Download Chest Compressions Cause Recurrence of Ventricular Fibrillation

Chest Compressions Cause Recurrence of Ventricular
Fibrillation After the First Successful Conversion by
Defibrillation in Out-of-Hospital Cardiac Arrest
Jocelyn Berdowski, MSc, MSE; Jan G.P. Tijssen, PhD; Rudolph W. Koster, MD, PhD
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Background—Unlike Resuscitation Guidelines (GL) 2000, GL2005 advise resuming cardiopulmonary resuscitation (CPR)
immediately after defibrillation. We hypothesized that immediate CPR resumption promotes earlier recurrence of
ventricular fibrillation (VF).
Methods and Results—This study used data of a prospective per-patient randomized controlled trial. Automated external
defibrillators used by first responders were randomized to either (1) perform postshock analysis and prompt rescuers to
a pulse check (GL2000), or (2) resume CPR immediately after defibrillation (GL2005). Continuous recordings of ECG
and impedance signals were collected from all patients with an out-of-hospital cardiac arrest to whom a randomized
automated external defibrillator was applied. We included patients with VF as their initial rhythm in whom CPR onset
could be determined from the ECG and impedance signals. Time intervals are presented as median (Q1-to-Q3). Of 361
patients, 136 met the inclusion criteria: 68 were randomly assigned to GL2000 and 68 to GL2005. Rescuers resumed
CPR 30 (21-to-39) and 8 (7-to-9) seconds, respectively, after the first shock that successfully terminated VF (P⬍0.001);
VF recurred after 40 (21-to-76) and 21 (10-to-80) seconds, respectively (P⫽0.001). The time interval between start of
CPR and VF recurrence was 6 (0-to-67) and 8 (3-to-61) seconds, respectively (P⫽0.88). The hazard ratio for VF
recurrence in the first 2 seconds of CPR was 15.5 (95% confidence interval, 5.63 to 57.7) compared with before CPR
resumption. After more than 8 seconds of CPR, the hazard of VF recurrence was similar to before CPR resumption.
Conclusions—Early CPR resumption after defibrillation causes early VF recurrence.
Clinical Trial Registration— clinicaltrials.gov Identifier: ISRCTN72257677.
(Circ Arrhythm Electrophysiol. 2010;3:72-78.)
Key Words: cardiopulmonary resuscitation 䡲 defibrillation 䡲 electrocardiography 䡲 fibrillation 䡲 resuscitation
䡲 heart arrest
V
entricular fibrillation (VF) is common in patients with
out-of-hospital cardiac arrest, varying from 18% to 63%
of all cases.1,2 About half of these patients have VF recurrence within the first 2 minutes after successful VF conversion,3 and 74% of the patients have VF recurrence sometime
during prehospital care.4 The number of VF recurrences
during the resuscitation period is negatively associated with
survival.5
The purpose of our study was to investigate the relation
between CPR resumption after the first successful VF conversion and the recurrence of VF. We hypothesize that (1)
chest compressions stimulate recurrence of VF and (2)
patients who are resuscitated according to the Resuscitation
Guidelines 2005 and receive immediate CPR after a shock
refibrillate earlier in comparison to patients who are resuscitated according to the Resuscitation Guidelines 2000 and
receive delayed CPR.
Clinical Perspective on p 78
A recent animal study found a clear relation between
initiation of chest compressions and the recurrence of VF.6
The current guidelines for cardiopulmonary resuscitation
(CPR) issued in 2005 advise immediately resuming cardiopulmonary resuscitation for 2 consecutive minutes after a
defibrillation shock to minimize CPR interruption.7,8 Guidelines for CPR issued in 2000 advised performing postshock
rhythm analysis and checking for signs of life, thus delaying
resumption of CPR for about half a minute.9,10
Methods
Setting
The Amsterdam Resuscitation Studies (ARREST) research group
prospectively collects data of all resuscitation efforts in the Dutch
province North Holland, covering approximately 2671 km2 and a
population of 2.4 million people. The area includes both urban and
rural communities. In case of a medical emergency, people dial the
national emergency number, where the operator transfers the call to
the regional ambulance dispatch center. When suspecting a cardiac
Received May 23, 2009; accepted December 16, 2009.
From the Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Correspondence to Jocelyn Berdowski, MSc, MSE, Department of Cardiology, F3-241, Academic Medical Center–University of Amsterdam,
Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. E-mail [email protected]
© 2010 American Heart Association, Inc.
Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org
72
DOI: 10.1161/CIRCEP.109.902114
Berdowski et al
Table 1.
Chest Compressions Cause Refibrillation
73
AED Settings for Randomization
Resuscitation
Guidelines 2000
Resuscitation
Guidelines 2005
Preshock CPR time, s
OFF
15
Postshock rhythm analysis
ON
OFF
Pulse check, s
10
OFF
Time interval shock, CPR prompt, s
32
7
CPR time, shockable rhythm, s
Shock sequence
60
120
Maximum 3 stacked
shocks
1 single shock
200–200–360
200, then 360
Energy sequence, J
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arrest, the ambulance dispatcher sends out 2 ambulances of a single
tier. Also, the dispatcher sends out a first responder—firefighters,
policemen, or a general practitioner, equipped with an automated
external defibrillator (AED) (LIFEPAK 500/LIFEPAK 1000, Physio
Control, Redmond, Wash). All ambulance personnel are equipped
with a manual defibrillator (LIFEPAK 12, Physio Control) and
qualified to perform Advanced Life Support (ALS) according to the
guidelines of the European Resuscitation Council.11
The ARREST 8 trial (http://www.controlled-trials.com; trial number ISRCTN72257677) investigates whether maximizing CPR during AED usage improves outcome. All first-responder AEDs are
individually randomized to 2 modes of resuscitation therapy (Table 1).
In the first mode, the AED is programmed according to Guidelines
2000, in which the AED analyzes outcome after a shock and prompts
to check for a pulse and to give CPR for 1 minute until the next
rhythm analysis. In the second mode, the AED is programmed
according to Guidelines 2005, in which the AED prompts to
immediately start CPR and continue for 2 minutes after a single
shock. In addition, these AEDs prompt for 15 seconds of preshock
CPR. AEDs are reprogrammed after each application of the device
according to a prespecified randomization list. Therefore, AED users
are blinded to the AED protocol until the AED is powered on but are
not blinded during AED usage.
The primary outcome of ARREST 8 is survival until admission to
a hospital. The Medical Ethics Committee of the Academic Medical
Center in Amsterdam approved this study and gave a waiver for the
requirement of informed consent before random assignment; all
surviving patients gave written consent for usage of the data. The
ARREST 8 trial started June 7, 2006, and recruitment is currently
ongoing. The planned enrollment is 198 patients with VF as initial
rhythm in each arm of the study.
Data Collection
All data concerning the resuscitation were prospectively collected
according to the Utstein recommendations.12 Study personnel visited the
site of the AED shortly after the cardiac arrest and downloaded the
electronic data recorded by the AED. Paramedics sent the electronic
data recorded by their defibrillator to the data center by modem
immediately after the resuscitation effort. These data were merged,
stored, and analyzed with dedicated software (Code Stat Reviewer
7.0, Physio Control).
Design of Current Analysis
The current analysis focused on the mechanism and timing of VF
recurrence in relation to CPR and uses data from the ARREST 8 trial
available at September 1, 2008. Patients were included in this
analysis if their initial rhythm was VF. We excluded patients to
whom an incorrectly programmed AED had been attached, patients
to whom an onsite AED had been attached before the AED of the
first responder, patients with missing or incomplete ECG recordings,
and patients who were dead on arrival. A patient was defined as dead
on arrival if clinical signs of death (ie, rigor mortis, marbling, or livor
mortis) were obvious. The moment of the first successful VF
conversion was defined as termination of VF for 5 seconds after the
Figure 1. Continuous ECG recording before and after filtering.
A, Continuous ECG recording before filtering. B, Continuous
ECG recording after filtering. One second after CPR resumption,
a narrow QRS complex is visible. One second later, a ventricular
premature complex initiates recurrence of VF.
shock irrespective of the subsequent rhythm and was read from the
AED ECG.13 The start of CPR after the shock was visible through
the impedance signal of the recording.14 If the start of CPR after the
shock could not be determined from the impedance signal recorded
by the AED, the patient was also excluded from the analysis.
The electric outcome of the study was recurrence of VF after the
first successful VF conversion. Two researchers individually annotated the moment of VF recurrence after the first successful VF
conversion. The annotations by the 2 researchers were considered to
be in agreement if the difference was less than 1 second, which was
the case in 94 cases (96%). In cases in which disagreement was more
than 1 second, the 2 researchers annotated the time of VF recurrence
by consensus. This annotation was made on the basis of the ECG of
the AED or the ECG of the manual defibrillator. We eliminated CPR
artifacts from the ECG by using filtering software (Physio Control),15 which allowed determination of VF recurrence onset during
CPR (Figure 1). We merged the AED recordings with those of the
manual defibrillator, synchronizing the clock times of both defibrillators. As shown in Figure 2, we measured 4 time intervals: from the
first VF conversion to the start of CPR; from the first VF conversion
to VF recurrence; from the start of CPR to VF recurrence; and from
VF recurrence to the second effective conversion—this represents
the time the patient was in VF after VF recurrence. The percentage
of time CPR had been given during AED connection was calculated
by dividing the time that CPR was given by the total time the patient
was connected to the AED.
The rhythm after VF conversion but before the start of CPR and
the rhythm before VF recurrence were analyzed during the 5 seconds
preceding CPR initiation and VF recurrence, respectively. Rhythms
were categorized as asystole or as an organized rhythm, which was
defined as at least 2 QRS complexes within 5 seconds.16
Statistical Analysis
All time intervals were expressed as median (Q1-to-Q3). Continuous
variables of patients treated with a delayed-CPR prompt and the
immediate-CPR prompt were compared by means of the Wilcoxon
rank sum test. Binary variables were compared between treatment
groups by ␹2 tests. The cumulative incidence in VF recurrence in
both treatment groups was assessed with the Kaplan-Meier method.
We used the Gehan-Breslow test to compare treatment groups
regarding time to onset of VF recurrence after successful VF
conversion. We used the Kolmogorov-Smirnov test to compare
treatment groups regarding time to onset of VF recurrence in regard
to CPR resumption. The instantaneous hazard of VF recurrence in
the first minute after the first VF conversion was calculated by
dividing the total amount of VF recurrences by the person-minutes at
risk. To examine whether the moment of VF recurrence was
associated with the start of chest compressions over time, we
separately calculated the hazard for VF recurrence for the first 2
seconds of CPR resumption, 3 to 5 seconds, 6 to 8 seconds, 9 to 30
seconds, 60 to 120 seconds, and ⬎120 seconds after CPR resump-
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Circ Arrhythm Electrophysiol
February 2010
Figure 2. Annotations and measured time intervals. Upper figure shows the annotations of an
AED programmed according to the delayed-CPR
prompt (Guidelines 2000) with continuous ECG
recording. Lower figure shows the annotations of
an AED programmed according to the immediateCPR prompt (Guidelines 2005) with continuous
ECG recording. Only the moment of “start CPR”
and “VF recurrence” was annotated manually; all
other annotations were registered automatically by
the AED. We measured the following time intervals: first effective VF conversion to start of CPR;
first effective VF conversion to VF recurrence; start
of CPR to VF recurrence; and VF recurrence to
second effective VF conversion.
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tion. Corresponding confidence intervals were calculated with the
Poisson distribution regression.
Analyses were based on the intention-to-treat principle; the patient
was analyzed according to the programming of the AED regardless
of whether the rescuer followed the resuscitation guideline prompted
by the AED. Probability values were 2-sided and were based on the
standard null hypothesis of no treatment difference. All analyses
were performed with the use of SPSS software for Macintosh,
version 16.0. All authors reviewed the manuscript and vouch for the
accuracy and completeness of the data.
Results
Inclusion and Administration of CPR
During 27 months, 410 patients were connected to a randomized AED: The AEDs were programmed to resuscitation
Guidelines 2000, prompting delayed CPR after a shock for
216 patients, and to resuscitation Guidelines 2005, prompting
immediate CPR after a shock for 194 patients. Figure 3 shows
the enrollment of patients for the current analysis. None of the
patients had been attached to an AED by bystanders before
the attachment of a first responder AED that was randomized
for the purpose of our study. A total of 136 patients met the
criteria for inclusion. There was a significant difference
between the 2 study groups in the percentage of time CPR had
been given and the rhythm before CPR (Table 2). Rescuers
resumed CPR after the first successful VF conversion a
median time of 30 (Q1, 21; Q3, 39) seconds in patients with
a delayed-CPR prompt and of 8 (Q1, 7; Q3, 9) seconds in
cases with an immediate-CPR prompt (P⬍0.001). None of
the included patients had return of spontaneous circulation
immediately after the first successful VF conversion. In all
patients, CPR was resumed within 1 minute after the first
successful VF conversion.
Recurrence of VF
VF recurred in 49 of 68 patients (72%) with a delayed-CPR
prompt and in 49 of 68 patients (72%) with an immediate-
Figure 3. Study subjects enrollment. Patients in
whom resuscitation was attempted and who had
VF as initial rhythm were included in the study.
Berdowski et al
Chest Compressions Cause Refibrillation
75
Table 2. Baseline and Operational Characteristics of the Study Subjects According to
Treatment Group
Delayed-CPR Prompt
(n⫽68)
Immediate-CPR Prompt
(n⫽68)
P
64 (54 to 73)
67 (52 to 76)
0.56
Male sex, n (%)
48 (71)
50 (74)
0.70
Caucasian race, n (%)†
59 (87)
58 (85)
0.81
Witnessed collapse, n (%)
58 (85)
59 (87)
0.81
Bystander CPR before AED
attachment by first responder, n (%)
39 (57)
45 (66)
0.56
Collapse at home, n (%)
52 (76)
48 (71)
0.34
AED connection time, min*
3.3 (2.2 to 4.6)
2.7 (1.9 to 4.6)
0.21
Percentage of time CPR was given during
AED connection*
44 (34 to 55)
64 (53 to 71)
⬍0.001
Asystole
33 (49)
42 (62)
Organized rhythm
24 (35)
24 (35)
VF
11 (16)
2 (3)
Variable
Demographic characteristics
Age, y*
Resuscitation characteristics
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Rhythm before CPR resumption, n (%)
0.03
*Expressed as median (Q1-to-Q3).
†Race was determined by the rescuers onsite.
CPR prompt. The cumulative incidence of VF recurrence
during the first 60 seconds after the first successful VF
conversion was substantially lower among patients with
delayed-CPR prompt (GL2000) than among patients with an
immediate-CPR prompt (GL2005) (Figure 4). The GehanBreslow test was statistically significant (P⫽0.001). There
was no appreciable difference in cumulative incidence after
60 seconds.
VF recurred 6 (Q1, 0; Q3, 67) seconds after CPR initiation
in patients with a delayed-CPR prompt (GL2000) and 8 (Q1,
3; Q3, 61) seconds after CPR initiation in patients with an
immediate-CPR prompt (GL2005; Kolmogorov-Smirnov
P⫽0.046; Figure 5). VF was terminated by the second
successful VF conversion after a median 98 (Q1, 62; Q3, 201)
seconds among patients with a delayed-CPR prompt
(GL2000) and after a median 141 (Q1, 82; Q3, 245) seconds
among patients with an immediate-CPR prompt (GL2005;
P⫽0.07).
The instantaneous hazard of VF recurrence per personminute was low (0.30) between the first effective shock and
the start of CPR, (Figure 6) and jumped to 4.68 in the first 2
seconds of CPR (hazard ratio [HR], 15.5; 95% confidence
interval [CI], 5.63 to 57.7). The hazard decreased over time
but remained elevated, with HRs of 8.1 (95% CI, 1.2 to 49.8)
and 6.9 (95% CI, 1.03 to 43.5) in the next 3-second intervals,
respectively. After 8 seconds, the hazard for VF recurrence
was once again low (0.41).
Thirteen of the 136 included patients showed VF recurrence before CPR resumption. Of the remaining 123 patients,
48 had an organized rhythm before CPR resumption and 75
had asystole before CPR resumption (Table 2). In total, 98
patients had VF recurrence; in 85 of these, VF recurred after
resumption of CPR. Of the 48 patients in an organized rhythm
at the moment of CPR resumption, 33 (69%) had VF
recurrence during CPR; of the 75 patients in asystole when
CPR resumed, 52 (69%) had VF recurrence (P⫽0.95). The
Figure 4. Kaplan-Meier curve of refibrillation incidence for the
time interval between the first effective defibrillation shock and
the moment of VF recurrence. The VF recurrence rate is clearly
larger in the first 25 seconds after shock in the immediate-CPR
prompt group.
Figure 5. Cumulative time interval between resumption of CPR
and frequency of refibrillation for all patients with VF recurrence.
Chest compressions are resumed at the time interval of 0 seconds on the x-axis. All refibrillations before this time point are
spontaneous and carry a negative time value. After 120 seconds, the curve slowly and gradually increases. The last patient
had VF recurrence at 17 minutes after the start of CPR, at
which time the cumulative frequency reaches 1.
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Circ Arrhythm Electrophysiol
February 2010
Figure 6. Instantaneous hazard of VF recurrence per personminute before CPR and during CPR, divided into 6 groups of
CPR duration.
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increase in the hazard of refibrillation in the first few seconds
of CPR did not differ significantly between patients with an
asystole before CPR resumption and patients with an organized rhythm before CPR resumption (HR, 18.0; 95% CI, 5.6
to 57.7 and HR, 11.5; 95% CI, 6.4 to 36.6, respectively).
There was no significant difference in the rhythm before VF
recurrence between the delayed CPR and immediate CPR
groups; 32 of the 49 patients (65%) with a delayed-CPR
prompt and 37 of the 49 patients (76%) with an immediateCPR prompt had an organized rhythm before the recurrence
of VF (␹2, 0.78; P⫽0.38). The remaining patients immediately refibrillated after a single ventricular premature complex. In total, 69 (70%) of the 98 patients who refibrillated did
so after an organized rhythm.
Discussion
The main finding of our study is that VF commonly recurs
within the first few seconds after CPR is initiated after
successful VF conversion. The hazard of VF recurrence was
15.5 times higher in the first 2 seconds of CPR relative to the
time before CPR initiation. Moreover, the timing of VF
recurrence relative to the start of CPR did not depend on the
timing of the CPR prompt (delayed or immediate); if rescuers
started CPR earlier, the patient had earlier VF recurrence as
well. To our knowledge, our study is the first to demonstrate
the temporal relation between the onset of chest compressions
and the onset of VF recurrence in patients with out-ofhospital cardiac arrest. These findings indicate a causal
relationship between the onset of manual chest compressions
and the recurrence of VF after the first successful VF
conversion.
An earlier retrospective observational study showed that
VF recurred in 16 of 32 patients (50%) while chest compressions were administered.17 The authors concluded that the
recurrence of VF during a postshock organized rhythm is
most commonly spontaneous and unrelated to chest compressions. However, the authors did not give a precise definition
of when chest compressions were associated with VF recurrence. In contrast to their findings, we found that VF is related
to chest compressions. By detailed analysis of timing, we
documented a burst of CPR-associated VF recurrence in the
first 2 seconds after CPR resumes.
Similar to our findings, a recent animal study showed that
VF recurred within the first 2 chest compressions in 4 of 8
swine. The authors showed that the electric stimulation of the
ventricles by chest compressions created a long-short activation sequence leading to VF recurrence.6 The long-short
activation sequence is a well-recognized mechanism by
which VF may be initiated.18 Similarly, low-energy impact to
the chest wall (commotio cordis) has been shown to stimulate
the ventricle during the vulnerable period and cause arrhythmias as well.19
Mechanical stimuli can exert delayed afterdepolarizationlike effects mediated by stretch. Mechanoelectric feedback,
the phenomenon by which electrophysiological changes of
the heart are brought about by mechanical changes, is a
potential mechanism explaining why stretch could contribute
to recurrence of VF.20 Stretch during diastole usually leads to
depolarization, resembling delayed afterdepolarization,
which may reach threshold and initiate a ventricular premature beat. A completely different mechanism that could play
a role in recurrence of VF is coronary reperfusion from chest
compressions. Reperfusion arrhythmias are a well-known
phenomenon after restoration of coronary blood flow during
reperfusion therapy in acute myocardial infarction.21 These
arrhythmias have been described as premature beats or (slow)
ventricular tachycardia, but rarely as VF.22,23 Furthermore, it
has been shown in animal experiments that it takes at least 2
to 3 chest compressions for the coronary perfusion to rise
substantially.24 Thus, reperfusion probably does not explain
the sudden strong increase in hazard of VF recurrence in the
first 2 seconds of CPR. Hence, we believe that a mechanoelectric mechanism is the most likely explanation of the
sudden increase in instantaneous hazard of VF recurrence.
Consequences for the Patient
This study demonstrates that the immediate resumption of
CPR in accordance with resuscitation Guidelines 2005, while
significantly decreasing postshock pause and increasing the
percentage of time CPR had been administered, also causes
earlier VF recurrence and a trend toward longer-lasting VF. It
is not yet clear how this finding affects patient outcome; the
benefit of increased CPR time and a reduced postshock pause
is well documented, but the effect of longer-lasting VF is not
clearly established. Preshock chest compressions for prolonged VF can “coarsen” the VF waveform and improve the
rate of successful resuscitation.25 Experimental studies have
shown that outcome is improved by limiting the preshock
pause26,27 and removing the postshock pause associated with
pulse or rhythm checks.28 Some authors have argued that
even interruptions for rescue breaths are detrimental for
survival rates.29,30
From a metabolic point of view, prolonged VF is more
energy-consuming than asystole. During VF, each myofibril
is activated and contracts at a rate of up to 3 to 5 depolarizations per second, depleting ATP and glycogen at a high
rate, and increasing glucose-6-phosphate and lactate in the
myocardium.31 This drop in energy availability causes the
heart to fatigue, resulting in little contractile force when an
organized rhythm returns. Administration of epinephrine
during VF, which is advised every 3 minutes by resuscitation
Berdowski et al
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ALS Guidelines, increases myocardial adenosine 3⬘,5⬘-cyclic
monophosphate concentrations and induces an even higher
oxygen consumption.32 Along these lines, a recent study
showed that the duration of VF during resuscitation efforts is
inversely correlated to the probability of return of spontaneous circulation.33 We hypothesize that the high oxygen
consumption of earlier VF recurrence partially defeats the
increase in CPR fraction. This could explain why the application of resuscitation Guidelines 2005 has improved survival
in only 1 of 2 observational studies34,35 and not in a randomized clinical trial.36
More research is needed to investigate the effect of early
VF recurrence during CPR on survival outcome. For example, new methods are being developed to identify a shockable
rhythm without interrupting chest compressions.37–39 With
these techniques, the metabolic downside of VF can be
avoided if the patient is defibrillated shortly after VF recurrence instead of completing the currently recommended
2-minute CPR cycle.
Limitations
Most of the VF recurrences occurred during CPR. The
movement artifacts in the ECG caused by CPR make it more
difficult to precisely annotate the moment of VF recurrence.
However, in 96% of cases, the difference between the
observations of the 2 researchers was less than 1 second.
Therefore, the filtering software cleared most uncertainty
about the exact moment of VF recurrence.
Second, we could not identify the exact underlying mechanism causing VF recurrence. Although motion artifacts were
sufficiently filtered to determine the onset of VF, the filtering
technique did not allow analysis of a long-short sequence
during CPR in all analyzed ECGs.
Third, we only evaluated the moment of the first recurrence
of VF. It must be further investigated whether our findings
are applicable to subsequent VF recurrences as well.
Conclusion
In out-of-hospital cardiac arrest, when CPR is reinitiated after
defibrillation, the heart often refibrillates within the first few
chest compressions, suggesting that chest compressions are
conducive to VF recurrence in this setting. Early resumption
of CPR after a defibrillation shock, as advised by the
resuscitation Guidelines 2005, is associated with earlier
recurrence of VF and possibly longer lasting VF. Further
research is needed to determine whether the possible metabolic negative effect of VF recurrence defeats the perfusion
benefit from early CPR resumption.
Acknowledgments
We are greatly indebted to the Amsterdam, Amstelveen, and Haarlemmermeer Fire Brigade, Kennemerland and Texel police, Schiphol
Airport, and Meditaxi for their contributions to the data collection.
We thank Michiel Hulleman, Esther Landman, and Renate van der
Meer for excellent data management and secretarial assistance; Nan
van Geloven and Aelko Zwinderman for contribution to the statistical analysis; and Isabelle Banville and Liesbeth van Zyll de Jong
for contribution to the ECG analysis. We thank all the students of the
University of Amsterdam who helped collecting the data and
randomized the AEDs onsite.
Chest Compressions Cause Refibrillation
77
Sources of Funding
This study was supported by a grant from Physio Control Inc,
Redmond Wash.
Disclosures
None.
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CLINICAL PERSPECTIVE
The current guidelines (GL) for cardiopulmonary resuscitation issued in 2005 advise to immediately resume cardiopulmonary resuscitation (CPR) after a defibrillation shock by abandoning postshock rhythm analysis and checking for signs
of life to minimize CPR interruption. This shortens the delay to CPR resumption by about half a minute. At the same time,
the CPR cycle is extended from 1 to 2 minutes. This study analyzed the relation between CPR resumption, ventricular
fibrillation (VF) recurrence, and VF duration after a first successful shock during randomized treatment with resuscitation
GL2000 or GL2005. Our study demonstrated a close relation between initiation of chest compressions and recurrence of
VF. In the first 2 seconds of CPR resumption, the hazard of VF recurrence was 15 times larger than before the start of CPR,
regardless of the preceding rhythm or guideline used. The hazard remained increased during the first 8 seconds of CPR.
VF recurred in 72% of cases in both groups. Because of earlier resumption and longer duration of CPR, the patient treated
with GL2005 had VF recurrence significantly sooner and stayed in VF longer as well—a median of 40 seconds in the first
CPR cycle. From a metabolic point of view, prolonged VF is more energy-consuming than asystole. This could possibly
explain why the application of GL2005 did not show improved survival in all published literature. Further research is
needed to determine whether prolonged VF recurrence during CPR influences survival.
Chest Compressions Cause Recurrence of Ventricular Fibrillation After the First
Successful Conversion by Defibrillation in Out-of-Hospital Cardiac Arrest
Jocelyn Berdowski, Jan G.P. Tijssen and Rudolph W. Koster
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Circ Arrhythm Electrophysiol. 2010;3:72-78; originally published online December 30, 2009;
doi: 10.1161/CIRCEP.109.902114
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