the use of such drugs does help selected patients regain a pulse, the patients receiving them are less likely to be alive at 1 month than patients who don’t. The hope is that improvements in after-resuscitation care will allow those who regain a pulse in the field to survive longer with less disability, but after nearly two decades of additional research, this hasn’t panned out, perhaps, because the drugs don’t work or because those receiving them are sicker from the start. In either case, the use of drugs hasn’t preserved neurologic function or improved survival.

 

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Epinephrine, the poster child of resuscitation drugs, is the best example of a medicine that helps patients regain a pulse without improving their survival. The best data comes from a Japanese national registry of cardiac arrest patients from 2005 to 2008. Reviewing the outcomes of more than 417,000 out-of-hospital cardiac arrests, the authors found marked improvement in ROSC (Return Of Spontaneous Circulation, i.e. blood pressure and pulse) in the patients receiving epinephrine, but worse outcomes at one month. And this makes sense; epinephrine stimulates the heart to contract, to beat more forcefully, and to beat faster—all of which favor short-term success. But epinephrine also causes blood vessels to constrict, limiting critical blood flow to the brain, while increasing the heart’s oxygen demand at a time when oxygen is in short supply—factors that work against long-term survival. In the Japanese registry, despite an advanced EMS system and rapid response times, the results were pretty abysmal; just 1.4% of the epinephrine-receiving patients were alive with a favorable neurologic outcome at 1 month. Those patients who didn’t receive epinephrine fared only slightly better, 2.2% alive and functional at 1 month. The results of another large, updated Japanese registry, published in 2013, confirmed the results of the prior study; epinephrine when administered to patients presenting with shockable rhythms (i.e. the ones most likely to survive) is associated with worse 1-month survival rates. Dead people tend to stay dead.

 

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Knowing the results of these and other studies, I expected the new AHA guidelines issued in 2015 to stop recommending epinephrine in cardiac arrest patients with shockable rhythms. They didn’t. And this isn’t the only place where the guidelines appear to contradict the evidence. A drug called amiodarone, used to treat malignant rhythms associated with cardiac arrest, is still recommended despite evidence that it doesn’t work very well, if at all. A recent systematic review on the drug revealed what studies on other resuscitation drugs have shown; while amiodarone improves the short-term return of a pulse, it doesn’t improve neurologic outcomes or 1-month survival rates. A 2016 randomized controlled trial comparing amiodarone to lidocaine (an older, cheaper anti-arrhythmic agent), found that neither worked better than a placebo to treat malignant heart rhythms unresponsive to a shock. So why are these drugs still being recommended?

The last two iterations of the AHA guidelines, published in 2010 and 2015, respectively, both placed huge emphasis on the importance of continuing chest compressions at all times (except when delivering of a shock). While the data here is pretty solid, some of the AHA recommendations regarding chest compressions are not. For instance, the AHA recommends withholding a second shock attempt if the first one fails until completing a 2-minute trial of chest compressions. Prior guidelines had recommended 3 consecutive shock attempts before returning to chest compressions. The evidence suggests that the prior guidelines were right. A 2016 BMJ study found that 6% more patients survived to hospital discharge when consecutive shocks were administered rather than waiting for two minutes.

What about post-resuscitation care? Do the AHA guidelines fit the data here? Again, the answer is sometimes yes, sometimes no. You may have heard about cooling patients for 24-hours after successfully resuscitating them from a cardiac arrest. It’s been in the lay press, touted as yet another “miracle” cure, the premise being that cooling slows down brain metabolism and the accumulation of toxins that occur post-arrest. Although the AHA softened their recommendation for therapeutic hypothermia (now referred to as “targeted temperature management”) in their 2015 guidelines, it remains a class 1 recommendation (and not a cheap one either, as it requires keeping the patient intubated on a ventilator, in an induced coma, in the ICU for 24 hours or more). Meanwhile, a recent retrospective review of more than 26,000 patients in 355 US hospitals treated with hypothermia after cardiac arrest found lower survival rates and worse neurologic outcomes associated with its use.

I have been down this road many times before with other “latest-greatest” treatment recommendations—from high-dose steroids after spinal cord injury, to thrombolytic drugs for stroke, to beta-blockers for heart attack. After small initial studies show seemingly, too-good-to-be-true, results, the treatment comes into widespread use, only to find that larger trials are unable to replicate the initial promise, and ultimately after huge numbers of patients have been treated and bureaucrats have mandated its use, the treatment is found to be of no benefit, or even causes harm. And, so it appears with therapeutic hypothermia. Another one bites the dust. What’s more likely in this case is not that cooling patients confers a survival benefit, but rather that preventing fever improves outcomes. But then again, there’s little money to be made by simply pushing Tylenol.

Does anything help? There are two—and only two—treatments that have reliably and repeatedly demonstrated benefit in the prehospital setting: bystander chest compressions delivered as soon as possible to arrest victims, and rapidly shocking those with malignant rhythms using an automated defibrillator. Fortunately, these two things represent the simplest components of the algorithm and can be performed by anyone reading this post. And, if you want to know the truth, you don’t need to take an AHA course to perform them.

What should you do if someone arrests in front of you? First, establish that the patient is unresponsive, isn’t breathing, and doesn’t have a pulse (feel for the carotid artery in the neck, 2 to 3 finger-breadths to the side of the Adam’s apple). Second, call for help (9-1-1). Third, begin chest compressions. You’ll be nervous. Your own heart will be racing. You’ll be scared. None of that matters. What I can offer is the simple notion offered to me by a senior resident when I was a medical student off to my first code: “You can’t hurt a dead person.” The only wrong thing to do in such situations is nothing. While it might be psychologically difficult to entertain the notion of performing chest compressions, it’s not difficult physically: lock your hands, straighten your arms, place your palms over the lower third of the patient’s breastbone, push hard and deep at a rate of 100-120/minute using your body weight to do the work. If you aren’t sure how fast to push, just start singing the Bee Gees song “Stayin Alive.” Perform a compression on every “ah” of the chorus: “Ah … ah … ah … ah … stayin’ alive, stayin’ alive.” If you’ve got the beat, then you’ve got the heartbeat. (Note: On TV, the actors performing CPR always bend their elbows and push with their wrists—that’s wrong!) Keep your elbows locked. The actors aren’t really trying to compress the chest, but you will be. If you push hard enough to crack a rib, don’t worry—you can’t hurt a dead person.

 

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Don’t let your fear of performing mouth-to-mouth ventilation stop you from compressing the chest! Chest compression-only CPR works just fine. In two major trials, patients undergoing chest compression-only CPR actually had better 1-month survival rates than those receiving both compressions and ventilations (mouth-to-mouth, or bag-to-mouth). So, if you don’t have a mask and aren’t trained to ventilate patients, don’t worry—just compress the chest.

 

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The second part of the equation is defibrillation. This is not a post about the nuances of rhythm recognition. To operate a defibrillator requires no knowledge of heart rhythms. The portable units are incredibly simple. Most current models contain just 2 buttons: 1) Power button; 2) Shock button. There are two pads with sticky backs. Turn on the defibrillator. Cut or remove the patient’s shirt. Place the pads across the victim as shown on the diagram on the back of each pad. All modern devices have voice monitors. At this point the device will advise you to not touch the patient while it analyzes the patient’s heart rhythm. There are only 2 responses: 1) no shock needed, 2) shock needed. The unit will tell you. In the former case, begin chest compressions. In the latter, the unit will charge automatically and warn bystanders to stay clear of the patient. You will then be advised to administer a shock. This is when you get to say “Clear!” Take one last look to ensure that nobody is touching the patient, then push the shock button. You will see the body jump, just like in the movies. Electricity is not contagious. It is safe to touch the patient immediately after a shock is delivered. The unit will reinterpret the rhythm. You will be advised to check the patient. If the patient revives, heave a huge sigh of relief, and give yourself a pat on the back. Check your own pulse. You’re a hero!

 

www.nhibi.nih.gov

www.nhibi.nih.gov

 

 

If the patient does not revive, you did nothing wrong. Resume compressions. After 2 minutes, the device will advise you to not touch the patient again, while it determines if an additional shock is needed. Repeat the process until help arrives, or the patient revives. Although the situation is very intimidating, operating an automated defibrillator isn’t. The only wrong action is inaction. Overcome your fear, and save a life! Who knows, you might even find that you like the rush and decide to become an EMT.

 

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The Arizona story is particularly enlightening. In 2005, 30 EMS agencies across the state participated in a government-sponsored program designed to improve outcomes for out-of-hospital cardiac arrest: the SHARE (Save Hearts in Arizona Registry and Education) program. By the end of the study, 90 agencies providing services to approximately 80% of the state’s population had joined SHARE. Components of the program included: a brief online video training program; in-person, free community training at multiple sites; free school training to grades 6 through 12; on-air public service announcements; utility bill educational inserts; tables set up at health and safety fairs; newspaper articles and editorials; training videos looped on public access cable channels; summer youth classes; and special features on local and national television. The hallmark of the program was training citizens to provide chest compression-only CPR to cardiac arrest victims. After 5 years, more than 30,000 citizens had received direct training in the technique, while an estimated 500,000 of the state’s 6.6 million population had received exposure to one or more components of the program. The result was a huge uptick in bystander chest compression CPR, from 20% at the start of the program to 76% afterward, and a near tripling of the survival rate from 3.7 to 9.8%. After a similar nationwide initiative was instituted in Denmark, bystander CPR increased from 21% to 45%, with a concomitant tripling of the survival rate from 3.5 to 10.8%. As several studies have shown, just training 9-1-1 dispatchers to provide chest compression-only CPR instructions to callers increases survival rates. It’s important to note that patients with shockable rhythms have much higher survival rates than those with non-shockable rhythms. CPR buys time for the defibrillator to arrive. For every minute after a cardiac arrest without chest compressions, survival rates drop by 10%.

In 2015, a group of researchers with too much time on their hands decided to re-visit the success rate of CPR as depicted on television, this time watching 91 episodes of “Grey’s Anatomy” and “House.” Not much had changed; the TV survival rate remained about 70%. Those dramatic depictions create false expectations of what medicine can realistically achieve, but now you know the truth. At day’s end, you don’t need fancy drugs, sophisticated equipment, high tech airways, or expensive cooling machines to save lives; you just need a pair of arms and the courage to act.

A final scold: If the American Heart Association really wanted to save as many lives as possible, they would freely publish their guidelines and training manuals online. Dedicating a reviewer to update the results of ongoing resuscitation trials on their website wouldn’t hurt either. The organization could still charge folks for taking certification tests, but the information should be there for all to see. That would be a true innovation.

References:

  1. Susan Diem et al., “Cardiopulmonary Resuscitation on Television: Miracles and Misinformation,” NEJM 1996; 334: 1578-82.
  2. AHA 2015-2016 Audited Financial Statement, heart.org/HEARTORG/General/AHA-Financial-Information_UCM_303567_Article.jsp#WPt66YVnh3Q.
  3. AHA 2015-2016 National Center Support from Pharmaceutical Companies and Device Manufacturers and AHA Total Corporate Support, heart.org/HEARTORG/General/AHA-Financial-Information_UCM_303567_Article.jsp#WPt66YVnh3Q.
  4. The nation’s top 100 charities. forbes.com/companies/american-heart-association/
  5. Carl van Walraven et al., “Do Advanced Cardiac Life Support Drugs Increase Resuscitation Rates from In-Hospital Cardiac Arrest?” Annals of Em Med 1998; 32 (5): 544-53.
  6. Akihito Hagihara et al., “Prehospital Epinephrine Use and Survival Among Patients with Out-of-Hospital Cardiac Arrest,” JAMA 2012; 307: 1161-8.
  7. Yoshikazu Goto et al., “Effects of Prehospital Epinephrine During Out-Of-Hospital Cardiac Arrest with Initial Nonshockable Rhythm: An Observational Cohort Study,” Critical Care 2013; 17 (5): R188-99.
  8. Ageliki Laina et al., “Amiodarone and Cardiac Arrest: Systematic Review and Meta-Analysis,” Internat’l J of Card 2016: 221: 780-8.
  9. PJ Kudenchuk et al., “Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest,” NEJM 2016; 374 (18): 1711-23.
  10. Steven Bradley et al., “Defibrillation Time Intervals and Outcomes of Cardiac Arrest in Hospital: Retrospective Cohort Study from Get With The Guidelines-Resuscitation Registry,” BMJ 2016, 353: i1653-9.
  11. Paul Chan et al., “Association Between Therapeutic Hypothermia and Survival After In-Hospital Cardiac Arrest,” JAMA 2016; 316 (13): 1375-82.
  12. Florence Dumas et al., “Chest Compression Alone Cardiopulmonary Resuscitation Is Associated with Better Long-Term Survival Compared with Standard Cardiopulmonary Resuscitation,” Circulation 2013; 127: 435-32.
  13. Bentley Bobrow et al., “Chest Compression–Only CPR by Lay Rescuers and Survival from Out-of-Hospital Cardiac Arrest,” JAMA 2010; 304 (13): 1447-54.
  14. Mads Wissenberg et al., “Association of National Initiatives to Improve Cardiac Arrest Management With Rates of Bystander Intervention and Patient Survival After Out-of-Hospital Cardiac Arrest,” JAMA 2010; 310 (13): 1377-84.
  15. Jaclyn Portanova et al., “It Isn’t Like This on TV: Revisiting CPR Survival Rates Depicted on Popular TV Shows,” Resuscitation 2015; 96: 148-50.

2 thoughts on “I’m skeptical about … CPR.

  1. I really like this post! I have also heard and have told new nurses, emts and non-medical people that once a person is dead you can’t really make them any more dead!

    I think the public is not educated as well as they could be when it comes to helping a person who had collapsed. Doing chest compressions is the best way to help and NO that does not mean you have to do the mouth to mouth part if you are not comfortable. Last time I checked, studies showed that the chest compressions performed ASAP were far more important than providing that rescue breath. It was found that many bystanders did not want to initiate CPR because of the whole mouth to mouth thing.

    Epinephrine is another drug I have actually asked questions about during an ACLS class. I actually asked if it really was found to help with long term survival AND quality of life, since quality of life is very important to most people. Epinephrine does vasoconstrict the limbs severely, often to the point of making them extremely pale and blue. To me, it seemed as though the blood was not being perfused really anywhere, including the brain. I don’t know very many who want to have so much brain damage that they cannot function at all…but I suppose some people prefer that to the alternative and that is ok-it is their choice. Anyway, I asked if all that vasoconstriction prevented blood flow to the brain- since CPR actually is supposed to help circulate the blood around the body, especially the brain- but how can anything circulate when the vessels were so constricted? The answer I received was confusing but I basically took it as the instructor really did not know. Reading what you have wrote really did help me make sense of it.

    I have worked as an ER nurse for about 8 years now and honestly, I have rarely if ever, seen any patient “come back” from a true cardiac arrest. I have seen patients come back from arrythmias that are fatal, such as ventricular fibrillation, if they are treated appropriately, by receiving a shock and not just epi, as well as chest compressions. Many people are scared to start CPR and I can understand that, especially when you are freaking out because it is someone you love. But I think people really need to be educated on this more because Instant chest compressions upon the patient collasping and before help arrives, is the BEST and ONLY way that I know of that may help the patient have a fighting chance and a decent quality of life if they do make it.

    So I have to ask, why do you think epi is still considered the most vital part of treatment for a patient in cardiac arrest? I understand that there is research out there to support the use of epinephrine in cardiac arrest but all too often research can be tweeked to support what the researcher wants it to support. I am not saying this is what is happening when it comes to the research done on this topic, but it is a possibility. I can’t honestly recall a time we have resuscitated a person who was in a complete cardiac arrest, I mean someone with asystole on the monitor when helped arrived. We seem to give so much epi that the patients limbs and faces, become pale and blue in color. All the blood is gone. And on ultrasound all that can be seen is a slight quivering of heart. Some of the research that says that epi is effective does not support what I personally have seen in real life. I don’t mean to sound like my experiences are the only ones that count, I am just stating what MY experience has been. I want to also add that I have been in many different codes with many different doctors in several different hospitals over the last 8-9 years so I do not think that what I have seen can be attributed to bad practice by any certain doctor or facility. So I have to ask what is really the truth about the use of some of these cardiac arrest drugs?? Could it be that as doctors and nurses we have the desire to want to help some and to be proactive? As in we just can’t sit there and not give any medications at all? I suppose that legally the doctors have to do what the protocols say to do or else they could be liable for neglect or malpractice. I understand that much. I wonder when these associations, like the American Heart Association, will re-evaluate these standards of care. Could there possibly be any other medications that could be utilized? Will the drug companies create newer medications that work better? As of right now, I am pretty sure there is not a super high demand set in place for such changes to be made. It seems that epinephrine is going to continue to be the gold star standard in cardiac arrest treatment. Maybe I am completely wrong and way off base. Maybe there are plenty of occurrences where epi used in cardiac arrest has worked miracles. Having said all of this I do want to say that epinephrine does work wonders in certain medical emergencies, like anaphylaxis, and severe asthma attacks. I have seen it work first hand in those emergencies. I am not trying to suggest that epinephrine is a useless medication. I simply have some questions when it comes to its effectiveness in cardiac arrests.

    I wrote all that to support what you have written in this blog and also because I think it is important for people in healthcare, including the AHA, to re-evaluate practices. Maybe, the protocols can be seriously revisited to possible allow for more lives to be saved as well as to increase the quality of life for those who do survive a cardiac arrest.

    Perhaps, there really are no other drugs that can be used to try to bring someone back from cardiac arrest. Death, sadly, is a part of life. This is something that should be considered as well when it comes to some cases we come across. But that is a completely different topic for another day.

    I know I wrote a lot, it seems to be a common theme with me after reading your blogs but they really do make me think! I think they are great!

    • I am not certain why the AHA continues to recommend epinephrine. A double-blind RCT (randomized controlled trial) comparing epinephrine to placebo would answer the question, but to date the trials have been epinephrine versus no-epinephrine. The degree to which money plays a role is anybody’s guess, but it’s clear that the AHA continues to accept huge contributions from Pharma.

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