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Background In a departure from the previous strategy of immediate defibrillation, the 2005 resuscitation guidelines from the American Heart Association–International Liaison Com mittee on Resuscitation suggested that emergency medical service (EMS) personnel could provide 2 minutes of cardiopulmonary resuscitation (CPR) before the first analysis of cardiac rhythm. We compared the strategy of a brief period of CPR with early analysis of rhythm with the strategy of a longer period of CPR with delayed analysis of rhythm. Methods We conducted a cluster-randomized trial involving adults with out-of-hospital cardiac arrest at 10 Resuscitation Outcomes Consortium sites in the United States and Canada. Patients in the early-analysis group were assigned to receive 30 to 60 seconds of EMS-administered CPR and those in the later-analysis group were assigned to receive 180 seconds of CPR, before the initial electrocardiographic analysis. The primary outcome was survival to hospital discharge with satisfactory functional status (a modified Rankin scale score of ≤3, on a scale of 0 to 6, with higher scores indicating greater disability). Results We included 9933 patients, of whom 5290 were assigned to early analysis of cardiac rhythm and 4643 to later analysis. A total of 273 patients (5.9%) in the later-analysis group and 310 patients (5.9%) in the early-analysis group met the criteria for the primary outcome, with a cluster-adjusted difference of −0.2 percentage points (95% confidence interval, −1.1 to 0.7; P = 0.59). Analyses of the data with adjustment for confounding factors, as well as subgroup analyses, also showed no survival benefit for either study group. Conclusions 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. (Funded by the National Heart, Lung, and Blood Institute and others; ROC PRIMED ClinicalTrials.gov number, NCT00394706.)

Background— The 2010 American Heart Association guidelines suggested an increase in cardiopulmonary resuscitation compression depth with a target >50 mm and no upper limit. This target is based on limited evidence, and we sought to determine the optimal compression depth range. Methods and Results— We studied emergency medical services–treated out-of-hospital cardiac arrest patients from the Resuscitation Outcomes Consortium Prehospital Resuscitation Impedance Valve and Early Versus Delayed Analysis clinical trial and the Epistry-Cardiac Arrest database. We calculated adjusted odds ratios for survival to hospital discharge, 1-day survival, and any return of circulation. We included 9136 adult patients from 9 US and Canadian cities with a mean age of 67.5 years, mean compression depth of 41.9 mm, and a return of circulation of 31.3%, 1-day survival of 22.8%, and survival to hospital discharge of 7.3%. For survival to discharge, the adjusted odds ratios were 1.04 (95% CI, 1.00–1.08) for each 5-mm increment in compression depth, 1.45 (95% CI, 1.20–1.76) for cases within 2005 depth range (>38 mm), and 1.05 (95% CI, 1.03–1.08) for percentage of minutes in depth range (10% change). Covariate-adjusted spline curves revealed that the maximum survival is at a depth of 45.6 mm (15-mm interval with highest survival between 40.3 and 55.3 mm) with no differences between men and women. Conclusions— This large study of out-of-hospital cardiac arrest patients demonstrated that increased cardiopulmonary resuscitation compression depth is strongly associated with better survival. Our adjusted analyses, however, found that maximum survival was in the depth interval of 40.3 to 55.3 mm (peak, 45.6 mm), suggesting that the 2010 American Heart Association cardiopulmonary resuscitation guideline target may be too high. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00394706.

Introduction : In 2005, the American Heart Association recommended increased “hands-on time” during cardiopulmonary resuscitation (CPR) based on animal research and small case series. This study estimated the effect of increasing CPR fraction (proportion of resuscitation time with active CPR) on survival in a cohort of patients with out-of hospital ventricular fibrillation or ventricular tachycardia (VF/VT). Methods: Patients were selected from the ROC Epistry who had a confirmed VF/VT cardiac arrest that was not witnessed by Emergency Medical Services (EMS), received no public access defibrillation shock prior to EMS arrival, and had impedance recordings of CPR before the first shock. The proportion of each minute with active CPR, from defibrillator pad application until the first shock, was measured from the electronic resuscitation record by skilled readers who were blinded to hospital discharge outcome. The effect of increasing CPR fraction on survival to hospital discharge was adjusted for age, sex, bystander CPR, public location, interval from 911 call to defibrillator activation, chest compression rate, and ROC community. Results: Of 7963 EMS-treated cases of cardiac arrest without public access defibrillation, 1893 had an initial rhythm of VF/VT and 283 of those had electronic tracings and confirmed outcome. Mean age was 63 years and 81% were male. Bystanders performed CPR on 51% and 41% arrested in a public location. Outcomes and odds ratios (OR) with 95% confidence intervals (CI) of survival are shown from lowest to highest category of CPR fraction. Conclusions: This study provides preliminary evidence that increasing CPR fraction is associated with increased survival from VF/VT cardiac arrest. Though the study was observational, relatively small, and able only to measure CPR fraction after pad application, these findings suggest that provision of minimally interrupted CPR has direct clinical impact on survival after VF cardiac arrest.

Triage reliability studies typically use hypothetical scenarios and weighted kappa scores where agreement within one level is considered satisfactory. But if triage category is used to help define ED case-mix groups for comparative or benchmarking processes, agreement on exact triage level and major system involved is important. Our hypothesis was that a computerized menu that links presenting complaints to preferred triage levels (PC-linked triage) would provide high triage reliability.Our objective was to assess inter-rater reliability of PC-linked triage using the Canadian Emergency Department Triage and Acuity Scale (CTAS) in a real-time clinical setting, considering agreement on exact triage level and primary body system involved.On duty triage nurses entered patient presenting complaint and PC-linked triage level as per standard procedure. In a convenience sample of patients, a second nurse, blinded to triage assignment, observed the triage interaction and independently entered presenting complaint and triage level on a dummy terminal.During the study, 15 nurse pairs triaged 266 patients. Study patients matched actual emergency department case mix closely. Triage nurses agreed exactly in 74% of cases and within one level in 94% of cases. The unweighted kappa value was 0.66 (95% confidence interval [CI], 0.60-0.73) and the quadratic weighted kappa value was 0.75 (95% CI, 0.68-0.81). Kappa for agreement on major system involved was 0.80 (95% CI, 0.69-0.91).PC-linked triage has high inter-rater reliability in a real-time clinical setting. PC-linked triage may be useful as one factor in defining case-mix groups for benchmarking and comparative purposes.