Evidence Supporting Cardio-Cerebral Resuscitation - Literature review Example

?Running head: CARDIOCEREBRAL RESUSCITATION Evidence supporting Cardio-Cerebral Resuscitation (school) Evidence Supporting Cardio-Cerebral Resuscitation Cardiocerebral resuscitation, otherwise known as CCR, is currently considered to be the most effective means of resuscitating patients who have suffered cardiac arrest. It is a process which includes three elements: first, continuous chest compression for bystander resuscitation; second, updated algorithm for emergency medical services; and third, aggressive post-resuscitation management (Ewy and Kern, 2009). The initial elements of CCR have been conceptualized in Tucson, Arizona in 2003, and were later adopted in various territories, including Wisconsin in 2004 and Phoenix Arizona in 2005 (Kern, Timerman, Gonzalez, and Ramires, 2010). In Australia and New Zealand, the Resuscitation Council (2012) implemented changes in accordance with the recommendations of the International Liaison Committee on Resuscitation. The increased ratio of 30:2 (compressions: ventilations) was also implemented in 2010 (Robinson, Swain, Hoyle, and Larsen, 2010). This method is a favourable option for arresting patients because it has been known to improve the survival rate of patients, specifically those whose arrest have been witnessed by bystanders and those who have “shockable” heart rhythm upon the arrival of the emergency medical services (Ewy and Kern, 2009). This method also supports continuous chest compressions without mouth-to-mouth ventilations, as well as the application of defibrillation. For bystanders who can gain access to automated defibrillators, the immediate use of the defibrillator is recommended (Seethala, Esposito, and Abella, 2010). The use of CCR is, however, not yet fully supported in the medical community because some argue that no significant improvements in survival rate of arresting patients have been seen (Ong, Ng, Anushia, Tham, Leong, Tiah, and Lim, 2008). Various issues in its application have also been presented. These issues mostly relate to interruptions in the chest compressions and the risk of transmission of infections through mouth-to-mouth resuscitation (Boucek, Phrampus, Lutz, Dongilli, and Bircher, 2009). This paper shall now discuss CCR and the contrasting views related to its application. It shall discuss the argument that CCR is superior to CPR (cardiopulmonary resuscitation) in terms of survival rates and neurological outcomes. Supporting evidence on both sides of the issue shall be presented, along with more specific data which can be utilized to either support or disprove the general application of this intervention. Discussion CCR is superior to CPR I believe that CCR is an effective method of resuscitation as it can improve survival rates of arresting patients. A study by Ewy and Kern (2009) is based on a literature review of current studies supporting the application of CCR. The study points out that there are various issues in the use of CPR. Firstly, the bystanders witnessing arresting patients may be willing to notify the EMS; however, they may not be willing to carry out mouth-to-mouth ventilation (Ewy and Ker, 2009). Secondly, stopping the chest compression in order to ventilate the patient can often reduce the patient’s survival rate. Lastly, positive pressure ventilation in the CPR process for arresting patients can increase intrathoracic pressure, reduce venous return to the thorax, as well affect the circulation to the heart and brain (Ewy and Kern, 2009). These elements, when taken as a whole, make CPR a less effective means of managing arresting patients. The results of this study are, however, not significantly reliable because the data is based on secondary research. There are various pitfalls of secondary data, including the unreliability of the data gathered and the lack of control on the initial data gathered by the researchers (Yilmaz, 2009). Moreover, no actual clinical study was carried out by the authors, but their extrapolations were drawn from the primary studies of other researchers. In order to increase reliability of studies research related to cardiovascular research, a randomized controlled trial would have been more appropriate (Stanley, 2007). I support the application of cardiocerebral resuscitation for arresting patients. CCR does not include mouth-to-mouth ventilation, making it a more desirable option for bystanders attending to arresting patients (Bray, Deasy, Walsh, Bacon, Currell, and Smith, 2011). In CCR, the role of positive pressure ventilation by the EMS is reduced, and chest compressions are emphasized in the immediate moments following the arrest (Sayre, Berg, Cave, Page, Potts, and White, 2008). In a report by the International Liaison Committee on Resuscitation (2005), they established that chest compression-only resuscitation carried out on patients with a shockable rhythm, the rate of survival was higher as compared to CPRs. This report was able to establish strong and well-supported results for the application of CCR among arresting patients. There are various elements of CCR which are not adequately understood by the general public. It is important to understand however that CCRs are usually carried out for patients who have suffered cardiac arrest and CPRs are still appropriate for patients who have suffered respiratory arrest (International Liaison Committee on Resuscitation, 2005). This study also bases its data on reports by other international organizations, particularly the American Heart Association. Most of the data presented in this research is however also secondary information, making its results derivative and unoriginal (Shi, 2008). Without early defibrillation on a patient who suffered a cardiac arrest, the survival rate past the first five-minute period from the arrest is primarily based on sufficient coronary and cerebral perfusion pressures which can be established with chest compressions (Murthy and Hooda, 2009). Where both early defibrillation and bystander CCR are absent, the rate of patient survival is significantly reduced. This study by Murthy and Hooda (2009) is also a literature review and presents information from other studies which have already been carried out on the subject matter (Rubin, 2011). The crucial points of discussion are, however, well supported based on primary resources and research-based evidence. Moreover, the data presented by the authors follow the aggregate trends set by previous studies on the same issue (Gallin and Ognibene, 2011). The study also establishes various elements of CCR which have been supported by earlier and current research. In recent years, the usual practice of applying two ventilations for every 15 chest compressions was deemed inadequate for patient survival. The proportion was increased to 2 ventilations for every 30 chest compressions (Australian Resuscitation Council, 2012). This change did not however consider a major issue – the fact that bystanders are often unwilling to carry out mouth-to-mouth resuscitation on arresting individuals. As was also mentioned in the study by Alexander, Chinery, Swales, and Sutton (2009), a major factor affecting their unwillingness is the fact that mouth-to-mouth contact opens one to the exchange of salivary fluids which may cause the transfer of bacteria. Murthy and Hooda (2009) further point out that the fact that mouth-to-mouth ventilation may be a life-saving intervention is not sufficient to change their perception. Murthy and Hooda’s study (2009) is, however, lacking in various points of clinical application. Their results need more support from other studies, specifically randomized controlled trials which can implement specific and adequately managed variables (Cates, 2006). Various researchers have been carried out on CCR and its general applicability for arresting patients. In the paper by Mosier, Itty, Sanders, Mohler, Wendel, and Poulsen, (2010) the authors set out to compare the rate of survival of patients receiving CCR with those receiving ALS, assessing their neurologic outcomes and other factors affecting their survival. About 1024 patients receiving either CCR or ALS (advanced life support) were evaluated for this study. The results established that individuals who received CCR had better survival outcomes (Mosier, et al., 2010). The higher survival rate was more apparent in those whose arrest has been witnessed by bystanders. Survival rate, however, decreased with the advancing age of patients. Neurologic outcomes were also better for the CCR group as compared to the ALS group (Mosier, et al., 2010). All in all, the study indicates that the use of CCR presents with higher survival rates in most age groups, with more patients presenting with better neurological outcomes. The study above, however, has a lesser reliability because it is a retrospective analysis (Gallin and Ognibene, 2011). A randomised controlled trial would have provided a stronger analysis of the variables. However, carrying out a randomized controlled trial would likely be challenged by various ethical considerations, especially those involving risks on human respondents (Osrin, Azad, Fernandez, Manandhar, Mwansambo, Tripathy, and Costello, 2009). The post-resuscitation care of the patients was also not considered in the Mosier study, and yet these are elements of the practice which would likely affect results. In another study, authors Kellum, Kennedy and Ewy (2006) set out to evaluate the impact of two protocols implemented in two rural Wisconsin counties. The authors observed results after the protocols were implemented and compared with subjects observed in a three-year period before the protocol was carried out. The new protocol was based on the CCR method, whereas, the old protocol which was implemented in the three year period prior to the initiation of the study was based on CPR. The study revealed that in the three years before the implementation of the new protocol, there were 92 cardiac arrests witnessed. Standard CPR was applied to them (Kellum, et al., 2006). Eighteen patients were able to survive and 15% were neurologically undamaged. After the new protocol was carried out, of the 33 cardiac arrests witnessed, 19 survived and 48% did not suffer any neurological injury (Kellum, et al., 2006). In effect, the CCR proved to be a more effective protocol in the management of cardiac arrests, presenting with higher survival rates and less neurological damage. This study presented a timely evaluation for the respondents, without putting their lives at risk for the sake of the variables being studied (Osrin, et al., 2009). It is still an observation study with historical limitations (Kellum, et al., 2006). The increased rates of survival can only be considered as preliminary results, without any other controls and variables in place. Future studies therefore have to be carried out to evaluate the impact of defibrillation on arresting patients (Kellum, et al., 2006). In general, however, the authors were able to apply reliable and valid methods, using statistical measures for related variables, with clear and concise elements assessed based on applicability. Hallstrom, Cobb, Johnson, E. and Copas, (2000) sought to compare the application of CCR and CPR in an urban fire-department-based EM system. Bystanders at the scene were asked to either carry out CCR or CPR. There were 241 patients who were assigned to receive CCR and 279 were assigned to receive CPR. Detailed instructions to bystanders were given for each episode (Hallstrom, et al., 2000). The study was able to establish that outcomes in relation to survival and hospital discharge were higher in the CCR group as compared to the CPR group; however, the difference was not significant. Nevertheless, the authors supported the use of CCR as the preferred and more efficient approach for arresting patients. This study however did not follow an intention-to-treat analysis and this decreased the reliability of the results (Hallstrom, et al., 2000). The data from various patients were not included in the analysis, therefore specific qualities which may impact on results were not considered. This is, however, understandable because of the fact that dispatchers often do not have time to inquire about the specific details on arresting patients. The randomization process applied provided significant validity to the results. Moreover, the population was sufficient to establish the generalizability of said results (Stanley, 2007). Bobrow, Clark, Ewy, Chikani, Berg and Richman (2008) were also interested in evaluating the comparative efficacy of CCR with CPR among cardiac arrest patients. They carried out their prospective study, assessing patients with out-of-hospital cardiac arrests in Arizona before and after CCR training of fire department and emergency personnel. Another assessment was carried out on the two cities, comparing those who actually received CCR and those who received standard CPR. The respondents were assessed based on survival-to-hospital discharge. The study revealed that the survival-to-hospital discharge rate was increased from 1.8% before the CCR training to 5.4% after the CCR training (Bobrow, et al., 2008). In effect, the authors also echoed the previous results as emphasised in the above studies – that the survival rate for cardiac arrest patients is higher when CCR (as opposed to CPR) was applied. These results, however, have to be confirmed through a randomized controlled trial in order to lend greater reliability to the results. The respondents were not randomly chosen or assigned to particular protocols and this limited the generalizability of the results (Stanley, 2007). These results help reinforce the favourability of CCR among arresting patients, improving their survival rate and reducing their risk of suffering any neurological injury. CCR is not superior to CPR It is important to note that the use of CPR is not necessarily the better option for arresting patients. Some studies also discuss the more or less equal survival rates for patients regardless of the type of protocol applied (CCR or CPR). In the recent study by Svensson, Castren, Bohm, Pettersson, Engerstrom, and Herlitz (2010), the authors established that using CCR, instead of CPR, for cardiac arrest patients before paramedics arrive did not significantly improve outcomes for patients. When the 1 day and 30 day rates of survival were compared, similar results were still drawn. Studies where animal subjects were used also saw similar results, including similar neurological outcomes upon application of either CPR or CCR. In fact, in an older study carried out by Kern, Hilwig, Berg, and Ewy (1998), they were able to establish that both methods are equally effective in establishing improved patient outcomes. The application of pulmonary ventilation has been known to support the resuscitation process, preventing lung collapse and causing greater respiratory distress (Kern, et al., 1998). This study is not recent and more current results provide more reliable outcomes for this issue. No randomization techniques were applied and other outcome measures were not adequately studied by the researchers, thereby reducing the general applicability of the results (Stanley, 2007). Although these studies indicate that CCR is not superior to CPR, it does indicate that CCR is most likely the less risky choice (in terms of infection) to the bystander and EMS responder, as well as the patient because no mouth-to-mouth resuscitation is administered. Conclusion Cardiocerebral resuscitation is superior to CPR in terms of survival rates, neurological outcomes, and bystander/EMS risk. Continued chest compression is one of the main elements of cardiovascular resuscitation. Stopping the process to deliver pulmonary ventilation compromises the efficacy of the resuscitation and negatively affects patient outcomes. Studies above provide strong support for the preferred application of CCR. Weaknesses in this study are, however, found in terms of the lack of randomized controlled trials carried out on patients. There are some significant ethical issues which surround the application of randomized controlled trials because of the risks which are incurred by patients whose options of resuscitation lie in the researchers. The opposing evidence does not necessarily oppose the use of CCR, but it places both CPR and CCR on equal levels of efficacy, most especially in terms of higher survival rates and lower incidents of neurological damage. Such opposing evidence, however, is not convincing in terms of proving that CPR is the better option to CCR because in the end, the bystanders and EMS responders prefer not to carry out mouth-to-mouth resuscitations. Mouth-to-mouth resuscitation presents actual risks for both patient and rescuer, and therefore makes CPR the less desirable option. References Alexander, R., Chinery, J., Swales, H., & Sutton, D. 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