Favourable outcome after 26 minutes of "Compression only" resuscitation: a case report
© Steen-Hansen; licensee BioMed Central Ltd. 2010
Received: 1 February 2010
Accepted: 16 April 2010
Published: 16 April 2010
A 49 year old man had ventricular fibrillation in his home, at room temperature, due to an ST-elevation myocardial infarction. He received Cardiac compression only resuscitation (CC-only) for 26 minutes by his wife, followed by four minutes of standard CPR by other lay persons until EMS-arrival. Gasping and moaning were observed during most of the CC-only period. The ambulance arrived at 30 minutes. The first ECG showed a fine ventricular fibrillation. Restoration of spontaneous circulation (ROSC) was achieved at 49 minutes after a total of four defibrillatory shocks. The patient recovered without any cerebral damage, and was discharged to his home after eight days hospitalization.
This case demonstrates that early and powerful cardiac compressions alone without rescue breaths may maintain sufficient circulation and gas exchange to prevent neurological damage for more than 25 minutes. This should be kept in mind for Emergency Medical Dispatch Centrals giving Pre-arrival instructions to bystanders.
Telephone CPR , Dispatch guided CPR or Pre-arrival instructions are terms of efforts by the dispatcher to motivate bystanders performing CPR until EMS arrival. There is a debate about the safety of giving CC-only for not CPR-trained lay people when the cause of arrest is cardiac. ERC Guidelines of 2005 , states that CC-only may be used if the rescuer is not able or is unwilling to give rescue breaths. For dispatcher instruction, a recommendation of four minutes CC-only followed by a compression-ventilation ratio of 100:2 was proposed in 2005 . Some studies have shown better or equal effect of CC-only than traditional CPR on survival [4–6].
The Norwegian 2009 consensus for Dispatch guided CPR states that CC-only should be given for 10 minutes, before rescue breaths are given .
In December 2009, rescue breaths instructions for cardiac caused arrests were removed completely from the protocols at our Emergency Medical Communication Centre (EMCC) in Tønsberg, covering Vestfold and Telemark Counties. CC-only instructions should be given regardless of time axis.
There were several reasons for this decision. Median ambulance response times for the covered area (29 ambulances, 11 000 square kilometres and a population of 360 000), the possible confusion in and between EMCC and caller by switching of protocols during the pre-arrival instructions, and almost two decades of negative experience with existing rescue breaths instructions were decisive elements.
Within 14 days use of the new CC-only protocol, the following case presented.
A 49 year old male suddenly lost consciousness, in front of his wife at 01:48 AM the first night in the New Year. This happened in door, at room temperature. Seconds earlier, he said he could not feel his heartbeat any more. The wife confirmed an immediate respiratory arrest and no other signs of life.
In addition, the patient's mother-in-law, were present in the house. The family lives in a remote mountain area. The nearest ambulance station is located 21 km away, the roads are narrow, winding and on this night also snowy and icy.
The wife phoned the medical emergency number 1-1-3 to the EMCC, explained the situation, exact localisation, handed the telephone over to her mother and started to give CC-only as instructed by the dispatcher.
Accumulated time h:mm:ss
Emergency call received
Exact localization documented
Instruction to open airway
Respiratory arrest confirmed
Instruction to give CC-only, without any rescue breaths
Certain respiratory efforts observed. Compressions paused shortly
Gasping and moaning between compressions could be heard in the phone
Dispatcher emphasizes that the compression rate should be powerful and at a frequency about 100/min
Efforts to find some close living persons to assist on the scene
Two adult persons arrived at the front door. Shortly afterwards they took over the CPR process with 30:2 compression: ventilation ratio
First ambulance arrived (outside the house)
A fine VF is documented, and the first defibrillator shock given
Sustained ROSC achieved after 4 defibrillatory shocks
12 channel ECG shows STEMI
Air ambulance arrived
Patient arrived at a regional centre for invasive cardiology
During the flight, the helicopter physician administered tenecteplase as thrombolytic treatment because of long flight duration, and gave amiodarone because of an episode of VT.
This report demonstrates that if powerful cardiac compressions are started early, in this case less than two minutes after normothermic arrest, it is possible to maintain circulation and a sort of spontaneous respiratory movements resulting in gas exchange for more than 25 minutes. For this patient, this kind of respiration was sufficient for survival without neurological damage.
CC-only resuscitation without the time limits proposed until now may be kept in mind and taken in to consideration for Emergency Medical Dispatch Centres giving Pre-arrival instructions to bystanders.
Written informed consent for publication as case report was obtained from the patient.
Cardiac compression-only resuscitation
Cerebral Performance Category
Cardio Pulmonary Resuscitation
Emergency Medical Communication Centre
Emergency Medical System
European Resuscitation Council
Overall Performance Category
Percutaneous coronary intervention
Restoration of spontaneous Circulation
ST-elevation myocardial infarction
Unni L Luteberget, giving Pre-arrival instructions and representing the EMCC, Jostein Sandvik, the first arriving paramedic representing the ambulance crews, Michael Uchto, cardiologist, representing the PCI centre, and Lars Erik Fjellet, anaesthetist representing the Air Ambulance, both Sørlandet Hospital, for information regarding transfer and hospital treatment. Susan R Hebbert for language comments.
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