Kylie and Russell Cox were slated to get married when a guest collapsed and she gave the man mouth-to-mouth CPR in a purported heart attack, reported the Daily Mirror.

Cox managed to keep the man alive with CPR with the help of an uncle and a bridesmaid. An ambulance was called and she went with her new husband to the hospital with the man.

He is expected to make a full recovery.

“Our friend asked me for a dance, but while we were on the dance floor, he fell faint. I turned round to give him a chair and he collapsed,” said Cox, a staff nurse from Par, Cornwall, according to the tabloid.

She continued: “Me and Russell spent the first night of our marriage at the hospital, because we didn’t know whether our friend was going to live or die. The doctors told us it was a miracle he survived.”

In 2010, a study that mouth-to-mouth CPR is about as effective as the hands-only chest-pumping method.

The modern version CPR, which includes both chest-pumping and breathing, has been around for a half a century. The New England Journal of Medicine said that chest-pumping is more important.

“Eliminating mouth-to-mouth from CPR may make a layperson less reticent to act and if they act, they can save a life,” said Dr. Thomas Rea, the leader of the study, at the time. “Chest compression alone is simpler and intuitively easier.”

“It didn’t seem heroic to me, a situation just presented itself to me and I had to go help,” Trevor said. “It’s not hard to help people when you know what to do.”The identity of the man Trevor helped is not known at this time, nor is his current status.

Performing CPR was something that Trevor had just been trained to do a little over two weeks before at an Athletes Saving Athletes program at his school. He had even taken part in a CPR demonstration video.

Athletes Saving Athletes was created by Advocates for Injured Athletes, an organization co-founded by local resident Beth Mallon and her son Tommy after Tommy suffered a life-threatening neck fracture in 2009 while playing lacrosse at Santa Fe Christian School.

Student athletes are nominated to attend the day-long program to learn how they can help save a life in the event of head and neck injuries, sudden cardiac arrest, heat illness, diabetes and asthma.

“I just started sobbing when I heard, absolutely sobbing,” Mallon said of Trevor’s actions. “It’s coming up on the four -year anniversary of Tommy’s accident and to have the program actually bring a direct result, to know one of the athletes was able to recognize the situation and step up and intervene, that’s the whole purpose of the program. It shows it works.”

The program started in March 2012 and has trained over 1,000 athletes across San Diego County.

“It’s been so much hard work and it was all worth it in that one minute,” Mallon said

Trevor, the co-captain of the Cathedral Catholic tennis team, was selected to participate in Athletes Saving Athletes by his coach. The training session was held on March 18.

“I was going in pretty cold, I didn’t know a lot of what they taught me, especially I didn’t know much about cardiac arrest,” Trevor said.

That Wednesday just a couple weeks later, Trevor and his mom were going to get a post-tennis practice snack at El Pollo Loco in the Highlands. As they were leaving, his mom pointed out that a man appeared to be in trouble.

“She said, ‘That doesn’t look good’ and I looked over to see a man laying on the ground with his arms sprayed across the asphalt and a woman panicking on a cell phone, doing CPR with one hand,” Trevor said. “I recognized from my training that one-handed CPR wouldn’t be effective.”

Trevor got out of the car and went over to tell the woman he could perform CPR. He found that the man was blue in the face, was not responsive and he couldn’t get a pulse.

Trevor began compressions.

“After about 30 seconds he made a gasping, gurgling noise so I thought I must be doing something right so I continued compressions,” Trevor said.

He kept doing compressions for what he said felt like a long time but was probably only about three minutes until the paramedics arrived, one bystander honking the horn of their car to alert the ambulance of their location.

After the paramedics treated the man and had loaded him into the ambulance, a few of them came over to congratulate and thank Trevor for his actions. One told him that he can usually tell who is going to make it and who is not and it looked like this man would recover.

“I was really happy and excited to hear that he was going to be OK,” Trevor said.

Trevor realized that day he just happened to be wearing his Athletes Saving Athletes shirt during the incident. He said he definitely thinks the program is important and that the training can go far beyond just saving an athlete’s life.

Trevor, who has always wanted to be a doctor, will attend Occidental College in the fall and plans on majoring in biology. He plans to play tennis as well.

“We nominate leadership athletes to take part in Athletes Saving Athletes,” Mallon said. “For him to step up and have the confidence to say ‘I can do this’…it’s just so wonderful.”

Except most of the story isn’t true. Lorraine Bayless lived at a Bakersfield (CA) continuing care community called Glenwood Gardens, but in independent living, not in its skilled nursing facility. She did not die of a heart attack but of a stroke, according to the death certificate signed by her personal physician. CPR may have saved her, but it is very unlikely.

And there is more. Mrs. Bayless did not want life-prolonging medical interventions, and her family is fully satisfied with the care she received. And the staffer who called 9-11 may not have been a licensed nurse at all. One piece of the story is true: Glenwood Garden staffers are prohibited from performing CPR or other medical interventions and are instructed to call 9-11 in the event of emergencies.

Still, even the real story raises some important questions. If you or a loved one live in residential care, here are five lessons to learn from this episode:

What level of care can you expect? Independent living communities are not nursing homes or assisted living facilities. You should not expect them to provide medical care or even personal assistance. You have an apartment and perhaps access to a dining room and some social activities. Emergency response is probably limited to a pull cord in your unit.

If you need additional assistance, you’re responsible for hiring your own aide. CCRC’s are more complicated since they may have a licensed nursing facility on site. Still, if you are living in an independent unit, don’t expect skilled nursing care.

Is staff trained and permitted to perform emergency care? Does the facility have at least one staffer trained in CPR and first aid on duty at all times? She doesn’t need to be a licensed nurse. And what is the staff allowed to do—bandage a cut, put ice on a bruise, CPR, or nothing? One CCRC director told me her staffers are trained in first aid but her facility’s lawyers urged her to instruct employees to always call 911.

What emergency care do you want? This may be the most important question of all. Mrs. Bayless’ family says she did not want life-prolonging emergency care. It is not clear whether she had a living will or do not resuscitate order, or had designated a family member as her healthcare proxy. But if you are old enough to be reading this, you should discuss end-of-life issues with family members and prepare your own advanced directives. Right now.

Is the facility aware of your wishes? It does you no good to prepare these legal documents if you don’t share them with the care facility, your physicians, your local hospital, and your family. You should distribute advanced directives as widely as necessary. Remember, people cannot follow your wishes if they don’t know what they are. The best outcome for Mrs. Bayless may have been for the staffer to not call 911 at all but rather to hold her in her arms until she passed away. But she had to know that.

Finally, lesson No. 5: Don’t believe all the news you read on the Web.

Study Highlights:

• Many hospitalized children survive after prolonged resuscitation (more than 35 minutes) for cardiac arrest.
• Over half of survivors of prolonged resuscitation had good neurologic outcomes.
• Longer duration of CPR, previously associated with helpless outcomes, may save the lives of children who otherwise would have died.

DALLAS, Jan. 21, 2013 — Many hospitalized children can survive cardiac arrest after prolonged CPR, according to new research in Circulation, an American Heart Association journal.

In the largest study conducted of in-hospital cardiac arrest among children, researchers analyzed records of 3,419 children at 328 U.S. and Canadian hospitals participating in the American Heart Association’s Get With The Guidelines^®-Resuscitation program from January 2000 -December 2009. The program is the only registry of its kind in the United States and is aimed at improving care and saving lives by tracking and analyzing resuscitation of in-hospital cardiac arrests.

Nationally, 0.7 percent to 3 percent of hospitalized children suffer cardiac arrest. Experts have previously considered duration of CPR longer than 20 minutes to be futile.

In this study, researchers found that nearly 28 percent of resuscitated patients survived to hospital discharge. About 17 percent of these patients underwent CPR for more than 35 minutes. Of those who survived, 60 percent had good neurologic outcomes.

“This study dispels common misperceptions that CPR is futile beyond 20 minutes,” said Renée I. Matos, M.D., M.P.H., the study’s lead author and a recent fellowship graduate in pediatric critical care at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center.  “We believe that healthcare providers now will consider longer-duration CPR for some patients, and that a thoughtful approach to providing longer durations of CPR to some children will save more lives.”

Although many patients survived after prolonged CPR, shorter durations were associated with better survival rates overall.

• On average, resuscitation time among surviving patients was 10 minutes, compared to 25 minutes among those who died.
• The adjusted probability of survival was 41 percent for CPR duration of 1-15 minutes and 12 percent for more than 35 minutes.
• Compared to general medical patients, cardiac surgery patients had more than twice the odds for survival and favorable neurologic outcomes across all durations of CPR.
• Overall, almost one-fifth (19 percent) of surviving patients who required CPR during their hospitalization had favorable outcomes.

“The probability of survival and favorable neurologic outcome decrease with each passing minute,” Matos said. “So while these results are supportive of doing CPR longer, it’s still critical that high-quality life support be started immediately.”

In many cases, cardiac arrest in hospitalized children may be due to a preexisting lung or heart condition or other factors. Survival depends on immediate CPR to restore normal heart rhythm and blood circulation.

The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care acknowledge that there is not yet enough scientific evidence to guide the ability to tell when further efforts would be futile for an individual patient and do not currently recommend a specific duration for resuscitation attempts.

Information gathered in the association’s quality improvement programs like Get With The Guidelines-Resuscitation helps generate critical questions and provide answers that can improve care for patients everywhere.

Co-authors are R. Scott Watson, M.D., M.P.H.; Vinay M. Nadkarni, M.D.; Hsin-Hui Huang, M.D., M.P.H.; Robert A. Berg, M.D.; Peter A. Meaney, M.D., M.P.H.; Christopher L. Carroll, M.D.; Richard J. Berens, M.D.; Amy Praestgaard, M.S.; Lisa Weissfeld, Ph.D.; and Philip C. Spinella, M.D. Author disclosures are on the manuscript.

The American Heart Association has a variety of information and resources about sudden cardiac arrest, the current guidelines for emergency cardiovascular care response and CPRfor both healthcare providers and layperson.

For the latest heart news, follow us on Twitter: @Heart News.

Chad Jackson was in a foul mood. The truck he relied upon for his summer lawn-mowing business was broken down. Some of his customers wanted their lawn mowed, which exacerbated his grumpiness. It was October. Who mows their lawn in October? But the customer is always right.

So, he stopped by his father’s place to borrow his Suburban to cart the equipment trailer. That day of all days, his father, Ken Jackson, asked if he could accompany his son.

Chad balked.

His mother insisted. “Your dad wants to spend time with you,” she said. “Let him go along.”

Irritated, Chad, 32, relented.

The father-son duo worked in tandem to manicure the lawn of a home on Avenue E. Dad, 66, mowed the front; Chad clipped the back.

As they finished about 11:30 a.m. the elder Jackson took one staggered step, collapsed on the ground and rolled to his left side. His eyeglasses were askew on his forehead, minus a left lens, which had popped out and lacerated his eye. Blood and vomit pooled around him. His nose was broken.

“Don’t die on me, Dad,” Chad pleaded. “Don’t die on me, Dad.”

Ken’s heart had stopped.

Chad, who coaches girls and boys basketball and girls volleyball and is certified in CPR, began performing chest compressions. As he cradled his cellphone between his ear and shoulder, he dialed 911 and continued to pump his father’s chest. Ken was “growling,” “yelling” and making “strange sounds.”

“His eyes were open but he wasn’t responsive,” Chad said. “He wasn’t looking at me. Nothing.”

As he pumped his father’s chest, Chad’s mind was racing. Each thump of his hand was accompanied by a thought. What if Dad didn’t make it? What if Dad wasn’t the same? What if Grandpa wasn’t there for Chad’s two children, Ellie and Isaac?

Ken remembers nothing, not even mowing the lawn that morning.

“I lost about three days of my life,” Ken said.

Chad continued to pump his father’s chest until the ambulance arrived and transported him to Billings Clinic, minutes away from where they had been mowing the lawn.

If Chad had followed his normal routine that morning, they would have been on the city’s West End. In his self-described stubbornness, he did the opposite of what he usually did.

“It was fantastic,” Ken said. “The timing was perfect in every respect.”

Some plaque in his heart dislodged and blocked his main artery, causing Ken, who has worked the past 15 years on getting his blood pressure and cholesterol in check, to go into cardiac arrest.

He was one of the lucky ones. Sudden cardiac arrest results in the deaths of more than 650 adults and children each day in the United States, according to the American Heart Association.

“It doesn’t get more serious than that,” said Dr. Ronny Jiji, a cardiologist at Billings Clinic, who treated Ken. Had it not been for Chad’s knowledge of CPR, Ken likely would not have had a chance at survival.

“It was key,” Jiji said. “Immediate, rapid, high-quality CPR is lifesaving for an out-of-hospital arrest.”

Between 75 and 80 percent of all sudden cardiac arrest cases happen at home, so being trained to perform CPR can mean the difference between life and death for a loved one, according to the AHA. CPR provided immediately after sudden cardiac arrest can double or even triple a victim’s chance of survival.

Survival of sudden cardiac arrest can be as high as 90 percent if treatment is administered within four to six minutes of the arrest.

Ken is living proof.

His “owie,” as 2½-year-old Ellie called it, is healed. He is back to work full time as a licensed clinical professional counselor at Billings Clinic.

“How much more special can it be that your oldest son saves your life?” Ken said. “It’s incredible. It’s just incredible. He saved my life. We have a special bond as a result.”

As it turned out, Oct. 13, 2012 was, in the end, a day when everything seemed to go exactly right.

The goal behind the proposed bill, number 6054, is “to increase cardiac arrest save rates by requiring cardiopulmonary resuscitation training prior to the issuance of a motor vehicle operator’s license.”

The bill would prohibit the commissioner of the state Department of Motor Vehicles from issuing or renewing a driver’s license if an applicant has not received a civilian certification in cardiopulmonary resuscitation.

State Rep. Diana Urban, of North Stonington and Stonington proposed the legislation, which hasgenerated hundreds of comments on the NBC Connecticut Facebook page.

Some question whether the state will pay for the certification.

Others said the state should not be able to force people to learn CPR, it should be a choice or left to the professionals.

Some people feared the diseases performing CPR could lead to.

Some also brought up the liability for lawsuits.

“I see lawsuits claiming that bystander drivers had a duty to act and try to save people in accidents. It could make some feel obligated to put themselves in dangerous positions in an attempt to help.” one person posted.

• A new Japanese study shows that early compression-only CPR, without rescue breathing, kept more people alive with good brain function after they had a sudden cardiac arrest.
• Survival rates of more than 40 percent were noted when cardiac arrests were observed, bystanders provided early compression-only CPR, and an electric shock was given from a publicly accessed defibrillator.

• More than 46 percent (46.4) of the compression-only CPR patients were alive, compared to 39.9 percent of those who received conventional CPR.
• The chest-compression-only CPR led to 40.7 percent of patients having favorable brain function compared to 32.9 percent of those who received traditional CPR. Patients were considered to have favorable neurological status if they had normal brain function or if they lived independently — even if they had some neurological impairment.

She hesitated but answered yes when Russell McGinnis asked whether she knew how to do cardiopulmonary resuscitation. Even if she hadn’t known the basics, McGinnis would have talked her through the procedure.

These days, instead of asking callers whether they want to do CPR, Columbus firefighters are telling callers they’re going to do it.

The American Heart Association changed its CPR guidelines last year to an option of compressions only — no more mouth-to-mouth — in an effort to get more bystanders to help people whose hearts have stopped. That prompted the Columbus Division of Fire to have its 911 staff be a little pushy with callers and not take no for an answer.

“We work with dispatchers to be as aggressive as they can and encouraging to callers to do CPR until the paramedics arrive,” said Dr. David Keseg, medical director of the Columbus Division of Fire.  The national survival rate of cardiac arrest is 6.4 percent. In Columbus, the survival rate is about 11 percent, Keseg said.

Several studies, including two published in 2010, in The New England Journal of Medicine and The Journal of the American Medical Association, found that people in cardiac arrest have a better chance of survival when chest compressions are started quickly.

Emergency dispatchers can play a pivotal role. Columbus dispatchers aim to get CPR started within 20 seconds of the call.

That was the case with the woman and her grandmother. McGinnis told the woman where to place her hands on her grandmother’s chest and how deep to push.

“Come on, you got to do this,” he told her. “Chest compressions, 1-2-3-4. Count. 1-2-3-4-5-6-7-8-9-10. Don’t stop, don’t stop, keep going. Come on.”

The woman cried, counted with McGinnis, and then cried some more. Through heavy breaths, she told him it wasn’t working.

“This is probably going to be the hardest thing you have to do your whole life,” he said. “Don’t stop until the paramedics walk through the door.”

Five minutes and 37 seconds after she called, paramedics arrived. Her grandmother survived that day but died a week later in a hospital.

Keseg said the stepped-up approach is making a difference, although he doesn’t have the data yet to show how many more lives have been saved.

Che Sitton called 911 in January after his mother, Nancy, collapsed in her room at their North Side home. He told the dispatcher that he knew CPR, but that was the last thing on his mind as he stared at his mom.

Sitton, 40, said of the dispatcher: “He could tell the stress of my voice, and he said, ‘You can do this,’ and I started the chest compressions.”

The dispatcher kept him motivated by counting compressions and reminding him to push deeply and fast even as his arms tired and his hope faded.

If Sitton hadn’t had that encouragement, “I would have given up,” he said.

His mom spent about a month in a hospital, had a pacemaker implanted and has recovered.

Other local dispatching agencies vary on how aggressive they are about getting callers to start CPR.

The Franklin County sheriff’s office asks callers whether they want to do CPR and leaves it up to them.

An official at the Metropolitan Emergency Consortium Communications Center, a consortium of townships on the east side of the county, said dispatchers there push callers to do compressions.

Dr. Michael Sayre, an associate professor of emergency medicine at Ohio State University who helped Columbus fire officials develop their protocol, said one-third of cardiac-arrest victims in Columbus get CPR before paramedics arrive.

A key is for dispatchers to help callers through difficult situations.

“You don’t have the luxury of a lot of time,” Sayre said. “There are a few effective methods, including taking control and getting the rescuer to get done what needs to be done.”

Columbus fire officials strive for a response time of zero.

“You don’t want to ask them if they want to do it,” said Rick Johnson, a Columbus firefighter who takes emergency calls. “You’re letting them know this is the best way we know for your loved one to survive.

“You need to be forceful, direct and respectful.”

The quality of CPR has been an underappreciated factor and is only now beginning to emerge as an important aspect of successful resuscitation. Manual chest compressions are often done incorrectly, especially in the back of a moving ambulance, and incorrect chest compression can negatively impact survival.(4,5)

Fortunately, there are tools that hold promise for helping providers overcome these inaccuracies: mechanical CPR devices.

The Problem with Manual CPR

The quality of CPR is an important factor that contributes to survival in sudden cardiac arrest. In one experimental study, pigs received 4 minutes of VF and then 9 minutes of CPR before defibrillation. In the group that received suboptimal compressions (1.5 inches depth and 80 per minute), two out of nine pigs survived; in the group that received optimal compressions (2 inches depth and 100 per minute), eight of nine pigs survived.(6)

The study of adult patients from the Resuscitation Outcomes Consortium Cardiac Arrest Epistry with confirmed ventricular fibrillation (VF) or ventricular tachycardia (VT) has shown that increasing chest compression fraction (hands-on time) during out-of-hospital resuscitation of patients with VF/VT is an independent determinant of survival to hospital discharge.(7) However, three human observational studies showed that interruptions of chest compressions were common, averaging 24% to 57% of the total arrest time.(8)

Interrupting CPR can result in precious seconds lost in trying to “reprime” the pump and results in pooling of blood in the right ventricle. In a study looking at this important element of the pathophysiology of cardiac arrest, VF was induced in air-ventilated pigs, after which ventilation was withdrawn. During the first 3 minutes of VF, arterial blood was transported to the venous circulation, with the consequence that the left ventricle emptied and the right ventricle became greatly distended.

It took 2 minutes of mechanical CPR to re-establish an adequate coronary perfusion pressure, which was lost when interrupted. In this pig model, VF caused venous congestion, an empty left heart, and a greatly distended right heart within 3 minutes. Adequate heart massage before and during defibrillation greatly improved the likelihood of return of spontaneous circulation (ROSC).(9)

It is widely accepted that one of the best predictors of ROSC is attaining a coronary perfusion pressure (CPP) of more than 15 mm Hg in animals and humans.(10–18) Every interruption of CPR causes the CPP to drop immediately.In the same pig study referenced above, when VF was induced, CPP fell from 60 mmHg to 15 mmHg in 15 seconds and continued to plummet into negative numbers. After CPR was restarted, the CPP remained negative for the first minute; it took 90 seconds for it to get back up to 15 mmHg.

Another pig study demonstrated that mean CPP was 20 mmHg in the mechanical group compared to around 5 mmHg in the manual group. All eight pigs in the mechanical group achieved ROSC, as compared with just three pigs in the manual group.(19)

With manual CPR, many factors come into play, including fatigue, physical abilities, focus on several simultaneous tasks, poor-quality CPR during transportation on a stretcher and in the back of a transport vehicle, interruptions during movement of patient and variations in technique and training.

Just maintaining the proper rate is a major challenge. In one study, it was demonstrated that manual CPR resulted in a rate of less than 80 compressions/minute 37% of the time.(20) Other studies looked at the challenges in performing correct CPR in various settings. They found the following percentages of correctly performed CPR:

54–78% on the floor;

• 46% in the back of a moving ambulance; and

• 21% while transporting on a stretcher.(21,22)

Besides the poor-quality CPR that occurs in the back of a moving ambulance, the risk of injury to the crew members is unacceptable. It has been reported that ambulance personnel who perform CPR in a moving ambulance are at least four times more like to have a fatal or incapacitating injury than personnel who are restrained.

Mechanical CPR allows high-quality CPR to be performed while EMS personnel are restrained; this reduces risk of injury to the crew.(23,24) Restrained ambulance occupants involved in a crash have been shown to have 3.77 times lower risk of fatality and 6.49 times lower risk of incapacitating injury than unrestrained occupants.(24)

Consistent-Quality CPR

The use of automatic mechanical CPR devices can provide a consistent rate and depth of compression and is one way of improving the quality of chest compression and contributing to EMS personnel safety.

There is compelling physiological and animal data suggesting that mechanical chest-compression devices are more effective than manual CPR. At best, standard manual CPR produces coronary and cerebral perfusion that is just 30% of normal.(25)

Some studies that demonstrate the advantages of mechanical CPR devices include:

• Increased brain flow by as much as 60% vs. manual measured in pigs.(26,27)

• Adequate heart pressures—exceeding 15 mmHg in pigs19 and humans—significantly improved over manual CPR.(28,29)

• Increased EtCO2 levels in prehospital cluster randomized patients.(30)

• Increased hands-on times to up to 90% of the time—significantly improved over manual.(31)

A study from Kramer-Johansen et al states, “The poorer results with sinusoidal than trapezoidal chest compressions add to the arguments that mechanical chest compressions can ensure better quality CPR for more than short intervals of time, unless the logistics around applying a mechanical device has too many negative effects.”(23)

Another advantage of mechanical CPR: it can allow for defibrillation during compressions. In a study on the LUCAS device, it showed that defibrillations did not compromise CPR and can be delivered during ongoing mechanical compressions without any pauses.(32)

These devices are also helpful in maintaining perfusion during cardiac arrest while undergoing a cardiac catheterization interventional procedure. The AHA 2010 Guidelines (Part 12: Cardiac Arrest in Special Situations) state: “Mechanical chest compression devices have been used successfully in an animal model and adult humans to provide maintenance of circulation in cardiac arrest while continuing a percutaneous coronary procedure. It is reasonable to use mechanical CPR during PCI (Class IIa, LOE C).”(33)

Mechanical CPR Concerns

Mechanical CPR is a recent development and as such, the literature around its effect on outcomes is still evolving. Not everyone is a fan of mechanical CPR. A recent systematic literature review of mechanical CPR devices compared to manual CPR during OHCA and ambulance transport concluded that there was insufficient evidence to support or refute the use of mechanical CPR devices in these settings. The study also said that while there was some low-quality evidence suggesting that mechanical CPR can improve consistency and reduce interruptions in chest compressions, there is no evidence that mechanical CPR devices improve survival and may worsen neurological outcome.(34)

One area of concern with mechanical CPR devices has been the time off the chest while applying the device. However, in our experience with the LUCAS device in Columbus, Ohio, we have found that application takes only 15–60 seconds and that the time off the chest is minimal. In addition, it is important to take into account the total time on and off the chest. In a prehospital real-use study, the hands-off ratio with manual CPR was on average 22%; however, with mechanical CPR it was just 9%, as measured over the entire resuscitation episodes of approximately 33–40 minutes.

The interruptions in manual CPR increased from 19% on the scene to 27% during transport, whereas those with the mechanical CPR device stayed at the same low ratio (8–10%) both on scene and during transport.(34)

Another more practical concern is the cost of these devices. They can cost nearly the same as a monitor/defibrillator, a cost that many feel is too high for a mechanical device that is not as technology-packed as a cardiac monitor. In addition, one unit sold in the U.S., the ZOLL AutoPulse, has a one-time use band that must be replaced after each use; and this replacement cost is not currently reimbursed by most insurance agencies.

Types of Mechanical CPR Devices

There are several types of mechanical CPR devices.

Piston CPR Devices: Piston compression devices use battery power (e.g., the LUCAS 2 from Physio-Control) or pneumatic power derived from compressed oxygen (e.g., the LifeStat from Michigan Instruments, which also features an associated integrated ventilator). Early studies found that mechanical piston CPR improved hemodynamic parameters, but not survival.(35–38) However, these studies were performed prior to the latest AHA guidelines and before crews began using compressions-only CPR, early adult IO (EZ-IO) establishment, impedance threshold devices (ResQPOD), therapeutic hypothermia and a “pit crew” approach to resuscitation.

Piston chest compression devices have been shown to be actually less damaging than manual CPR.(39,40) Trauma, such as rib fractures, is an occasional occurrence in CPR and a complication of this and other mechanical devices.

The 2010 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science state, “There is insufficient evidence to support or refute the routine use of mechanical piston devices in the treatment of cardiac arrest. Mechanical piston devices may be considered for use by properly trained personnel in specific settings for the treatment of adult cardiac arrest in circumstances (e.g., during diagnostic and interventional procedures) that make manual resuscitation difficult (Class IIb, LOE C).”(41)

However, EMS insiders believe that the positive results being realized by EMS systems using mechanical CPR devices applied early and efficiently; the move to compressiond-only CPR and its proven efficacy; and the results of Dr. Idris’ study (see p. 4 of this supplement), which shows the need to keep compressions within a defined range of 100–120 compressions per minute, will result in a stronger position for mechanical CPR in the future.

Active Compression-Decompression (ACD) Devices: This piston technique, not yet approved for use in the U.S., integrates a suction cup that allows for active return of the chest and provides both active chest compression and active chest decompression (ACD-CPR).

A 2005 study demonstrated that incomplete chest recoil during CPR worsens hemodynamics. The study, although performed in piglets, indicated that leaning on the chest during CPR and not allowing the chest to fully expand on the upstroke led to worse systolic blood pressure, worse coronary perfusion pressure and substantially reduced myocardial blood flow.(42)

Load-Distributing Band (LDB): The ZOLL AutoPulse device uses a load-distributing band that is placed around the patient’s chest and circumferentially tightens and loosens around the patient, distributing the force evenly to generate changes in intrathoracic pressure.

Initial studies of the device had found improved hemodynamic parameters and coronary perfusion pressures as well as improved prehospital survival to the emergency department.(43–47) Recent trials showed improved hemodynamics, with coronary perfusion pressures above the level generally associated with improved survival, as well as improvement in survival to arrival at the emergency department when compared with manual CPR.(17,43)

A multi-site cluster-randomized trial (ASPIRE) that the Columbus (Ohio) Division of Fire participated in was terminated early due to a lack of benefit and apparent harm.(48) It is believed that site-specific factors had led to the poorer results,49 and further clinical research is still ongoing.

However, in the 2006 JAMA article, the authors looked at 783 adults with non-traumatic cardiac arrest in the prehospital setting.(49) They compared resuscitation outcomes before and after switching over their urban EMS system to a load-distributing band (LDB) CPR device. They compared 499 patients in the manual CPR phase and 284 patients in the LDB CPR phase. The LDB device was placed on 210 out of the 284 patients in this last phase.

Rates for ROSC and survival were increased with LDB CPR compared with manual CPR. Survival to hospital admission was 20.9% in the LDB CPR group vs. 11.1% in the manual CPR group, and survival to hospital discharge was 9.7% vs 2.9% respectively.

In secondary analysis of the 210 patients on whom the LDB device was applied, 38 patients (18.1%) survived to hospital admission (95% CI, 13.4%–23.9%) and 12 patients (5.7%) survived to hospital discharge (95% CI, 3.0%–9.3%). Among patients in the manual CPR and LDB CPR groups who survived to hospital discharge, there was no significant difference between groups in cerebral performance category (P=.36) or overall performance category (P=.40).

Their final conclusion: Compared with resuscitation using manual CPR, a resuscitation strategy using LDB CPR on EMS ambulances is associated with improved survival to hospital discharge in adults with out-of-hospital nontraumatic cardiac arrest.

According to the 2010 AHA Guidelines, “The LDB may be considered for use by properly trained personnel in specific settings for the treatment of cardiac arrest (Class IIb, LOE B). However, there is insufficient evidence to support the routine use of the LDB in the treatment of cardiac arrest.”(41)

The Columbus Experience

The Columbus (Ohio) Division of Fire has had the opportunity to use and evaluate several types of mechanical CPR devices. We used the Thumper devices in the 1970s and 1980s, and we were one of the participating systems in the ASPIRE trial, which provided exposure to the Autopulse device.

In July 2011, we put LUCAS devices on three of our EMS officer vehicles. In the first six months of usage, we used the devices 71 times. Although this was not a scientific study, our average ROSC rate with manual CPR was 30.5% and our hospital discharge rate was just 11.1%. With the LUCAS device it was 19% and 2.3%.

During the first six months of 2012, the ROSC rate and hospital discharge rate with manual CPR was 33% and 12% respectively and with the LUCAS it was 30% and 4%.

Our results are not as positive as some other systems that have mechanical CPR devices on all of their ALS vehicles because the LUCAS devices were only available on our EMS officer vehicles. Although manual CPR had been going on from the start of each arrest, the device was being applied late into most cardiac arrests. It was also being applied to patients who had not quickly converted from a ventricular fibrillation or ventricular tachycardia rhythm.

The Columbus Department of Fire EMS staff has a favorable attitude about mechanical CPR devices. The advantages in terms of job enhancement have already been discussed. In a survey we conducted, our EMS personnel reported the following:

• 60% of providers surveyed said application time for the LUCAS device was less than 30 seconds; 40% said it was 30–60 seconds.

• 100% of providers surveyed said the LUCAS 2 device makes the treatment of cardiac arrest patients in the field go smoother than with manual CPR.

• 100% of providers surveyed said they perceived that they obtain ROSC (pulses) more often on patients that have the LUCAS device applied than with manual CPR.

• 100% of providers surveyed said they see no drawbacks to using mechanical CPR in the field.

• Responders identified the following advantages to using the LUCAS device in the field: It gives them more time to focus on other skills and patient care; it is safer for transport in the back of the medic (no one standing to perform CPR); it can be applied rapidly and, once applied, provides consistent CPR with no interruptions.

Summary

In the Cochrane review, a large literature review of randomized controlled trials (RCTs), cluster RCTs and quasi-randomized studies that compared mechanical chest compressions to manual chest compressions, the authors conclude: “There is insufficient evidence from human RCTs to conclude that mechanical chest compressions during cardiopulmonary resuscitation for cardiac arrest are associated with benefit or harm. Widespread use of mechanical devices for chest compressions during cardiac is not supported by this review. More RCTs that measure and account for CPR process in both arms are needed to clarify the potential benefit from this intervention.”(50)

Further studies are needed to truly determine the efficacy of mechanical CPR devices. The LINC study, a large RCT comparing LUCAS to manual CPR, is ongoing and expected to complete enrollment in the next few months. The LINC trial is a prospective randomized multicenter study where LUCAS will be used with simultaneous defibrillation compared to manual chest compressions. The study is being conducted in first-tier systems, where LUCAS always will be placed in the first-arriving ambulance.

There also has been promising research showing benefit of Active Compression Decompression CPR and it is expected that the LUCAS device and others will utilize this method of CPR in the future. Studies with these devices will also be critical in assessing the overall survival of patients receiving combined mechanical and ACD CPR.