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Advice to delay second shock not linked with improved survival

  • 8 Comments

Advice to delay giving a second heart shock to patients with cardiac arrest in hospital is not associated with improved survival, according to US researchers.

US national guidelines were revised in 2005 to recommend deferring a second defibrillation attempt to allow time for chest compressions.

However, study authors said data on the effect of the guideline changes on survival for patients with cardiac arrest in hospital were lacking.

They used data from a national registry to examine trends in the time interval between first and second defibrillation attempts among 2,733 patients undergoing cardiac arrest in 172 hospitals.

In line with the guidelines, the proportion of patients with a deferred second defibrillation attempt doubled from about 25% in 2004 to slightly more than 50% in 2012.

However, deferred second defibrillation was not found to be associated with improved survival.

Writing in the British Medical Journal, the authors said the findings raised questions about the specific benefit of deferred second defibrillation attempts for patients in hospital.

Meanwhile, a second study in the BMJ found early administration of adrenaline – within two minutes after the first defibrillation – was associated with poorer outcomes in hospital patients with cardiac arrest and a shockable rhythm.

Researchers looked at data on almost 3,000 patients with cardiac arrest at more than 300 US hospitals.

In a comment piece in the same journal, UK experts from Warwick Medical School said the results from the two studies should inform practice.

Meanwhile, Dr Carl Gwinnutt, president of the UK’s Resuscitation Council, noted that its current UK guidelines, published in October 2015, differed from those in the US.

The UK guidance recommend that, where a patient suffers a witnessed and monitored arrest, for example in a critical care area, three shocks are given in quick succession – referred to as “stacked shocks”. In other situations, the guidelines advocate that between the first and second shocks there should be a two-minute period of chest compressions.

Dr Gwinnutt also highlighted that there might be other explanations for the US study findings.

Resuscitation Council

Defib timing in resuscitation guidelines questioned

Carl Gwinnutt

For example, a greater proportion of patients in the shock delay group had sepsis, which is associated with a very poor outcome from cardiac arrest, and more were also being cared for in wards where they were not on heart monitors, which may have delayed the start of resuscitation.

He added: “There is evidence that outcome is worse in those patients where there is a prolonged delay between stopping chest compressions and delivering the shock, and this may have been a further factor influencing the findings.

“Consequently, the current guidelines issued by the Resuscitation Council (UK) advocate two minutes of high quality chest compressions between the first and second shocks with an interruption to chest compressions of less than five seconds whilst the shock is delivered,” he said.

  • 8 Comments

Readers' comments (8)

  • michael stone

    It isn't easy to 'set up any sort of controlled experiment' for CPR, so analysing whatever data there is is always going to be tricky. CPR is a relatively ineffective treatment - which is not to say it shouldn't be an option - but I do wish that people would stop confusing CPR with various other things, as I recently explained:

    http://www.bmj.com/content/352/bmj.i1494/rr-3

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  • Michael Stone, you miss the point entirely. Do you even understand what the article is about? Once again you see a headline vaguely related to your 'interest' and try to gain attention by twisting the subject of the article to meet your own ends as well as posting your views in other publications which could seriously mislead the public.

    As you had issues with how your affairs were handled by the police, where all your problems stem from, have you gone into all the details with them that you have done in this professional nursing journal on an almost daily basis for years and the BMJ, which you treat with greater respect, and told them how you think they should do their job?

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  • michael stone

    ANONYMOUS 10 APRIL, 2016 8:26 AM

    I don't 'miss the point' - this piece is in support of attempting CPR using, to use my phrase here, 'the best available of some fairly poor-quality evidence about CPR'. Before it reached NT, the story was covered on BMJ.

    Yes, I do moan at police officers - most recently at the police officers who are on the MCA Implementation Group being lead by Baroness Finlay. A couple of weeks ago, one of them admitted that police officers cannot be expected to understand the MCA, which clearly will not help if they start to interact with welfare attorneys.

    I don't have less respect for NT than for BMJ: the two things are different, but quite why you think I somehow 'disrespect' NT puzzles me.

    As for:

    'As you had issues with how your affairs were handled by the police, where all your problems stem from'

    not quite the situation. My concerns about behaviour for EoL at home, did stem from the behaviour of 999 (paramedics and police) but the issue is the contemporary guidance, and the lack of joined-up and perspective-balanced behaviour, and 'mindsets'. My concerns are about why what happened to me, happened: because it wasn't just 'bad luck' it was deeply connected to training and attitude [although I am perfectly willing to admit, that it angered, and angers, me].

    But, very probably pointless, trying to explain anything to you.

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  • michael stone

    ANONYMOUS 10 APRIL, 2016 8:26 AM

    By the way, none of the issues I mentioned in the BMJ piece I linked to above, dig into an analysis of the immediate post-mortem behaviour which afflicted me - they are all about either poor understanding, or very similar issues, connected to CPR.

    It IS TRUE, that clinicians seem much keener to discuss how CPR can be best performed, than to discuss those issues - which is rather the point !

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  • Stone. Clearly you haven't bothered to read the article before taking to the keyboard or lack the clinical background knowledge to understand it.

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  • We have always used 'stacked shocks' without the compressions in a specialist PPCI cardiology dept I currently work for.
    If I attend a cardiac arrest which is unexpected, I assess accordingly and if stacked shocks are required, then thats what I do.
    As for the 'troll' who has issues with your journalist on here, dont feed it!
    Im sick and tired of reading the vitriolic comments this troll has and thier anger is disproportionate and scary. I hope this 'person' is not an RN as I would question their ability to behave as a professional with patients.

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  • Diazimuls

    Shame you are not professional enough to grasp the difference between constructive feedback and trolling. Careful you don't label yourself as the troll here as your comment suggests.

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  • ,If I attend a cardiac arrest which is unexpected, I assess accordingly and if stacked shocks are required, then thats what I do.'

    please explain how this comment contributes to the professional knowledge base required to inform best practice?
    What are the patient outcomes of these actions?

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