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Continue massage verdubbelt overleving

11 maart 2008 - Medisch

Breaking news uit ACEP-mail. Een verdubbeling in overleving van reanimatie is mogelijk door continue massage. 

The introduction of a new method of cardiopulmonary resuscitation to fire departments in two Arizona cities was associated with a doubling in survival of patients with out-of-hospital cardiac arrest and a more than threefold improvement in those whose coronary event was witnessed, according to new findings.Those results, though unconfirmed, show that minimally interrupted cardiac resuscitation (MICR), also known as cardiocerebral resuscitation, can improve survival in these patients, in the view of two cardiologists not affiliated with the study.The investigators’ report, published in the March 12 issue of JAMA, presented two analyses. The first compared data before and after the introduction of MICR at two Arizona municipal fire departments. About 2,000 firefighters were trained in the new protocol, which emphasizes early, uninterrupted chest compressions, with tracheal intubation either delayed or eliminated. A 6-month baseline period provided pre-MICR survival data, which showed an overall survival-to-discharge rate of 1.8% (4 of 218 patients). In the 2-year period following the introduction of MICR in the first city fire department to receive the training, 36 of 668 patients (5.4%) survived to discharge, according to Dr. Bentley J. Bobrow of the Mayo Clinic, Scottsdale, Ariz., and colleagues. The improvement was even greater in a subgroup of 174 patients whose event was witnessed and who had a shockable rhythm; before MICR introduction, 2 of 43 such patients (4.7%) survived, versus 23 of 131 (17.6%) who had cardiac arrest after the establishment of the MICR protocol.The second analysis assessed protocol compliance in patients whose treatment with either the MICR protocol or conventional resuscitation was confirmed; this analysis included patients initially treated by the initial two Arizona cities plus 60 additional fire departments, over the course of nearly 3 years. Of 1,799 who did not receive MICR, 1,730 died and 69 survived, for a survival rate of approximately 4%. Among 661 who did receive MICR, 60 survived, for a better than 9% survival rate. Despite the large survival advantage seen with MICR, the investigators cautioned that the findings require confirmation in a randomized study (JAMA 2008;299:1158-65).These improved survival rates with MICR are likely due in great part to several deleterious aspects of conventional CPR, Dr. Bobrow and colleagues noted. One likely factor is the prolonged period of inadequate perfusion that occurs with conventional resuscitation. In addition, conventional resuscitation prescribes defibrillation only after 5 minutes or longer of ventricular fibrillation, during which myocardial high-energy phosphates are greatly depleted. The VF waveform also becomes more fine over the course of the event; prior studies have shown that preshock compressions can coarsen the VF wave, which improves the likelihood of successful resuscitation, they noted. In addition, the conventional sequential defibrillator shocks interrupt cerebral and myocardial blood flow – as might positive pressure ventilations – by increasing intrathoracic pressure and reducing venous return.The results show that “outcomes for resuscitating patients in cardiac arrest remain dismal, yet significant improvements are possible,” Dr. Mary Ann Peberdy and Dr. Joseph P. Ornato, both of Virginia Commonwealth University, Richmond, wrote in an accompanying editorial. MICR requires a dramatic change in behavior for emergency medical services personnel, they noted. Still, “the need for minimally interrupted chest compression and the lesser importance of positive pressure ventilation, is a meaningful development in the evolution of resuscitation science,” they concluded. They reported no financial disclosures (JAMA 2008;299:1188-90).MICR for prehospital responders specifies an initial 200 uninterrupted chest compressions at 100 compressions per minute, rhythm analysis with a single shock when indicated, immediately followed by 200 postshock compressions before any pulse check or rhythm reanalysis, according to Dr. Bobrow and colleagues. Endotracheal intubation should be delayed until after three cycles of chest compressions and rhythm analysis, and 1 mg IV epinephrine should be given as soon as possible and repeated with each cycle of chest compressions and rhythm analysis.

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