Elsevier

Resuscitation

Volume 41, Issue 1, June 1999, Pages 33-38
Resuscitation

Increased frequency of thorax injuries with ACD-CPR

https://doi.org/10.1016/S0300-9572(99)00033-7Get rights and content

Abstract

A prospective, randomised out-of-hospital study in a two-tiered system with active compression–decompression (ACD) cardiopulmonary resuscitation (CPR) versus standard (STD) CPR in patients following non-traumatic cardiac arrest was planned to test the hypothesis that ACD-CPR by the first tier may increase the occurrence of ventricular fibrillation as compared with STD-CPR. Furthermore, in a later phase of the study, sternal and rib fractures induced by both CPR methods were determined by extensive autopsy. After enrolling 90 patients the study was terminated because of a high frequency of chest injuries found at autopsy. Forty-two patients received STD-CPR from the first tier and ACD-CPR from the second tier. Thirty-three patients received ACD-CPR only by the first and the second tier, while 15 patients received STD-CPR only from the first and second tiers. In order to obtain a sufficiently large control group for autopsy findings after STD-CPR, STD-CPR was performed in an additional 33 patients within a second period of 4 months. There was no improvement in the number of patients found in ventricular fibrillation after ACD-CPR as compared to STD-CPR performed by the first tier. In patients undergoing autopsy (n=35) there were significantly more sternal fractures with ACD-CPR versus STD-CPR (14/15 vs. 6/20; P<0.005) and rib fractures (13/15 vs. 11/20; P<0.05) In conclusion, ACD-CPR appears to cause more CPR-related injuries than does standard CPR, but as a result of a number of limitations on this study, this fact cannot be proven beyond doubt.

Introduction

In 1992 a new cardiopulmonary resuscitation (CPR) device was introduced into emergency medicine to actively compress and decompress the thorax during CPR (active compression–decompression, ACD-CPR) [1]. Subsequent animal and in-hospital studies showed improved haemodynamic variables during ACD-CPR [2], [3], [4], and partially an improved short-term survival rate as compared to standard cardiopulmonary resuscitation (STD-CPR) [5], [6]. To date, all out-of-hospital ACD-CPR studies with the exception of one [7] failed to show an improved outcome in out-of-hospital cardiac arrest patients.

In one animal study, myocardial and cerebral blood flow significantly increased with ACD-CPR as compared with standard (STD)-CPR [8] in the absence of, and 5 min after, adrenaline. Thus, the potential benefit of ACD-CPR observed during basic life support (BLS) may be non-existent during advanced cardiac life support (ACLS) when adrenaline is given every 3 min. In all out-of-hospital ACD studies, except one [7], ACD-CPR was performed as an adjunct technique during ACLS.

The emergency medical technicians in our Emergency Medical Service (EMS) usually arrive before the ACLS unit and are allowed to provide only BLS. We hypothesized that ACD-CPR may improve outcome in this setting. Since an enormous number of cardiac arrest patients must be enrolled in order to show a significant improvement in outcome criteria, we concentrated on occurrence of ventricular fibrillation (VF) as the first ECG rhythm. VF usually correlates with outcome criteria such as return of spontaneous circulation (ROSC), hospital admission, or hospital discharge. Optimal BLS may prolong the time before VF deteriorates to a non-shockable rhythm such as asystole or electro-mechanical dissociation. Therefore, we hypothesised that ACD-CPR as a BLS skill may improve occurrence of VF and thus performed a randomised, prospective study to determine the effect of ACD-CPR versus STD-CPR during BLS on occurrence of VF.

Section snippets

Setting

Innsbruck has a population of approximately 130 000. The EMS is a two-tiered system with the first tier being ambulance cars staffed with two emergency medical technicians and the second tier a mobile intensive care unit with an anaesthetist and two emergency medical technicians. When an emergency is reported, the first and second tiers are dispatched simultaneously, with the first tier arriving earlier in most cases. The emergency medical technicians of the first tier are allowed to perform

Results

In the 10-month study period, 90 patients after out-of-hospital cardiac arrest were treated by the first tier with STD-CPR or ACD-CPR in random order. The second tier started ACD-CPR, or continued ACD-CPR after arrival at the scene. On the basis of personal judgement, some physicians decided not to start with ACD-CPR, but to continue STD-CPR in 15 of the 90 patients. As the study was not an ACLS-ACD-CPR study, but a BLS-ACD-CPR study, this was not considered a protocol violation. For

Discussion

This ACD-CPR study was terminated by the Ethics Committee because of the alarmingly high frequency of chest injuries associated with ACD-CPR. Thus, our hypothesis that early ACD-CPR during BLS may increase the number of patients found in VF could not be verified. Sternal fractures were found significantly more frequently after ACD-CPR than after STD-CPR. For example, in two patients fragments of sternal fractures caused potential lethal vessel and heart injuries [11]. Sternal fractures are

References (23)

  • Th. Schneider et al.

    Active compression-decompression cardiopulmonary resuscitation—instructor and student manual for teaching and training

    Resuscitation

    (1996)
  • Cited by (80)

    • Characteristics of mechanical CPR-related injuries: A case series

      2020, Journal of Forensic and Legal Medicine
    • Breaking your heart—A review on CPR-related injuries

      2018, American Journal of Emergency Medicine
      Citation Excerpt :

      ACD-CPR uses a chest compression device that uses a suction cup applied to the mid-sternum, generating negative intrathoracic pressure during the decompression phase that facilitates increasing venous return to the heart [10]. ACD-CPR has been associated with increased incidence of rib and sternal fractures compared to standard CPR in non-traumatic OHCA [11,12]. The Piston device is another type of automated machine used to compress the chest at a set rate [10].

    View all citing articles on Scopus

    No author has a conflict of interest with regard to the device used for ACD-CPR.

    View full text