Increased frequency of thorax injuries with ACD-CPR☆
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
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2018, American Journal of Emergency MedicineCitation 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].
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No author has a conflict of interest with regard to the device used for ACD-CPR.