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EMS CC only vs standard CPR

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest outside of a hospital  (P), does provision of chest compressions with delayed ventilation by EMS (I), compared with chest compressions with early ventilations by EMS (C), change survival with favorable neurologic outcome, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, time to first shock, time to first compressions, CPR quality (O)?
Consensus on Science:
For the critical outcome of survival to hospital discharge with favorable neurologic outcome in all OHCAs, we have identified very-low-quality evidence (downgraded for risk of bias and indirectness) from 1 observational trial(Bobrow 2009, 656) that enrolled 1019 patients showing no benefit (unadjusted OR, 1.07; 95% CI, 1.41–8.79).For the critical outcome of survival with favorable neurologic outcome in the subset of witnessed arrest/shockable rhythm OHCA, we identified very-low-quality evidence (downgraded for risk of bias and indirectness) from 3 observational studies(Kellum 2006, 335; Kellum 2008, 244; Bobrow 2009, 656) that enrolled 1325 patients showing benefit: OR, 3.6 (95% CI, 1.77–7.35)(Kellum 2008, 244); OR, 5.24 (95% CI, 2.16–12.75)(Kellum 2006, 335); and adjusted OR, 2.5 (95% CI, 1.3–4.6).(Bobrow 2009, 656)For the critical outcome of survival to hospital discharge in the subgroup of all OHCAs, we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 3 observational studies(Bobrow 2008, 1158; Mosier 2010, 269) showing benefit: OR, 3.26 (95% CI, 2.46–4.34)(Mosier 2010, 269); OR, 2.50 (95% CI, 1.75–3.58; cohort)(Bobrow 2008, 1158); and OR, 3.05 (95% CI, 1.07–8.66; before-after).(Bobrow 2008, 1158)For the critical outcome of survival to hospital discharge in the subgroup of witnessed arrest/shockable rhythm cardiac arrest, we identified very-low-quality evidence (downgraded for indirectness and imprecision) in 3 observational studies(Kellum 2006, 335; Bobrow 2008, 1158; Kellum 2008, 244) that showed benefit: OR, 3.67 (95% CI, 1.98–7.12)(Kellum 2008, 244); OR, 5.58 (95% CI, 2.36–13.20)(Kellum 2006, 335); OR, 2.94 (95% CI, 1.82–4.74); and OR, 4.3 (95% CI, 0.98–19.35).(Bobrow 2008, 1158)For the critical outcome of ROSC in all out of hospital cardiac arrest patients, we identified very-low-quality evidence (downgraded for risk of bias and indirectness) in 1 observational study(Bobrow 2009, 656) showing no benefit (OR, 0.85; 95% CI, 0.64–1.11) to EMS provision of chest compressions with delayed ventilation.
Treatment Recommendation:
We suggest that where EMS systems* have adopted bundles of care involving minimally interrupted cardiac resuscitation†, the bundle of care is a reasonable alternative to conventional CPR for witnessed shockable out of hospital cardiac arrest (weak recommendation, very-low-quality evidence).*Priority-based dispatch systems, multitiered response, EMS in urban and rural communities.†Up to 3 cycles of passive oxygen insufflation, airway adjunct insertion, and 200 continuous chest compressions with interposed shocks.Values, Preferences, and Task Force Insights This recommendation places a relatively high value on (1) the importance of provision of high-quality chest compressions and (2) simplifying resuscitation logistics in the out-of-hospital setting in a defined EMS system with demonstrated clinical benefit, and a relatively low value on the uncertain effectiveness, acceptability, feasibility, and resource use in different EMS systems compared with those in this CoSTR. We acknowledge the pending results of the important and very large clinical trial with a primary aim to compare survival at hospital discharge after continuous chest compressions versus conventional CPR with interrupted chest compressions in patients with OHCA.
CoSTR Attachments:
BLS 360 0.0 Lit Search Inclusion Exclusion Summary_n.xlsx    
BLS 360 1.0 Final Bias Assessment 20150114.pdf    
BLS 360 2.1 Evidence Profile Table 20150120.pdf    

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