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BLS-08-v1
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RECOVER 2.0 Worksheet
QUESTION ID: BLS-08
PICO Question:
In cats and dogs in CPA (P), does the use of any other specific timing for interruptions to chest compressions to diagnose the heart rhythm (I), compared to ECG check every 2 minutes (C), improve ... (O)?
Outcomes:
Favorable neurologic outcome, Surrogate marker(s) of perfusion, Survival to discharge, ROSC
Prioritized Outcomes (1= most critical; final number = least important):
- Favorable neurological outcome
- Survival to discharge
- ROSC
- Surrogate markers of perfusion
Domain chairs: Steve Epstein, Kate Hopper; final edits by Jamie Burkitt
Evidence evaluators: Colin Reich, Janine Calabro
Conflicts of interest: none reported
Search strategy: See attached document
Evidence Review:
Add rows to the table to incorporate all outcomes evaluated as part of the evidence review and all study types. You can use this template to add a new outcome by copying and pasting it to the end of the table. Once you have completed your review, please delete this template from the document.
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Positive Quality Factors
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Dichotomous Outcome Summary |
Non-Dichotomous Outcome Summary
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Overall Quality
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Outcome: Favorable neurologic outcome, Survival to discharge, ROSC, Surrogate markers of perfusion |
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PICO Question Summary
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Introduction |
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There is evidence that performing high-quality chest compressions for 2 minutes before pausing to analyze the ECG rhythm during ALS improves outcome compared to stopping compressions more frequently.[ref[1]] Current human and previous veterinary guidelines have recommended changing chest compressors every 2 minutes based on the likelihood of rescuer fatigue with longer periods of continuous compressions.[ref] The ideal length of continuous chest compression cycle for dogs and cats is unknown.
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Consensus on science |
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For the most critical outcomes of FNO, Survival to discharge, ROSC, and Surrogate markers of perfusion, we identified no studies that address the PICO question.
There are currently no studies that directly address the question of specific timing for interruptions to chest compressions to diagnose the heart rhythm for any outcome of interest. There is evidence that the frequency and duration of interruptions to chest compressions can impact the outcome following CPR. In experimental pig studies, it has been shown that it takes approximately 60 seconds of continuous chest compressions to generate and maintain maximal CPP and pauses in chest compressions are associated with immediate decrease in CPP.1,2 There is some evidence from human clinical trials that a period of BLS CPR is beneficial prior to performing a rhythm check. In a prospective, observational analysis of witnessed human arrests, providing 2-minute (200 chest compressions at 100 compressions/min) blocks of uninterrupted chest compressions, pausing only to perform a rhythm check ± defibrillation, was associated with significant improvement in survival and neurological state when compared to a cohort of patients treated using the 2000 American Heart Association guidelines in which chest compressions were frequently interrupted.3 Mosier et al. reported similar results in a retrospective analysis of the use of the same protocol.4
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Treatment recommendation |
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In intubated dogs and cats undergoing CPR, we recommend delivering CPR in 2-minute cycles of continuous high-quality chest compressions. (strong recommendation, expert opinion)
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Justification of treatment recommendation |
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Recommendations for the 2-minute interval follow from the evidence that more frequent interruptions of chest compressions have been associated with worse outcome, while personnel may become fatigued when performing manual chest compressions for longer than 2 minutes. As a pause is needed for changing of compressors, it is a logical time to check the ECG.
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Knowledge gaps |
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The optimal cycle duration of continuous high-quality chest compressions during CPR in dogs and cats is unknown.
It is unknown whether the 2-minute chest compression cycle should be paused for patient and ECG evaluation when there is a marked increase in ETCO2 or another compelling sign of ROSC.
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References:
1. Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104(20):2465-2470.
2. Kern KB, Hilwig RW, Berg RA, Ewy GA. Efficacy of chest compression-only BLS CPR in the presence of an occluded airway. Resuscitation. 1998;39(3):179-188.
3. Kellum MJ, Kennedy KW, Barney R, et al. Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest. Ann Emerg Med. 2008;52(3):244-252.
4. Mosier J, Itty A, Sanders A, et al. Cardiocerebral resuscitation is associated with improved survival and neurologic outcome from out-of-hospital cardiac arrest in elders. Acad Emerg Med Off J Soc Acad Emerg Med. 2010;17(3):269-275.
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