The Cardiocerebral Resuscitation protocol for treatment of out-of-hospital primary cardiac arrest
© Ewy; licensee BioMed Central Ltd. 2012
Received: 13 April 2012
Accepted: 1 August 2012
Published: 15 September 2012
Out-of-hospital cardiac arrest (OHCA) is a significant public health problem in most westernized industrialized nations. In spite of national and international guidelines for cardiopulmonary resuscitation and emergency cardiac care, the overall survival of patients with OHCA was essentially unchanged for 30 years--from 1978 to 2008 at 7.6%. Perhaps a better indicator of Emergency Medical System (EMS) effectiveness in treating patients with OHCA is to focus on the subgroup that has a reasonable chance of survival, e.g., patients found to be in ventricular fibrillation (VF). But even in this subgroup, the average survival rate was 17.7% in the United States, unchanged between 1980 and 2003, and 21% in Europe, unchanged between 1980 and 2004. Prior to 2003, the survival of patients with OHCA, in VF in Tucson, Arizona was less than 9% in spite of incorporating previous guideline recommendations. An alternative (non-guidelines) approach to the therapy of patients with OHCA and a shockable rhythm, called Cardiocerebral Resuscitation, based on our extensive physiologic laboratory studies, was introduced in Tucson in 2003, in rural Wisconsin in 2004, and in selected EMS areas in the metropolitan Phoenix area in 2005. Survival of patients with OHCA due to VF treated with Cardiocerebral Resuscitation in rural Wisconsin increased to 38% and in 60 EMS systems in Arizona to 39%. In 2004, we began a statewide program to advocate chest compression-only CPR for bystanders of witnessed primary OHCA. Over the next five years, we found that survival of patients with a shockable rhythm was 17.7% in those treated with standard bystander CPR (mouth-to-mouth ventilations plus chest compression) compared to 33.7% for those who received bystander chest-compression-only CPR. This article on Cardiocerebral Resuscitation, by invitation following a presentation at the 2011 Danish Society Emergency Medical Conference, summarizes the results of therapy of patients with primary OHCA treated with Cardiocerebral Resuscitation, with requested emphasis on the EMS protocol.
KeywordsVentricular fibrillation Resuscitation Cardiac arrest Cardiopulmonary resuscitation Cardiocerebral resuscitation Primary cardiac arrest Emergency medical system Out-of-hospital cardiac arrest
Out-of-hospital cardiac arrest (OHCA) is a significant public health problem in most westernized industrialized nations . In spite of national and international guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care, the overall survival of patients with OHCA was essentially unchanged for 30 years—from 1978 to 2008 at 7.6% . A better indicator of an emergency medical system’s (EMS) effectiveness in treating patients with OHCA is to focus on the subgroup that has a reasonable chance of survival; patients found to be in ventricular fibrillation (VF) . But even in this subgroup, the average reported survival rate was 17.7% in the United States, unchanged between 1980 and 2003, and 21% in Europe, unchanged between 1980 and 2004 [4, 5]. Following the 2005 guidelines, the Resuscitation Outcomes Consortium, arguably representing some of the better EMS in the United States and Canada, reported that the median survival rates for patients with OHCA due to VF arrest managed with the 2005 guidelines had a survival rate of 22% . However there was wide variability in survival observed by the reporting sites, ranging from 7.7% to 39.9% . This uneven survival shows that following the same approach (in this case the 2005 national and international Guidelines for CPR and Emergency Cardiac Care) does not assure similar survival of patients with OHCA.
Because many believe that resuscitation for cardiac arrest guidelines should be predominantly based on randomized control trials in man, guideline changes were rarely influenced by basic experimental studies. In fact, in 2000, the weight of evidence for animal studies was markedly decrease by the American Heart Association Guidelines for CPR and ECC [7, 8].
In our experimental resuscitation laboratory, where the animals were anesthetized but not paralyzed, we found that survival was improved following several minutes of untreated ventricular fibrillation (VF) arrest by emphasizing chest compression only CPR (CO-CPR) and a new approach for advanced cardiac support .
The poor and stagnant survival rates of patients with OHCA due to VF arrest in our community led us to conclude that survival would be improved by applying in man the techniques that improved survival of VF arrest in our physiologic research laboratory [9, 10].
Cardiocerebral Resuscitation is advocated only for primary cardiac arrest. Note that it is not only for adults but also for younger individuals (such as those due to Commotio Cordis or congenital heart abnormalities) that result in primary cardiac arrest; an unexpected witnesses collapse in an individual who is not responsive. It is not recommended for cardiac arrest secondary to respiratory failure from drowning, drug overdose, or advanced pulmonary disease. Here chest compressions and assisted ventilations are necessary .
This new approach to primary cardiac arrest eliminated the term “pulmonary”, because of its initial lack of emphasis on mouth-to-mouth ventilation and prompt intubation and assisted positive pressure ventilation . Cardiocerebral Resuscitation emphasis is on near constant blood flow to the heart and the brain by near continuous chest compressions throughout resuscitation attempts . Assisted ventilation is initially not necessary at the onset of primary cardiac arrest, as the patient was breathing normally at the moment of the arrest. Therefore the arterial blood is oxygenated. Since the blood is essentially not circulating prior to initiation of chest compressions, the arterial blood remains oxygenated for several minutes .
The requirement for mouth-to-mouth ventilation as the first step of bystander resuscitation prevented most from initiation bystander CPR.
The community component of cardiocerebral resuscitation
The first component of Cardiocerebral Resuscitation is the Community (Figure 1) as the early initiation of bystander chest compressions significantly improves the chances of survival . The public is encouraged to “Check, Call, Compress.” If an automated external defibrillator (AED) is readily available, they are encouraged to use it as well (Figure 1) .
Essential to the “Check” is to determine if the patient has a primary cardiac arrest. Our Sarver Heart Center Resuscitation Research Group thinks this can best be accomplished by teaching that a primary cardiac arrest is an unexpected witnessed (seen or heard) collapse in an individual who is not responsive. An important part of the “Check” is to recognize gasping. Gasping, except in newborns is a sign of cardiac arrest and is common during the first few minutes of primary cardiac arrest [20, 21]. Gasping during resuscitation efforts is a sign of adequate blood flow to the brain stem. Survival is greater in patients who are gasping .
The EMS component of cardiocerebral resuscitation
The EMS or emergency medical service component of Cardiocerebral Resuscitation advocates a revised sequence of interventions for patients with primary cardiac arrest, not witnessed by EMS providers. This component advocates the prompt initiation of 200 continuous chest compressions prior to and immediately after a single indicated direct current shock, altered airway management to avoid prolonged interruptions of chest compressions and hyperventilation, and the early administration of epinephrine (adrenalin).
Defibrillation first for an observed, unexpectedly primary cardiac arrest
The individual with a witnessed unexpected collapse who is not responsive is usually in the electrical phase of ventricular fibrillation arrest. The most important intervention is prompt defibrillation. The highest survival rates of individuals with out-of-hospital cardiac arrest was reported from the casinos in Las Vegas where our colleagues taught the security guards to recognize primary cardiac arrest and to use an automated external defibrillator (AED) . Those individuals with a witnessed arrest who were shocked within 3 minutes had a survival rate of 74% and those shocked after 3 minutes had a survival rate of 49% . Thus if the patient’s arrest is witnessed, the initial step for EMS personnel is prompt defibrillation.
Chest compressions prior to defibrillation
For individuals no longer in the Weisfeldt and Becker’s “electrical phase” (the first four or so minutes) of VF arrest, chest compressions prior to defibrillation is recommended to decompress and to perfuse the heart . With cardiac arrest, the arterial pressure falls and the venous pressure rises, until Guyton’s mean circulatory filling pressure, is reached. Professor Stig Steen reported, in open chest swine, with the onset of ventricular fibrillation, as blood shifts from the high pressure arterial system into the lower pressure venous system, the right ventricle volume increases while the left ventricular volume decreases . We showed the same phenomenon with MRI imaging .
Whenever possible, two EMS individuals are assigned as “chest compressors” to take up their position on the opposite sides of the patient’s chest. The individuals providing chest compressions are encouraged to alternate every minute and, in the absence of a chest compression rate and depth detector, the other person is assigned the task of continuously monitoring the rate and the quality of chest compressions. Ideally, metronomes provide audible prompts of 100 per minute. Studies have indicated that while bystanders tend to compress too slowly, emergency medical service (EMS) personnel tend to compress too rapidly [32, 33]. The optimal compression rate in man is probably near 100/min, but in experimental animals we found that the cardiac output increases with rates up to 120/min . A recent editorial reviewing the currently available literature, concluded that, “the sweet spot for manual chest compressions is a rate of about 120 per minute” . None of these studies were with continuous chest compression CPR.
Airway management initially consists of passive ventilation by the insertion of an oral pharyngeal or supraglottic airway, and the provision of high flow oxygen via a non-rebreather mask (Figure 4) . This approach eliminates the two most common deleterious effects of endotracheal intubation (ETI) during cardiac arrest; prolonged interruptions of chest compressions and hyperventilation .
We delayed ETI by EMS, based on our observations during resuscitation efforts of patients with in-hospital cardiac arrest. We often observed prolonged interruptions of chest compressions while physicians accomplished ETI. We assumed that EMS providers had similar difficulties. Subsequently, Wang and associates documented that paramedic ETI for OHCA interrupts chest compressions for prolonged periods . They reported on 100 patients with OHCA; the median duration of first ETI was 47 seconds, almost one-third exceeded one minute and one-fourth exceeded 3 minutes . Interruptions of chest compressions for these durations during cardiac arrest are usually lethal. Eliminating the need for early ETI also frees up that EMS person to quickly apply the defibrillator pads, to turn on the defibrillator, and to perform other essential duties such as relieving the person doing chest compressions or providing the early administration of epinephrine (Figure 4) . Intubation is usually performed following ROSC to stabilize the patient’s airway during transportation.
Preventing deleterious effects of hyperventilation
Passive ventilation also prevents “Death by Hyperventilation.”  Following cardiac arrest, rapid, forceful positive pressure ventilations increase intrathoracic pressures, thereby decreasing venous return to the chest and heart . Unfortunately increases in intrathoracic pressures are transmitted, probably via increasing the spinal fluid pressures, to an increase in intracranial pressures, which decreases blood flow to the brain .
Each shock is immediately followed by 200 chest compressions
Following each defibrillation shock, EMS personnel are prohibited from looking at the electrocardiogram (EKG) or palpating for an arterial pulse (Figure 4) . The reason for this is that following prolonged untreated VF, a direct current shock will usually terminate the VF but will result in pulseless electrical activity (PEA) . In fact this is the way we produce PEA in the experimental physiologic laboratory. Ventricular fibrillation is induced but is not treated for 8 to 12 minutes. Electrical defibrillation then results in classic PEA, and a normal or near normal electrocardiographic waveform, but a blood pressure so low that it cannot be palpated . Medical personnel, not familiar with this phenomenon, observe the normal sinus rhythm on the EKG monitor and assume that the defibrillation shock has not only restored the sinus rhythm, but also the blood pressure. So viewing the resultant sinus rhythm on the EKG display, they do not resume chest compressions, but begin searching for a pulse. However PEA untreated usually deteriorates into heart block . Rather than resume chest compressions, the previous response was often to try to get a pacemaker—without resumption of chest compressions, the patient’s rhythm further deteriorates into asystole. Then resuscitation efforts would be resumed, but not for VF arrest, but for asystolic arrest where survival is unusual. In contrast the immediate resumption of chest compressions following an effective defibrillation shock improves coronary perfusion pressure and most often leads to an effective perfusion pressure.
The role of epinephrine
Based on findings in our and others experimental laboratories, early epinephrine administration is recommended [9, 40, 41]. To administer epinephrine early, intraosseous injection is often necessary . The late administration of epinephrine in man late in the cardiac arrest has not been shown to improve survival [42, 43]. Although the incidence of ROSC is improved, survival is not.
The only randomized, controlled, double-blind trial of epinephrine vs. placebo in man, analyzed by a Bayesian interpretation of the results, suggest a benefit of epinephrine (CI 2.1 with 95% credible interval of 0.8 to 6.6) [44, 45].
The hospital component
The third component of Cardiocerebral Resuscitation (Figure 1) is the “Hospital” component. In Arizona, hospitals are designated as “Cardiac Receiving Centers” once they have committed to providing optimal care to resuscitated but comatose cardiac arrest patients. In Arizona, it is acceptable for the EMS ambulance to bypass hospitals to transport patients with OHCA to a designated Cardiac Receiving Center. Multivariant analysis did not find an association between transport time and survival [46, 47]. Cardiac Receiving Center hospitals have the trained staff, the necessary equipment, the expertise and the commitment to provide optimal care, including therapeutic mild hypothermia and urgent cardiac catheterization “24/7” for patients who attain ROSC (most of whom are comatose) following cardiac arrest [48, 49].
There are areas of the world that have excellent survival rates following the national and international Guidelines, for example Seattle, Washington and Northern Netherlands [50, 51]. Both of these areas have a high incidence of bystander CPR and a record of dispatch assisted CPR (DA-CPR). A meta-analysis of randomized control trials of DA-CPR has shown that survival of patients with OHCA is improved with dispatch assisted chest-compression only CPR . These facts and the improved survival in Arizona where CO-CPR was and is advocated, supports the contention that one of the more important interventions is the early initiation of bystander CPR.
Out-of-hospital cardiac arrest is a major public health problem. In spite of recurrent updates of guidelines for CPR and ECC, survival of patients treated according to the guidelines is quite uneven, relatively good in a few areas, but poor in most. In contrast, everywhere that Cardiocerebral Resuscitation has been instituted survival of the subset of patients with the greatest chance of survival, those with an OHCA and a shockable rhythm has dramatically improved.
Every EMS system needs know the survival rate of those with OHCA and the best chance of survival—a primary cardiac arrest and a shockable rhythm. Knowing the survival rate of all patients with OHCA is not helpful as most such patients have little or no chance of survival, and leads to a defeatist mentality by EMS.
Therefore, in the authors view, if the survival rate of such patients with primary OHCA and a shockable rhythm in your community is less than 30%, you should seriously consider instituting Cardiocerebral Resuscitation for patients with primary cardiac arrest,
It is difficult to improve what you don’t measure.
- Lloyd-Jones DM, Hong Y, Labarthe D: Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation. 2010, 121 (4): 586-613. 10.1161/CIRCULATIONAHA.109.192703.View ArticlePubMed
- Sasson C, Rogers MA, Dahl J, Kellermann AL: Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2010, 3: 63-81. 10.1161/CIRCOUTCOMES.109.889576.View ArticlePubMed
- Chamberlain D, Cummins RO, Abramson N: Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: The Utstein style. Resuscitation. 1991, 22 (1): 1-26. 10.1016/0300-9572(91)90061-3.View Article
- Rea TD, Eisenberg MS, Sinibaldi G, White RD: Incidence of EMS-treated out-of-hospital cardiac arrest in the United States. Resuscitation. 2004, 63: 17-24. 10.1016/j.resuscitation.2004.03.025.View ArticlePubMed
- Atwood C, Eisenberg MS, Herlitz J, Rea TD: Incidence of EMS-treated out-of-hospital cardiac arrest in Europe. Resuscitation. 2005, 67: 75-80. 10.1016/j.resuscitation.2005.03.021.View ArticlePubMed
- Nichol G, Thomas E, Callaway CW: Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008, 300: 1423-1431. 10.1001/jama.300.12.1423.PubMed CentralView ArticlePubMed
- American Heart Association Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care: international consensus on science. Circulation. 2000, 102 ((I)): I-1-I-348.
- Ewy GA: Cardiocerebral resuscitation should replace cardiopulmonary resuscitation for out-of-hospital cardiac arrest. Curr Opin Crit Care. 2006, 12: 189-192. 10.1097/01.ccx.0000224859.25217.5b.View ArticlePubMed
- Ewy GA: Cardiocerebral resuscitation: the new cardiopulmonary resuscitation. Circulation. 2005, 111: 2134-2142. 10.1161/01.CIR.0000162503.57657.FA.View ArticlePubMed
- Kern KB, Valenzuela TD, Clark LL: An alternative approach to advancing resuscitation science. Resuscitation. 2005, 64: 261-268. 10.1016/j.resuscitation.2004.08.009.View ArticlePubMed
- Ewy GA: A new approach for out-of-hospital CPR: a bold step forward. Resuscitation. 2003, 58: 271-272. 10.1016/S0300-9572(03)00268-5.View ArticlePubMed
- Kellum MJ, Kennedy KW, Ewy GA: Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am J Med. 2006, 119: 335-340. 10.1016/j.amjmed.2005.11.014.View ArticlePubMed
- Kellum MJ, Kennedy KW, Barney R: Cardiocerebral Resuscitation Improves Neurologically Intact Survival of Patients With Out-of-Hospital Cardiac Arrest. Ann Emerg Med. 2008, 52: 244-252. 10.1016/j.annemergmed.2008.02.006.View ArticlePubMed
- Garza AG, Gratton MC, Salomone JA, Lindholm D, McElron J, Archer R: Improved patient survival using a modified resuscitation protocol for out-of-hospital cardiac arrest. Circulation. 2009, 119: 2597-2605. 10.1161/CIRCULATIONAHA.108.815621.View ArticlePubMed
- Bobrow BJ, Ewy GA, Clark L: Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. Ann Emerg Med. 2009, 54: 656-662. 10.1016/j.annemergmed.2009.06.011.View ArticlePubMed
- Berg RA, Wilcoxson D, Hilwig RW: The need for ventilatory support during bystander CPR. Ann Emerg Med. 1995, 26: 342-350. 10.1016/S0196-0644(95)70084-6.View ArticlePubMed
- Berg RA, Kern KB, Hilwig RW: Assisted ventilation does not improve outcome in a porcine model of single-rescuer bystander cardiopulmonary resuscitation. Circulation. 1997, 95 (6): 1635-1641. 10.1161/01.CIR.95.6.1635.View ArticlePubMed
- Rea TD, Helbock M, Perry S: Increasing use of cardiopulmonary resuscitation during out-of-hospital ventricular fibrillation arrest: survival implications of guideline changes. Circulation. 2006, 114: 2760-2765. 10.1161/CIRCULATIONAHA.106.654715.View ArticlePubMed
- Weisfeldt ML, Kerber RE, McGoldrick RP: Public access to defibrillation. The Automatic Defibrillation Task Force. Am J Emerg Med. 1996, 14 (7): 684-692. 10.1016/S0735-6757(96)90090-X.View ArticlePubMed
- Zuercher M, Ewy GA: Gasping during cardiac arrest. Curr Opin Crit Care. 2009, 15: 185-188. 10.1097/MCC.0b013e3283298e00.View ArticlePubMed
- Zuercher M, Ewy GA, Otto CW: Gasping in response to basic resuscitation efforts: observation in a Swine model of cardiac arrest. Critical Care Research and Practice. 2010, 1: 1-7.View Article
- Bobrow BJ, Zuercher M, Ewy GA: Gasping during cardiac arrest in humans is frequent and associated with improved survival. Circulation. 2008, 118: 2550-2554. 10.1161/CIRCULATIONAHA.108.799940.PubMed CentralView ArticlePubMed
- Bobrow BJ, Spaite DW, Berg RA: Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. JAMA. 2010, 304: 1447-1454. 10.1001/jama.2010.1392.View ArticlePubMed
- Valenzuela T, Roe D, Nichol G, Clark L, Spaite D, Hardman R: Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. New Eng J Med. 2000, 343: 1206-1209. 10.1056/NEJM200010263431701.View ArticlePubMed
- Weisfeldt ML, Becker LB: Resuscitation after cardiac arrest: a 3-phase time-sensitive model. JAMA. 2002, 288: 3035-3038. 10.1001/jama.288.23.3035.View ArticlePubMed
- Steen S, Liao Q, Pierre L, Paskevicius A, Sjoberg T: The critical importance of minimal delay between chest compressions and subsequent defibrillation: a haemodynamic explanation. Resuscitation. 2003, 58: 249-258. 10.1016/S0300-9572(03)00265-X.View ArticlePubMed
- Sorrell VL, Bhatt RD, Berg RA: Cardiac magnetic resonance imaging investigation of sustained ventricular fibrillation in a swine model–with a focus on the electrical phase. Resuscitation. 2007, 73 (2): 279-286. 10.1016/j.resuscitation.2006.08.032.View ArticlePubMed
- Ewy GA: Alternative approaches to external chest compression. Circulation. 1986, 74 (6 Pt 2): IV98-101.PubMed
- Ewy GA, Kellum MJ: Cardiocerebral resuscitation: a new approach to out-of-hospital cardiac arrest. Cardiac Arrest: The Science and Practice of Resuscitation Medicine, 2nd Edition Cambridge University Press. Edited by: Paradis NA, Halperin HR, Karn KB, Venzel V, Chamberlain DA. 2007, 747-756.
- Aufderheide TP, Pirrallo RG, Yannopoulos D: Incomplete chest wall decompression: a clinical evaluation of CPR performance by EMS personnel and assessment of alternative manual chest compression-decompression techniques. Resuscitation. 2005, 64: 353-362. 10.1016/j.resuscitation.2004.10.007.View ArticlePubMed
- Ewy GA, Kern KB: Recent advances in cardiopulmonary resuscitation: cardiocerebral resuscitation. J Am Coll Cardiol. 2009, 53: 149-157. 10.1016/j.jacc.2008.05.066.View ArticlePubMed
- Abella BS, Sandbo N, Vassilatos P: Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest. Circulation. 2005, 111: 428-434. 10.1161/01.CIR.0000153811.84257.59.View ArticlePubMed
- Feneley MP, Maier GW, Kern KB: Influence of compression rate on initial success of resuscitation and 24 hour survival after prolonged manual cardiopulmonary resuscitation in dogs. Circulation. 1988, 77: 240-250. 10.1161/01.CIR.77.1.240.View ArticlePubMed
- Nolan JP, Perkins GD, Soar J: Chest Compression Rate: Where is the Sweet Spot?. Circulation. 2012, 125: 2968-2970. 10.1161/CIRCULATIONAHA.112.112722.View ArticlePubMed
- Aufderheide TP, Lurie KG: Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation. Crit Care Med. 2004, 32: S345-351. 10.1097/01.CCM.0000134335.46859.09.View ArticlePubMed
- Wang HE, Simeone SJ, Weaver MD, Callaway CW: Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Ann Emerg Med. 2009, 54: 645-652. 10.1016/j.annemergmed.2009.05.024.View ArticlePubMed
- Aufderheide TP: The problem with and benefit of ventilations: should our approach be the same in cardiac and respiratory arrest?. Curr Opin Crit Care. 2006, 12: 207-212. 10.1097/01.ccx.0000224863.55711.56.View ArticlePubMed
- Yannopoulos D, Nadkarni VM, McKnite SH: Intrathoracic pressure regulator during continuous-chest-compression advanced cardiac resuscitation improves vital organ perfusion pressures in a porcine model of cardiac arrest. Circulation. 2005, 112 (6): 803-811. 10.1161/CIRCULATIONAHA.105.541508.View ArticlePubMed
- Ewy GA: Defining electromechanical dissociation. Ann Emerg Med. 1984, 13: 830-832. 10.1016/S0196-0644(84)80452-7.View ArticlePubMed
- Zuercher M, Kern KB, Indik JH: Epinephrine improves 24-hour survival in a swine model of prolonged ventricular fibrillation demonstrating that early intraosseous is superior to delayed intravenous administration. Anesth Analg. 2011, 112: 884-890. 10.1213/ANE.0b013e31820dc9ec.View ArticlePubMed
- Otto CW, Yakaitis RW, Ewy GA: Effect of epinephrine on defibrillation in ischemic ventricular fibrillation. Am J Emerg Med. 1985, 3: 285-291.View ArticlePubMed
- Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L: Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA. 2009, 302: 2222-2229. 10.1001/jama.2009.1729.View ArticlePubMed
- Haqihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S: Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012, 307: 1161-1168. 10.1001/jama.2012.294.View Article
- Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL: Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2012, 83: e105-View Article
- Youngquist ST, Niemann JT: Regarding"Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2012, 83: e105-View ArticlePubMed
- Spaite DW, Bobrow BJ, Vadeboncoeur TF: The impact of prehospital transport interval on survival in out-of-hospital cardiac arrest: implications for regionalization of post-resuscitation care. Resuscitation. 2008, 79 (1): 61-66. 10.1016/j.resuscitation.2008.05.006.View ArticlePubMed
- Spaite DW, Stiell IG, Bobrow BJ: Effect of transport interval on out-of-hospital cardiac arrest survival in the OPALS study: implications for triaging patients to specialized cardiac arrest centers. Ann Emerg Med. 2009, 54: 248-255. 10.1016/j.annemergmed.2008.11.020.View ArticlePubMed
- Bobrow BJ, Kern KB: Regionalization of postcardiac arrest care. Curr Opin Crit Care. 2009, 15: 221-227. 10.1097/MCC.0b013e328329c293.View ArticlePubMed
- Bobrow BJ, Vadeboncoeur TF, Clark L, Chikani V: Establishing Arizona's statewide cardiac arrest reporting and educational network. Prehosp Emerg Care. 2008, 12: 381-387. 10.1080/10903120802100670.View ArticlePubMed
- Becker L, Gold LS, Eisenberg M, White L, Hearne T, Rea T: Ventricular fibrillation in King County, Washington: A 30-year perspective. Resuscitation. 2008, 79: 22-27. 10.1016/j.resuscitation.2008.06.019.View ArticlePubMed
- Berdowski J, Blom MT, Bardai A, Tan HL, Tijssen JGP, Koster RW: Impact of onsite or dispatched automated external defibrillator use on survival after out-of-hospital cardiac arrest. Circulation. 2011, 124: 2225-2232. 10.1161/CIRCULATIONAHA.110.015545.View ArticlePubMed
- Hupfl M, Selig HF, Nagele P: Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis. Lancet. 2010, 376: 1552-1557. 10.1016/S0140-6736(10)61454-7.PubMed CentralView ArticlePubMed
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.