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Wik L, Hansen TB, Fylling F, et al. Delaying Defibrillation to Give Basic Cardiopulmonary Resuscitation to Patients With Out-of-Hospital Ventricular Fibrillation: A Randomized Trial. JAMA. 2003;289(11):1389–1395. doi:10.1001/jama.289.11.1389
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).
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.
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