Delaying Defibrillation to Give Basic Cardiopulmonary Resuscitation to Patients With Out-of-Hospital Ventricular Fibrillation: A Randomized Trial | Cardiology | JAMA | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 34.236.187.155. Please contact the publisher to request reinstatement.
1.
European Resuscitation Council.  Part 4: the automated external defibrillator: key link in the chain of survival.  Resuscitation.2000;46:73-91.Google Scholar
2.
Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest: a graphic model.  Ann Emerg Med.1993;22:1652-1658.Google Scholar
3.
Kern KB, Garewal HS, Sanders AB.  et al.  Depletion of myocardial adenosine triphosphate during prolonged untreated ventricular fibrillation: effect on defibrillation success.  Resuscitation.1990;20:221-229.Google Scholar
4.
Maldonado FA, Weil MH, Tang W.  et al.  Myocardial hypercarbic acidosis reduces cardiac resuscitability.  Anesthesiology.1993;78:343-352.Google Scholar
5.
Brown CG, Dzwonczyk R. Signal analysis of the human electrocardiogram during ventricular fibrillation: frequency and amplitude parameters as predictors of successful countershock.  Ann Emerg Med.1996;27:184-188.Google Scholar
6.
Eftestol T, Sunde K, Steen PA. Effects of interrupting precordial compressions on the calculated probability of defibrillation success during out-of-hospital cardiac arrest.  Circulation.2002;105:2270-2273.Google Scholar
7.
Niemann JT, Cairns CB, Sharma J, Lewis RJ. Treatment of prolonged ventricular fibrillation: immediate countershock versus high-dose epinephrine and CPR preceding countershock.  Circulation.1992;85:281-287.Google Scholar
8.
Cobb LA, Fahrenbruch CE, Walsh TR.  et al.  Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation.  JAMA.1999;281:1182-1188.Google Scholar
9.
World Medical Association.  Declaration of Helsinki. Helsinki, Finland: World Medical Association; 1964.
10.
 European Resuscitation Council guidelines for advanced life support.  Resuscitation.1998;37:81-90.Google Scholar
11.
Cummins RO, Chamberlain DA, Abramson NS.  et al.  Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style.  Circulation.1991;84:960-975.Google Scholar
12.
Safar P, Bircher NG. Cardiopulmonary cerebral resuscitation. In: Basic and Advanced Cardiac and Trauma Life Support: An Introduction to Resuscitation Medicine. 3rd ed. London, England: WB Saunders; 1988:267.
13.
Wik L, Steen PA, Bircher NG. Quality of bystander cardiopulmonary resuscitation influences outcome after prehospital cardiac arrest.  Resuscitation.1994;28:195-203.Google Scholar
14.
Sunde K, Eftestol T, Askenberg C, Steen PA. Quality assessment of defibrillation and advanced life support using data from the medical control module of the defibrillator.  Resuscitation.1999;41:237-247.Google Scholar
15.
Campbell JP, Maxey VA, Watson WA. Hawthorne effect: implications for prehospital research.  Ann Emerg Med.1995;26:590-594.Google Scholar
16.
Robinson JS, Davies MK, Johns BM, Edwards SN. "Out-of-hospital cardiac arrests" treated by the West Midlands Ambulance Service over a 2-year period.  Eur J Anaesthesiol.1998;15:702-709.Google Scholar
17.
Yakaitis RW, Ewy GA, Otto CW, Taren DL, Moon TE. Influence of time and therapy on ventricular defibrillation in dogs.  Crit Care Med.1980;8:157-163.Google Scholar
18.
Idris AH, Becker LB, Fuerst RS.  et al.  Effect of ventilation on resuscitation in an animal model of cardiac arrest.  Circulation.1994;90:3063-3069.Google Scholar
19.
Niemann JT, Cruz B, Garner D, Lewis RJ. Immediate countershock versus cardiopulmonary resuscitation before countershock in a 5-minute swine model of ventricular fibrillation arrest.  Ann Emerg Med.2000;36:543-546.Google Scholar
20.
Weaver WD, Cobb LA, Hallstrom AP, Fahrenbruch C, Copass MK, Ray R. Factors influencing survival after out-of-hospital cardiac arrest.  J Am Coll Cardiol.1986;7:752-757.Google Scholar
21.
Stults KR, Brown DD, Schug VL, Bean JA. Prehospital defibrillation performed by emergency medical technicians in rural communities.  N Engl J Med.1984;310:219-223.Google Scholar
22.
Saklayen M, Liss H, Markert R. In-hospital cardiopulmonary resuscitation: survival in 1 hospital and literature review.  Medicine.1995;74:163-175.Google Scholar
23.
Stueven HA, Waite EM, Troiano P, Mateer JR. Prehospital cardiac arrest—a critical analysis of factors affecting survival.  Resuscitation.1989;17:251-259.Google Scholar
24.
Weaver WD, Cobb LA, Hallstrom AP.  et al.  Considerations for improving survival from out-of-hospital cardiac arrest.  Ann Emerg Med.1986;15:1181-1186.Google Scholar
25.
Van Hoeyweghen RJ, Bossaert LL, Mullie A.  et al. for the Belgian Cerebral Resuscitation Study Group.  Quality and efficiency of bystander CPR.  Resuscitation.1993;26:47-52.Google Scholar
26.
Graves JR, Herlitz J, Bang A.  et al.  Survivors of out of hospital cardiac arrest: their prognosis, longevity and functional status.  Resuscitation.1997;35:117-121.Google Scholar
27.
Hsu JW, Madsen CD, Callaham ML. Quality-of-life and formal functional testing of survivors of out-of-hospital cardiac arrest correlates poorly with traditional neurologic outcome scales.  Ann Emerg Med.1996;28:597-605.Google Scholar
28.
Dybvik T, Strand T, Steen PA. Buffer therapy during out-of-hospital cardiopulmonary resuscitation.  Resuscitation.1995;29:89-95.Google Scholar
29.
Holmberg M, Holmberg S, Herlitz J, Gardelov B. Survival after cardiac arrest outside hospital in Sweden: Swedish Cardiac Arrest Registry.  Resuscitation.1998;36:29-36.Google Scholar
30.
Kloeck W, Cummins RO, Chamberlain D.  et al.  The universal advanced life support algorithm: an advisory statement from the Advanced Life Support Working Group of the International Liaison Committee on Resuscitation.  Circulation.1997;95:2180-2182.Google Scholar
31.
 Automated external defibrillators and ACLS: a new initiative from the American Heart Association.  Am J Emerg Med.1991;9:91-94.Google Scholar
32.
Weisfeldt ML, Becker LB. Resuscitation after cardiac arrest: a 3-phase time-sensitive model.  JAMA.2002;288:3035-3038.Google Scholar
Original Contribution
March 19, 2003

Delaying Defibrillation to Give Basic Cardiopulmonary Resuscitation to Patients With Out-of-Hospital Ventricular Fibrillation: A Randomized Trial

Author Affiliations

Author Affiliations: Norwegian Competence Center for Emergency Medicine, Institute for Experimental Medical Research (Dr Wik), Division of Surgery (Drs T. Steen and P. A. Steen, and Messrs Hansen and Fylling), Ulleval University Hospital, Oslo, Norway; Norwegian Defense Research Establishment Division of Protection and Material, Kjeller, Norway (Dr Vaagenes); and Department of Technology and Natural Science, Stavanger University College, Stavanger, Norway (Dr Auestad).

JAMA. 2003;289(11):1389-1395. doi:10.1001/jama.289.11.1389
Abstract

Context Defibrillation as soon as possible is standard treatment for patients with ventricular fibrillation. A nonrandomized study indicates that after a few minutes of ventricular fibrillation, delaying defibrillation to give cardiopulmonary resuscitation (CPR) first might improve the outcome.

Objective To determine the effects of CPR before defibrillation on outcome in patients with ventricular fibrillation and with response times either up to or longer than 5 minutes.

Design, Setting, and Patients Randomized trial of 200 patients with out-of-hospital ventricular fibrillation in Oslo, Norway, between June 1998 and May 2001. Patients received either standard care with immediate defibrillation (n = 96) or CPR first with 3 minutes of basic CPR by ambulance personnel prior to defibrillation (n = 104). If initial defibrillation was unsuccessful, the standard group received 1 minute of CPR before additional defibrillation attempts compared with 3 minutes in the CPR first group.

Main Outcome Measure Primary end point was survival to hospital discharge. Secondary end points were hospital admission with return of spontaneous circulation (ROSC), 1-year survival, and neurological outcome. A prespecified analysis examined subgroups with response times either up to or longer than 5 minutes.

Results In the standard group, 14 (15%) of 96 patients survived to hospital discharge vs 23 (22%) of 104 in the CPR first group (P = .17). There were no differences in ROSC rates between the standard group (56% [58/104]) and the CPR first group (46% [44/96]; P = .16); or in 1-year survival (20% [21/104] and 15% [14/96], respectively; P = .30). In subgroup analysis for patients with ambulance response times of either up to 5 minutes or shorter, there were no differences in any outcome variables between the CPR first group (n = 40) and the standard group (n = 41). For patients with response intervals of longer than 5 minutes, more patients achieved ROSC in the CPR first group (58% [37/64]) compared with the standard group (38% [21/55]; odds ratio [OR], 2.22; 95% confidence interval [CI], 1.06-4.63; P = .04); survival to hospital discharge (22% [14/64] vs 4% [2/55]; OR, 7.42; 95% CI, 1.61-34.3; P = .006); and 1-year survival (20% [13/64] vs 4% [2/55]; OR, 6.76; 95% CI, 1.42-31.4; P = .01). Thirty-three (89%) of 37 patients who survived to hospital discharge had no or minor reductions in neurological status with no difference between the groups.

Conclusions Compared with standard care for ventricular fibrillation, CPR first prior to defibrillation offered no advantage in improving outcomes for this entire study population or for patients with ambulance response times shorter than 5 minutes. However, the patients with ventricular fibrillation and ambulance response intervals longer than 5 minutes had better outcomes with CPR first before defibrillation was attempted. These results require confirmation in additional randomized trials.

×