El valor de las
compresiones cardíacas durante el RCP
Desde que en 1960 Kouwenhoven, Jude y Knickerbocker
propusieron en la revista JAMA los masajes cardíacos para mantener la circulación de los pacientes en paro cardíaco, ésto se ha adoptado en forma generalizada. Poco tiempo después
la ventilación externa se sumó a las compresiones para dar soporte vital básico. Desde entonces hubo muy pocos cambios en la realización de RCP.
En los últimos años trabajos con animales (cerdos) han aportado algunos conceptos: A) la interrupción de las compresiones
torácicas resulta en disminución de la perfusión coronaria durante la RCP y B) el aumento de la frecuencia de las ventilaciones con presión positiva disminuye la tasa de sobrevida
(por la interrupción de las compresiones y por la disminución del retorno venoso provocado por el aumento de la presión intratorácica)
Estos datos hicieron hipotetizar que la realización de compresiones solas mejorarían la sobrevida de los pacientes con
ataques cardíacos.
En 2 estudios recientemente publicados en NEJM (29 de Julio 2010
http://www.nejm.org/) se ha valorizado el papel de las compresiones cardíacas durante las maniobras de RCP por sobre las ventilaciones de rescate. Ambos estudios (uno sueco y otro multicéntrico USA/UK) demostraron que no
hay diferencias en la sobrevida entre los pacientes que recibieron RCP Standard (con ventilaciones de rescate) y aquellos que recibieron sólo compresiones torácicas.
Compression-Only CPR or Standard CPR in
Out-of-Hospital Cardiac Arrest
Leif Svensson, M.D., Ph.D., Katarina Bohm, R.N., Ph.D., Maaret Castrèn, M.D., Ph.D., Hans Pettersson, Ph.D.,
Lars Engerström, M.D., Johan Herlitz, M.D., Ph.D., and Mårten Rosenqvist, M.D., Ph.D.
BACKGROUND
Emergency medical dispatchers give
instructions on how to perform cardiopulmonary
resuscitation (CPR) over the telephone to
callers requesting help for a patient
with suspected cardiac arrest, before the
arrival of emergency medical services (EMS)
personnel. A previous study indicated that
instructions to perform CPR consisting
of only chest compression result in a
treatment efficacy that is similar or even superior
to that associated with instructions given
to perform standard CPR, which
consists of both compression and
ventilation. That study, however, was not powered
to assess a possible difference in survival.
The aim of this prospective, randomized
study was to evaluate the possible
superiority of compression-only CPR over
standard CPR with respect to
survival.
METHODS
Patients with suspected, witnessed,
out-of-hospital cardiac arrest were randomly assigned
to undergo either compression-only CPR or
standard CPR. The primary end
point was 30-day survival.
RESULTS
Data for the primary analysis were collected
from February 2005 through January
2009 for a total of 1276 patients. Of these,
620 patients had been assigned to receive
compression-only CPR and 656 patients had
been assigned to receive standard CPR.
The rate of 30-day survival was similar in
the two groups: 8.7% (54 of 620 patients)
in the group receiving compression-only CPR
and 7.0% (46 of 656 patients) in the
group receiving standard CPR (absolute
difference for compression-only vs. standard
CPR, 1.7 percentage points; 95% confidence
interval, −1.2 to 4.6; P = 0.29).
CONCLUSIONS
This prospective, randomized study showed no
significant difference with respect
to survival at 30 days between instructions
given by an emergency medical dispatcher,
before the arrival of EMS personnel, for
compression-only CPR and instructions
for standard CPR in patients with suspected,
witnessed, out-of-hospital cardiac arrest.
(Funded by the Swedish Heart–Lung Foundation
and others; Karolinska Clinical
Trial Registration number, CT20080012.)
CPR with Chest Compression Alone or with Rescue
Breathing
Thomas D. Rea, M.D., Carol Fahrenbruch, M.S.P.H., Linda Culley, B.A., Rachael T. Donohoe, Ph.D., Cindy
Hambly, E.M.T., Jennifer Innes, B.A., Megan Bloomingdale, E.M.T., Cleo Subido, Steven Romines, M.S.P.H., and Mickey S. Eisenberg, M.D., Ph.D.
Background
The role of rescue breathing in
cardiopulmonary resuscitation (CPR) performed by
a layperson is uncertain. We hypothesized
that the dispatcher instructions to bystanders
to provide chest compression alone would
result in improved survival as
compared with instructions to provide chest
compression plus rescue breathing.
Methods
We conducted a multicenter, randomized trial
of dispatcher instructions to bystanders
for performing CPR. The patients were
persons 18 years of age or older with out-ofhospital
cardiac arrest for whom dispatchers
initiated CPR instruction to bystanders.
Patients were randomly assigned to receive
chest compression alone or chest compression
plus rescue breathing. The primary outcome
was survival to hospital discharge.
Secondary outcomes included a favorable
neurologic outcome at discharge.
Results
Of the 1941 patients who met the inclusion
criteria, 981 were randomly assigned to
receive chest compression alone and 960 to
receive chest compression plus rescue
breathing. We observed no significant
difference between the two groups in the
proportion of patients who survived to
hospital discharge (12.5% with chest compression
alone and 11.0% with chest compression plus
rescue breathing, P = 0.31)
or in the proportion who survived with a
favorable neurologic outcome in the two
sites that assessed this secondary outcome
(14.4% and 11.5%, respectively; P = 0.13).
Prespecified subgroup analyses showed a
trend toward a higher proportion of patients
surviving to hospital discharge with chest
compression alone as compared
with chest compression plus rescue breathing
for patients with a cardiac cause of
arrest (15.5% vs. 12.3%, P = 0.09) and for
those with shockable rhythms (31.9% vs.
25.7%, P = 0.09).
Conclusions
Dispatcher instruction consisting of chest
compression alone did not increase the
survival rate overall, although there was a
trend toward better outcomes in key clinical
subgroups. The results support a strategy
for CPR performed by laypersons that
emphasizes chest compression and minimizes
the role of rescue breathing. (Funded
in part by the Laerdal Foundation for Acute
Medicine and the Medic One Foundation;
ClinicalTrials.gov number, NCT00219687.)
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