Clinical paper| Volume 121, P71-75, December 2017

End-tidal carbon dioxide and defibrillation success in out-of-hospital cardiac arrest



      Basing on the relationship between the quality of cardiopulmonary resuscitation (CPR) and the responsiveness of VF to the defibrillation we aimed to assess whether the values of ETCO2 in the minute before defibrillation could predict the effectiveness of the shock.

      Materials and methods

      We retrospectively evaluated the reports generated by the manual monitor/defibrillator (Corpuls by GS Elektromedizinische Geräte G. Stemple GmbH, Germany) used for cases of VF cardiac arrest from January 2015 to December 2016. The mean ETCO2 value of the minute preceding the shock (METCO260) was computed. A blind evaluation of the effectiveness of each shock was provided by three cardiologists.


      A total amount of 207 shocks were delivered for 62 patients. When considering the three tertiles of METCO260 (T1:METCO260 ≤ 20 mmHg; T2: 20 mmHg < METCO260 ≤ 31 mmHg and T3: METCO260 > 31 mmHg) a statistically significant difference between the percentages of shock success was found (T1: 50%; T2: 63%; T3: 78%; Chi square p = 0.003; p for trend <0.001). When the METCO260 was lower than 7 mmHg no shock was effective and when the METCO260 was higher than 45 mmHg no shock was ineffective. Shocks followed by ROSC were preceded by higher values of METCO260 as compared either to ineffective shocks or effective ones without ROSC.


      This is the first demonstration of the relation between ETCO2 and defibrillation effectiveness. Our findings stress the pivotal role of High Quality CPR, monitored via ETCO2, and suggest ETCO2 monitoring as an additional weapon to guide defibrillation.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Herlitz J.
        • Svensson L.
        • Engdahl J.
        • Angquist K.A.
        • Silfverstolpe J.
        • Holmberg S.
        Association between interval between call for ambulance and return of spontaneous circulation and survival in out-of-hospital cardiac arrest.
        Resuscitation. 2006; 71: 40-46
        • Indik J.H.
        • Donnerstein R.L.
        • Hilwig R.W.
        • Zuercher M.
        • Feigelman J.
        • Kern K.B.
        • et al.
        The influence of myocardial substrate on ventricular fibrillation waveform: a swine model of acute and postmyocardial infarction.
        Crit Care Med. 2008; 36: 2136-2142
        • Choi H.J.
        • Nguyen T.
        • Park K.S.
        • Cha K.C.
        • Kim H.
        • Lee K.H.
        • et al.
        Effect of cardiopulmonary resuscitation on restoration of myocardial ATP in prolonged ventricular fibrillation.
        Resuscitation. 2013; 84: 108-113
        • Achleitner U.
        • Wenzel V.
        • Strohmenger H.U.
        • Lindner K.H.
        • Baubin M.A.
        • Krismer A.C.
        • et al.
        The beneficial effect of basic life support on ventricular fibrillation mean frequency and coronary perfusion pressure.
        Resuscitation. 2001; 51: 151-158
        • Eftestøl T.
        • Wik L.
        • Sunde K.
        • Steen P.A.
        Effects of cardiopulmonary resuscitation on predictors of ventricular fibrillation defibrillation success during out-of-hospital cardiac arrest.
        Circulation. 2004 Jul 6; 110: 10-15
        • Firoozabadi R.
        • Nakagawa M.
        • Helfenbein E.D.
        • Babaeizadeh S.
        Predicting defibrillation success in sudden cardiac arrest patients.
        J Electrocardiol. 2013; 46: 473-479
        • Indik J.H.
        • Allen D.
        • Gura M.
        • Dameff C.
        • Hilwig R.W.
        • Kern K.B.
        Utility of the ventricular fibrillation waveform to predict a return of spontaneous circulation and distinguish acute from post myocardial infarction or normal Swine in ventricular fibrillation cardiac arrest.
        Circ Arrhythm Electrophysiol. 2011; 4: 337-343
        • Li Y.
        • Tang W.
        Optimizing the timing of defibrillation: the role of ventricular fibrillation waveform analysis during cardiopulmonary resuscitation.
        Crit Care Clin. 2012 Apr; 28: 199-210
        • Ristagno G.
        • Tang W.
        • Chang Y.T.
        • Jorgenson D.B.
        • Russell J.K.
        • Huang L.
        • et al.
        The quality of chest compressions during cardiopulmonary resuscitation overrides importance of timing of defibrillation.
        Chest. 2007 Jul; 132: 70-75
        • Soar J.
        • Nolan J.P.
        • Böttiger B.W.
        • Perkins G.D.
        • Lott C.
        • Carli P.
        • et al.
        Adult advanced life support section collaborators: european resuscitation council guidelines for resuscitation 2015: section 3. adult advanced life support.
        Resuscitation. 2015; 95: 100-147
        • Link M.S.
        • Berkow L.C.
        • Kudenchuk P.J.
        • Halperin H.R.
        • Hess E.P.
        • Moitra V.K.
        • et al.
        Part 7: adult advanced cardiovascular life support: 2015 american heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
        Circulation. 2015; 132: S444-64
        • Ward K.R.
        • Menegazzi J.J.
        • Zelenak R.R.
        • Sullivan R.J.
        • McSwain Jr., N.E.
        A comparison of chest compressions between mechanical and manual CPR by monitoring end-tidal PCO2 during human cardiac arrest.
        Ann Emerg Med. 1993; 22: 669-674
        • Axelsson C.
        • Karlsson T.
        • Axelsson A.B.
        • Herlitz J.
        Mechanical active compression-decompression cardiopulmonary resuscitation (ACD-CPR) versus manual CPR according to pressure of end tidal carbon dioxide (P(ET)CO2) during CPR in out-of-hospital cardiac arrest (OHCA).
        Resuscitation. 2009; 80: 1099-1103
        • Qvigstad E.
        • Kramer-Johansen J.
        • Tømte Ø.
        • Ska°lhegg T.
        • Sørensen Ø.
        • Sunde K.
        • et al.
        Clinical pilot study of different hand positions during manual chest compressions monitored with capnography.
        Resuscitation. 2013; 84: 1203-1207
        • Wik L.
        • Naess P.A.
        • Ilebekk A.
        • Nicolaysen G.
        • Steen P.A.
        Effects of various degrees of compression and active decompression on haemodynamics, end-tidal CO2, and ventilation during cardiopulmonary resuscitation of pigs.
        Resuscitation. 1996; 31: 45-57
        • Falk J.L.
        • Rackow E.C.
        • Weil M.H.
        End-tidal carbon dioxide concentration during cardiopulmonary resuscitation.
        N Engl J Med. 1988; 318: 607-611
        • Angelos M.G.
        • DeBehnke D.J.
        • Leasure J.E.
        Arterial pH and carbon dioxide tension as indicators of tissue perfusion during cardiac arrest in a canine model.
        Crit Care Med. 1992; 20: 1302-1308
        • Ornato J.P.
        • Garnett A.R.
        • Glauser F.L.
        Relationship between cardiac output and the end-tidal carbon dioxide tension.
        Ann Emerg Med. 1990; 19: 1104-1106
        • Touma O.
        • Davies M.
        The prognostic value of end tidal carbon dioxide during cardiac arrest: a systematic review.
        Resuscitation. 2013; 84: 1470-1479
        • Pernat A.
        • Weil M.H.
        • Sun S.
        • Tang W.
        Stroke volumes and end-tidal carbon dioxide generated by precordial compression during ventricular fibril-lation.
        Crit Care Med. 2003; 31: 1819-1823
        • Isserles S.A.
        • Breen P.H.
        Can changes in end-tidal PCO2 measure changes in cardiac output?.
        Anesth Analg. 1991; 73: 808-814
        • Shibutani K.
        • Muraoka M.
        • Shirasaki S.
        • Kubal K.
        • Sanchala V.T.
        • Gupte P.
        Do changes in end-tidal PCO2 quantitatively reflect changes in cardiac output?.
        Anesth Analg. 1994; 79: 829-833
        • Sheak K.R.
        • Wiebe D.J.
        • Leary M.
        • Babaeizadeh S.
        • Yuen T.C.
        • Zive D.
        • et al.
        Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest.
        Resusicitation. 2015; 89: 149-154
        • Bhende M.S.
        • Karasic D.G.
        • Menegazzi J.J.
        Evaluation of an end-tidal CO2 detector during cardiopulmonary resuscitation in a canine model for pediatric cardiac arrest.
        Pediatr Emerg Care. 1995; 11: 365-368
        • Grmec S.
        • Lah K.
        • Tusek-Bunc K.
        Difference in end-tidal CO2 between asphyxia cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest in the prehospital setting.
        Crit Care. 2003; 7: 139-144
        • Grmec S.
        • Kupnik D.
        Does the Mainz Emergency Evaluation Scoring (MEES) in combination with capnometry (MEESc) help in the prognosis of outcome from cardiopulmonary resuscitation in a prehospital setting?.
        Resuscitation. 2003; 58: 89-96
        • Raimondi M.
        • Savastano S.
        • Pamploni G.
        • Molinari S.
        • Degani A.
        • Belliato M.
        End-tidal carbon dioxide monitoring and load band device for mechanical cardio-pulmonary resuscitation: never trust the numbers, believe at the curves.
        Resuscitation. 2016; 103: e9-e10
        • Koster R.W.
        • Walker R.G.
        • van Alem A.P.
        Definition of successful defibrillation.
        Crit Care Med. 2006; 34: S423-6
        • Grmec S.
        • Lah K.
        • Tusek-Bunc K.
        Difference in end-tidal CO2 between asphyxia cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest in the prehospital setting.
        Crit Care. 2003; 7: 139-144
        • Heradstveit B.E.
        • Sunde K.
        • Sunde G.A.
        • Wentzel-Larsen T.
        • Heltne J.K.
        Factors complicating interpretation of capnography during advanced life support in cardiac arrest –a clinical retrospective study in 575 patients.
        Resuscitation. 2012; 83: 813-818
        • Chalkias A.
        • Georgiou M.
        • Böttiger B.
        • Monsieurs K.G.
        • Svavarsdóttir H.
        • Raffay V.
        • et al.
        Recommendations for resuscitation after ascent to high altitude and in aircrafts.
        Int J Cardiol. 2013; 167: 1703-1711