The impact of increased chest compression fraction on survival for out-of-hospital cardiac arrest patients with a non-shockable initial rhythm



      We evaluated the effect of chest compression fraction (CCF) on survival to hospital discharge and return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythms.


      This is a retrospective analysis (completed in 2016) of a prospective cohort study which included OHCA patients from ten U.S. and Canadian sites (Resuscitation Outcomes Consortium Epistry and PRIMED study (2007–2011)). We included all OHCA victims of presumed cardiac aetiology, not witnessed by emergency medical services (EMS), without automated external defibrillator shock prior to EMS arrival, receiving > 1 min of CPR with CPR process measures available, and initial non-shockable rhythm. We measured CCF using the first 5 min of electronic CPR records.


      Demographics of 12,928 adult patients were: mean age 68; male 59.9%; public location 8.5%; bystander witnessed 35.2%; bystander CPR 39.3%; median interval from 911 to defibrillator turned on 10 min:04 s; initial rhythm asystole 64.8%, PEA 26.0%, other non-shockable 9.2%; compression rate 80−120/min (69.1%); median CCF 74%; ROSC 25.6%; survival to hospital discharge 2.4%. Adjusted odds ratio (OR); 95% confidence intervals (95%CI) of survival for each CCF category were: 0−40% (2.00; 1.16, 3.32); 41−60% (0.83; 0.54, 1.24); 61−80% (1.02; 0.77, 1.35); and 81−100% (reference group). Adjusted (OR; 95%CI) of ROSC for each CCF category were: 0−40% (1.02; 0.79, 1.30); 41−60% (0.83; 0.72, 0.95); 61−80% (0.85; 0.77, 0.94); and 81−100% (reference group).


      We observed an incremental benefit from higher CCF on the incidence of ROSC, but not survival, among non-shockable OHCA patients with CCF higher than 40%.


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        • Nichol G.
        • Leroux B.
        • Wang H.
        • et al.
        Trial of Continuous or Interrupted Chest Compressions during CPR.
        New England J Med. 2015; 373: 2203-2214
        • Nichol G.
        • Thomas E.
        • Callaway C.W.
        • et al.
        Regional variation in out-of-hospital cardiac arrest incidence and outcome.
        JAMA. 2008; 300: 1423-1431
        • Vaillancourt C.
        • Stiell I.G.
        Canadian Cardiovascular Outcomes Research Team (CCORT). Cardiac arrest care and emergency medical services in Canada.
        Can J Cardiol. 2004; 20: 1081-1090
        • Grunau B.
        • Kawano T.
        • Dick W.
        • et al.
        Trends in care processes and survival following prehospital resuscitation improvement initiatives for out-of-hospital cardiac arrest in British Columbia, 2006-2016.
        Resuscitation. 2018; 125: 118-125
        • Stiell I.G.
        • Wells G.A.
        • Field B.
        • et al.
        Advanced cardiac life support in out-of-hospital cardiac arrest.
        New England Journal of Medicine. 2004; 351: 647-656
        • Idris A.H.
        • Guffey D.
        • Aufderheide T.P.
        • et al.
        Relationship between chest compression rates and outcomes from cardiac arrest.
        Circulation. 2012; 125: 3004-3012
        • Stiell I.G.
        • Brown S.P.
        • Christenson J.
        • et al.
        What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation?.
        Crit Care Med. 2012; 40: 1192-1198
        • Perkins G.D.
        • Travers A.H.
        • Berg R.A.
        • et al.
        Part 3: Adult basic life support and automated external defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations.
        Resuscitation. 2015; 95: e43-69
        • Kurz M.C.
        • Prince D.
        • Christenson J.
        • et al.
        Association of Advanced Airway Device with Chest Compression Fraction During Out-of-Hospital Cardiopulmonary Arrest.
        Resuscitation. 2016; 98: 35-40
        • Cheskes S.
        • Schmicker R.H.
        • Verbeek P.R.
        • et al.
        The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial.
        Resuscitation. 2014; 85: 336-342
        • Christenson J.
        • Andrusiek D.
        • Everson-Stewart S.
        • et al.
        Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation.
        Circulation. 2009; 120: 1241-1247
        • Rea T.
        • Olsufka M.
        • Yin L.
        • Maynard C.
        • Cobb L.
        The relationship between chest compression fraction and outcome from ventricular fibrillation arrests in prolonged resuscitations.
        Resuscitation. 2014; 85: 879-884
        • Wik L.
        • Olsen J.-A.
        • Persse D.
        • et al.
        Why do some studies find that CPR fraction is not a predictor of survival?.
        Resuscitation. 2016; 104: 59-62
        • Cheskes S.
        • Schmicker R.H.
        • Rea T.
        • et al.
        Chest compression fraction: A time dependent variable of survival in shockable out-of-hospital cardiac arrest.
        Resuscitation. 2015; 97: 129-135
        • Vadeboncoeur T.
        • Stolz U.
        • Panchal A.
        • et al.
        Chest compression depth and survival in out-of-hospital cardiac arrest.
        Resuscitation. 2014; 85: 182-188
        • Mehta C.
        • Brady W.
        Pulseless electrical activity in cardiac arrest: electrocardiographic presentations and management considerations based on the electrocardiogram.
        American Journal of Emergency Medicine. 2012; 30: 236-239
        • Vaillancourt C.
        • Everson-Stewart S.
        • Christenson J.
        • et al.
        The impact of increased chest compression fraction on return of spontaneous circulation for out-of-hospital cardiac arrest patients not in ventricular fibrillation.
        Resuscitation. 2011; 82: 1501-1507
        • Davis D.P.
        • Garberson L.A.
        • Andrusiek D.L.
        • et al.
        A descriptive analysis of Emergency Medical Service Systems participating in the Resuscitation Outcomes Consortium (ROC) network.
        Prehospital Emergency Care. 2007; 11: 369-382
        • Stiell I.G.
        • Nichol G.
        • Leroux B.G.
        • et al.
        Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest.
        New England Journal of Medicine. 2011; 365: 787-797
        • Morrison L.J.
        • Nichol G.
        • Rea T.D.
        • et al.
        Rationale, development and implementation of the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest.
        Resuscitation. 2008; 78: 161-169
        • Jacobs I.
        • Nadkarni V.
        • Bahr J.
        • et al.
        Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa).
        Circulation. 2004; 110: 3385-3397
        • Valenzuela T.D.
        • Kern K.B.
        • Clark L.L.
        • et al.
        Interruptions of chest compressions during emergency medical systems resuscitation.
        Circulation. 2005; 112: 1259-1265
        • Thomas A.J.
        • Newgard C.D.
        • Fu R.
        • Zive D.M.
        • Daya M.R.
        Survival in out-of-hospital cardiac arrests with initial asystole or pulseless electrical activity and subsequent shockable rhythms.
        Resuscitation. 2013; 84: 1261-1266
        • Prosen G.
        • Krizmaric M.
        • Zavrsnik J.
        • Grmec S.
        Impact of modified treatment in echocardiographically confirmed pseudo-pulseless electrical activity in out-of-hospital cardiac arrest patients with constant end-tidal carbon dioxide pressure during compression pauses.
        Journal of International Medical Research. 2010; 38: 1458-1467
        • Teran F.
        • Dean A.J.
        • Centeno C.
        • et al.
        Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department.
        Resuscitation. 2019; 137: 140-147
        • Wu C.
        • Zheng Z.
        • Jiang L.
        • et al.
        The predictive value of bedside ultrasound to restore spontaneous circulation in patients with pulseless electrical activity: A systematic review and meta-analysis.
        PLoS ONE [Electronic Resource]. 2018; 13 (Published online doi: 10.1371/journal.pone.0191636.)
        • Idris A.H.
        • Guffey D.
        • Pepe P.E.
        • et al.
        Chest compression rates and survival following out-of-hospital cardiac arrest.
        Crit Care Med. 2015; 43: 840-848