CPR - Chain of Survival

Need for more CPR Training

According to the latest Heart Disease and Stroke Statistics - 2018 Update by the American Heart Association (AHA), one of every 7.4 people in the United States will die of sudden cardiac death (SCD). The incidence of EMS-assessed out-of-hospital cardiac arrest (OHCA) is about 356,000 people per year in the USA. Even though the survival rate has improved, the survival rate is still as low as 10.8%. It is worth noting that in adult OHCA 20% of the patients had a shockable rhythm, i.e. ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), whereas in children only 7.2%. This indicates that cardiopulmonary resuscitation (CPR), either hands-only CPR or CPR including mouth-to-mouth breaths, represents the most important life-saving action in the event of a sudden cardiac arrest (SCA).

Because 68.1% of adult OHCA and 83.6% in children OHCA occur at home, immediate commencement of CPR, after calling for help (call 911 in the USA), is extremely important. The AHA found out in a 2015 survey in the U.S. that 18% of participants reported current CPR training and 65% reported having CPR training at some point. The AHA estimated that bystander CPR was performed in 45.7% in adult OHCA and 61.4% in children OHCA. Overall, less than 50% of bystanders apply life-saving CPR. Therefore, the AHA recognized the need for more CPR training to improve survival.

Chain of Survival

The concept of the chain of survival was introduced to highlight the interrelationship between key stages of resuscitation. To be most effective, every link must be strong to support the chain of survival. Bystanders of a sudden collapse with no pulse, no breath, and loss of consciousness must act immediately to improve survival.
Some authors report that sometimes regular breathing can persist for up to two minutes following OHCA (Online Link).

The five links in the adult out-of-hospital chain of survival are

  • Recognition of cardiac arrest and activation of the emergency response system
  • Early cardiopulmonary resuscitation (CPR) with high quality chest compressions
  • Early defibrillation with automated external defibrillator (AED)
  • Basic and advanced emergency medical services
  • Advanced life support and post-cardiac arrest care

Chain of Survival. High Quality CPR. Automated External Defibrillator (AED)

Recognition and activation of the emergency response system

Immediate high quality CPR

If shockable rhythm, rapid defibrillation

Emergency Medical Services (EMS)

Advanced Life Support and post arrest care

Usually, the first three links are in the hands of one or more lay-rescuers and need to be executed within the first 2-5 minutes. Immediate CPR helps to maintain life-saving circulation until the AED becomes available and the emergency team arrives. Time is the key determinant for improved survival.

Reduce Time Span to Bystander CPR

In a recent letter to the editor of the medical journal Resuscitation , the authors discuss how CPR training and phone-CPR can be used to overcome freezing in bystanders. They suggest strategies to turn the instinctive "flight" response into a "fight" response based on the 7 C's approach of the military's Combat and Operational Stress First Aid Program ( COSFA ): check - coordinate - cover - calm - connect - competence - confidence.

The authors suggest that CPR training could teach the 7 C's as a framework to make the student aware of the acute stress response and teach techniques how to lower stress levels. During real life CPR, the dispatcher of the emergency response system could ask the bystander to leave the phone on speakers and provide CPR instructions over the telephone. The operator should encourage the lay-rescuer to perform hands-only CPR. The dispatcher could ask questions about the victim to encourage the lay-rescuer to talk and thereby induce prolonged expiration. In addition, supportive talk could help to restore confidence and self-esteem. If the stress level remains high, the trained phone operator should instruct the rescuer to breath out slowly for a few seconds to increase the vagal tone.

The authors conclude, that
  1) Preparing for the acute stress response during CPR training and
  2) Teaching phone operators how to calm lay-rescuers
might be beneficial for both victims and bystanders. The rate of bystander CPR could improve and trauma responses be avoided.

Automated External Defibrillator (AED)

The third link represents external defibrillation which is often still in the hands of lay-rescuers. Ideally, the AED is retrieved by a second person as quick as possible while the first rescuer continues high-quality CPR. Modern AEDs are fully automatic and are designed in a way that an untrained rescuer can use them.

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The AHA states that survival in patients with ventricular fibrillation or pulseless ventricular tachycardia is highest when CPR and defibrillation is delivered within 3 to 5 minutes of collapse.

In a state-of-the-art review ("Defibrillation for Ventricular Fibrillation, A Shocking Update" ), Nichol et al. suggest strategies to increase AED use. They conclude that mobile phone-based reminder systems, personal deļ¬brillation, and possibly, wearable defibrillation devices might represent the most promising technologies to increase the survival rate of victims of sudden cardiac arrest with VF.