CPR First? Or Defibrillation First?

Ventricular Fibrillation is considered the most favorable cardiac arrest rhythm, and if treated promptly can result in ROSC
with a favorable neurological outcome. Most survival rates are reported using witnessed arrest with a shockable rhythm as
opposed to asystole or PEA, as the outcomes of these rhythms are comparatively very poor.

The Resuscitation Academy mantra “everyone in VF survives” has been adopted by many EMS systems around the world
to emphasize that these patients can and do survive, and it’s up to us to save them.

Major advances have been made over the past 10 years but CPR and defibrillation are still the bedrock of resuscitation
science. The attributes of high-quality CPR were re-affirmed in the 2015 AHA ECC Guidelines.

 Ensuring adequate rate (100-120)

 Ensuring adequate depth (2 to 2.4” or 5 to 6 cm)
 Allowing full chest recoil (avoid leaning)
 Minimizing interruptions to chest compressions
 Avoiding excessive ventilations

Is CPR Before Defibrillation Dogmatic?

In the context of a witnessed arrest by a trained first responder or bystander who has an AED or manual defibrillator, the
importance of early defibrillation is irrefutable. We have been told repeatedly that early defibrillation saves lives.

I initially began my research under the assumption that providing 1.5 to 3 minutes of CPR before defibrillation provides
oxygen and nutrients to the heart therefore making defibrillation more likely to be successful. However, recent evidence
suggests that performing chest compressions while setting up the defibrillator and charging the capacitor may be
adequate.

A “CPR first” approach is rooted in evidence suggesting the existence of 3 time-sensitive phases of VF arrest.

1. Electrical phase (0-4 minutes)

2. Circulatory phase (5-10 minutes)
3. Metabolic Phase (> 10 minutes)

Researchers suggested that a period of CPR prior to defibrillation might confer a benefit during the so-called “circulatory
phase” of the cardiac arrest.

Evolution of American Heart Association Recommendations

Because it is rare for EMS to arrive on scene during the electrical phase, the 2005 AHA ECC Guidelines made this
recommendation:

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel, they may give about 5 cycles of CPR before
checking the ECG rhythm and attempting defibrillation (Class IIb). One cycle of CPR consists of 30 compressions and 2
breaths. When compressions are delivered at a rate of about 100 per minute, 5 cycles of CPR should take roughly 2
minutes (range: about 1½ to 3 minutes). This recommendation regarding CPR prior to attempted defibrillation is supported
by 2 clinical studies (LOE 2, LOE 3) of adult out-of-hospital VF SCA. In those studies when EMS call-to-arrival intervals
were 4 to 5 minutes or longer, victims who received 1½ to 3 minutes of CPR before defibrillation showed an increased
rate of initial resuscitation, survival to hospital discharge, and 1-year survival when compared with those who received
immediate defibrillation for VF SCA. One randomized study, however, found no benefit to CPR before defibrillation for
non-paramedic-witnessed SCA.

Fast forward 10 years to the 2015 Guidelines.

Observational clinical studies and mechanistic studies in animal models suggest that CPR under conditions of prolonged
untreated VF might help restore metabolic conditions of the heart favorable to defibrillation…others have suggested that
prolonged VF is energetically detrimental to the ischemic heart, justifying rapid defibrillation attempts regardless of the
duration of arrest.

Evidence summary

Five RCTs, 4 observational cohort studies, 3 meta-analyses, and 1 subgroup analysis of an RCT addressed the question
of CPR before defibrillation. The duration of CPR before defibrillation ranged from 90 to 180 seconds, with the control
group having a shorter CPR interval lasting only as long as the time required for defibrillator deployment, pad placement,
initial rhythm analysis, and AED charging. These studies showed that outcomes were not different when CPR was
provided for a period of up to 180 seconds before attempted defibrillation compared with rhythm analysis and attempted
defibrillation first for the various outcomes examined, ranging from 1-year survival with favorable neurologic outcome to
ROSC. Subgroup analysis suggested potential benefit from CPR before defibrillation in patients with prolonged EMS
response intervals (4 to 5 minutes or longer) and in EMS agencies with high baseline survival to hospital discharge, but
these findings conflict with other subset analyses. Accordingly, the current evidence suggests that for unmonitored
patients with cardiac arrest outside of the hospital and an initial rhythm of VF or pVT, there is no benefit from a period of
CPR of 90 to 180 seconds before attempted defibrillation.

Specifically, the ROC PRIMED trial concluded that:

Among patients who had an out-of-hospital cardiac arrest, we found no difference in the outcomes with a brief period, as
compared with a longer period, of EMS-administered CPR before the first analysis of cardiac rhythm.

The ROC Investigators subsequently found that EMS systems with a VF survival rate < 20% appeared to do better with an
“analyze first” strategy. Conversely, EMS systems with a VF survival rate > 20% appeared to do better with a “analyze
late” strategy.

Can the VF Waveform Determine the Likelihood of Successful Defibrillation?

Ventricular fibrillation sometimes begins as ventricular tachycardia, and if left untreated deteriorates into fine VF. Fine VF
predictably results in conversion to asystole or continued VF, but rarely to a perfusing rhythm.

Berg et al. performed a randomized, controlled trial using animals. After inducing VF in swine for 8 minutes, they were
randomly assigned to either immediate defibrillation, or defibrillation provided after 90 seconds of CPR. Nine out of 15
attained ROSC in the CPR first group, and zero out of 15 who were defibrillated first resulted in ROSC. Their conclusion?

Pre-countershock CPR can result in substantial physiologic benefits and superior response to initial defibrillation attempts
compared with immediate defibrillation in the setting of prolonged ventricular fibrillation.

Additionally, they determined there was a mathematical relationship between the VF waveform and chances of successful
defibrillation. The animals who received CPR first had a much higher median frequency, and a much higher rate of ROSC
than those that did not.

In the field, whether or not VF is “fine” or “coarse” is typically based on visual inspection of the waveform. What if there
was a way to accurately determine which patients would benefit from defibrillation and those that would not, thus
eliminating unnecessary pauses and ineffective shocks?

Callaway et al. and Eftestol et al. supported the theory that VF frequency and amplitude could be used to determine which
patients will respond to countershock.

Eftestol et al. concluded:

CPR done by professionals can improve the chance for ROSC and ultimate survival of patients with prolonged cardiac
arrest and significantly deteriorated myocardium. This study also indicates that CPR periods of 3 minutes might be better
for the myocardium than shorter periods. Finally, together with the studies showing rapid deterioration of the myocardium
in even a few seconds without CPR after a cardiac arrest, it gives the important message that periods without CPR (for
ECG analysis, defibrillation charging, pulse checks, intubation attempts, etc) should be kept to a minimum. This is
frequently not the case clinically.
As promising as this may have seemed, an article in Circulation by Freese et al. evaluated the theory of defibrillation
based on waveform analysis, and the results were disappointing.

Use of a waveform analysis algorithm to guide the initial treatment of out-of-hospital cardiac arrest patients presenting in
VF did not improve overall survival compared with a standard shock-first protocol. Further study is recommended to
examine the role of waveform analysis for the guided management of VF.

The Bottom Line

The totality of the evidence suggests that defibrillation as soon as practicable (with the caveat that high quality chest
compressions are performed while setting up the defibrillator) is equivalent to a prescribed interval of CPR prior to the first
shock in most instances.

EMS systems that measure the “patient’s side to first shock” interval know that it usually takes at least 1 minute to power
on the defibrillator, extend the cables, attach the pads, charge the capacitor, and deliver the shock. During that interval,
there’s no reason that the patient can’t receive continuous chest compressions.

One benefit to emphasizing a “shock as soon as possible” approach is that it’s the same for EMS-witnessed cardiac
arrest.

Alternatively, defibrillation can be delivered after the first 2-minute cycle. It seems likely that CPR quality plays a more
important role than the exact timing of the first shock.

References

Baker PW, Conway J, Cotton C, Ashby DT, Smyth J, Woodman RJ, Grantham H; Clinical Investigators. Defibrillation or
cardiopulmonary resuscitation first for patients with out-of-hospital cardiac arrests found by paramedics to be in ventricular
fibrillation? A randomised control trial. Resuscitation. 2008;79:424–431. doi: 10.1016/j.resuscitation.2008.07.017.

Bradley SM, Gabriel EE, Aufderheide TP, Barnes R, Christenson J, Davis DP, Stiell IG, Nichol G; Resuscitation
Outcomes Consortium Investigators. Survival increases with CPR by Emergency Medical Services before defibrillation of
out-of-hospital ventricular fibrillation or ventricular tachycardia: observations from the Resuscitation Outcomes
Consortium. Resuscitation. 2010;81:155–162. doi: 10.1016/j. resuscitation.2009.10.026.

Cobb LA, Fahrenbruch CE, Walsh TR, Copass MK, Olsufka M, Breskin M, Hallstrom AP. Influence of cardiopulmonary
resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA. 1999;281:1182–1188.

Freese J, Jorgenson D, Liu P et al. Waveform Analysis-Guided Treatment Versus a Standard Shock-First Protocol for the
Treatment of Out-of-Hospital Cardiac Arrest Presenting in Ventricular Fibrillation: Results of an International Randomized,
Controlled Trial. Circulation. 2013;128(9):995-1002. doi:10.1161/circulationaha.113.003273.

Gilmore C, Rea T, Becker L, Eisenberg M. Three-Phase Model of Cardiac Arrest: Time-Dependent Benefit of Bystander
Cardiopulmonary Resuscitation. The American Journal of Cardiology. 2006;98(4):497-499.
doi:10.1016/j.amjcard.2006.02.055.

Hayakawa M, Gando S, Okamoto H, Asai Y, Uegaki S, Makise H. Shortening of cardiopulmonary resuscitation time
before the defibrilla- tion worsens the outcome in out-of-hospital VF patients. Am J Emerg Med. 2009;27:470–474. doi:
10.1016/j.ajem.2008.

Huang Y, He Q, Yang LJ, Liu GJ, Jones A. Cardiopulmonary resuscitation (CPR) plus delayed defibrillation versus
immediate defibrillation for out-of-hospital cardiac arrest. Cochrane Database Syst Rev. 2014;9:CD009803. doi:
10.1002/14651858.CD009803.pub2.

Jacobs IG, Finn JC, Oxer HF, Jelinek GA. CPR before defibrillation in out-of-hospital cardiac arrest: a randomized
trial. Emerg Med Australas. 2005;17:39–45. doi: 10.1111/j.1742-6723.2005.00694.x.

Kleinman M, Brennan E, Goldberger Z et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation
Quality. Circulation. 2015;132(18 suppl 2):S414-S435. doi:10.1161/cir.0000000000000259.
Safety by design: effects of operating room floor marking on the
position of surgical devices to promote clean air flow compliance
and minimise infection risks.
de Korne DF1, van Wijngaarden JD, van Rooij J, Wauben LS, Hiddema UF, Klazinga NS.

Author information
Abstract

OBJECTIVE:

To evaluate the use of floor marking on the positioning of surgical devices within the clean air flow in an operating room (OR) to
minimise infection risk. Laminar flow clean air systems are important in preventing infection in ORs but, for optimal results,
surgical devices must be correctly positioned.

METHODS:

The authors evaluated floor marking in four ORs at an eye hospital using time series analysis. Through observations during 829
surgeries over a 20-month period, the positions of surgical devices were determined. Eight semistructured interviews with
surgical staff were conducted to assess user experiences and team dynamics.

RESULTS:

Before marking, the instrument table was positioned completely within the laminar flow in only 6.1% of the cases. This increased
to 36.1% and finally 53.8%. Mayo stands were increasingly positioned within the laminar flow: from 74.2% to 84.7%. The
surgical lamp decreasingly obstructed flow: from 41.8% to 28.7%. At T3 (20 months), however, in 48.6% of the applicable cases
the lamp was positioned in the flow again. Discussions and site visits between airside operators and surgical staff resulted in
increasing awareness of specific risk areas in the OR.

CONCLUSIONS:

OR floor markings facilitated and stimulated safety awareness and resulted in significantly increased compliance with the
positioning of surgical devices in the clean air flow. Safety and quality approaches in hospital care, therefore, should include a
human factors approach that focuses on system design in addition to teaching clinical and non-technical skills.