Washington University Emergency Medicine Journal Club – March 2025
Vignette
You’re working a TCC shift when you encounter a patient brought in by EMS in cardiac arrest. He is a 58-year-old male with a witnessed cardiac arrest with bystander CPR. On EMS arrival they switched the patient over to the LUCAS II chest compression system for transport. The patient was initially in ventricular fibrillation and received shocks X 3, Epi x3, and amidoamine x1. Total down time prior to arrival is only 20 mins. You move the patient over to the hospital stretcher and he is intubated while he is hooked up to our devices. During his first rhythm check he is found to be in PEA and compressions are continued with the LUCAS device. You notice that his ETC02 during compressions is 8. Given his short down time with bystander CPR, you expected him to have better ETCO2. You wonder if compression quality would be better with manual compressions instead of the LUCAS device…
PICO Question
Population: Adult patients suffering out-of-hospital cardiac arrest
Intervention: CPR using mechanical chest compression devices
Comparison: CPR using manual chest compressions
Outcome: ROSC, survival to hospital admission, survival to hospital discharge,
survival at 1, 3, 6 months, and survival with a good functional neurologic outcome
Search Strategy
Article 1: Hallstrom A, Rea TD, Sayre MR, Christenson J, Anton AR, Mosesso VN Jr, Van Ottingham L, Olsufka M, Pennington S, White LJ, Yahn S, Husar J, Morris MF, Cobb LA. Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial. JAMA. 2006 Jun 14;295(22):2620-8. doi: 10.1001/jama.295.22.2620. PMID: 16772625. Answer Key
Article 2: Perkins GD, Lall R, Quinn T, Deakin CD, Cooke MW, Horton J, Lamb SE, Slowther AM, Woollard M, Carson A, Smyth M, Whitfield R, Williams A, Pocock H, Black JJ, Wright J, Han K, Gates S; PARAMEDIC trial collaborators. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet. 2015 Mar 14;385(9972):947-55. doi: 10.1016/S0140-6736(14)61886-9. Epub 2014 Nov 16. PMID: 25467566. Answer Key
Article 3: Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, Halliwell D, Box M, Herlitz J, Karlsten R. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA. 2014 Jan 1;311(1):53-61. doi: 10.1001/jama.2013.282538. PMID: 24240611. Answer Key
Article 4: Larik MO, Ahmed A, Shiraz MI, Shiraz SA, Anjum MU, Bhattarai P. Comparison of manual chest compression versus mechanical chest compression for out-of-hospital cardiac arrest: A systematic review and meta-analysis. Medicine (Baltimore). 2024 Feb 23;103(8):e37294. doi: 10.1097/MD.0000000000037294. PMID: 38394534; PMCID: PMC10883626. Answer Key
Bottom Line
Three large trials performed in multiple countries, each representing multiple
ambulances and multiple EMS systems, have now demonstrated no benefit to
mechanical chest compression devices for OHCA compared to manual chest
compressions, with some evidence for worsened functional status in survivors in
whom these devices were used.
Hallstrom et al: A cluster randomized controlled trial conducted at multiple cities in
Canada and the US with 767 total patients found no significant difference in survival
at 4 hours after the 911 call between the manual CPR group and the mechanical
chest compression group (RR 1.07, 95% CI 0.84 to 1.36). Survival to hospital
discharge was lower in the mechanical compression group(5.8% vs. 9.9%; p = 0.04)
as was survival with a CPC score of 1 or 2 (RR 0.41, 95% CI 0.21 to 0.79).
PARAMEDIC Trial: A pragmatic, cluster randomized controlled trial conducted using
91 ambulance stations in four UK National Health Service (NHS) Ambulance
Services with 4471 patients found no difference in 30-day survival between
mechanical and manual chest compression (6% vs. 7%, adjusted OR 0.86; 95% CI
0.64–1.15). The proportion of patients achieving any ROSC (OR 1.02, 95% CI 0.89–
1.16) and sustained ROSC to transfer of care at the receiving hospital (OR 0.97, 95%
CI 0.83–1.14) was similar in the two groups, as was survival at 3 months (OR 0.89,
95% CI 0.69–1.15). The number of patients with a favorable neurological outcome at
3 months was lower in the mechanical compression group than in the control group
(OR 0.77, 95% CI 0.59–1.02).
LINC Trial: A multi-center, randomized controlled trial conducted in 6 advanced life
support emergency medical systems in Sweden, the Netherlands, and the United
Kingdom enrolling 2589 patients found no significant difference in 4-hour survival
between the mechanical CPR group and the manual CPR group (23.6% vs 23.7%,
risk difference [RD] −0.05%; 95% CI, –3.3% to 3.2%). There was also no significant
difference in the proportion of patients who arrived at the emergency department
with a palpable pulse (RD 0.46%, 95% CI -3.0% to 3.9%), no significant difference in
the proportion of patients surviving to ICU discharge with a good neurologic
outcome (RD 1.18%, 95% CI -0.8% to 3.1%) or surviving to hospital discharge with
a good neurologic outcome (RD 0.55%, 95% CI -1.5% TO 12.6%), and no significant
difference in the proportion of patients with 1-month (RD 0.78%, 95% CI -1.3% to
2.8%) or 6-month (RD 0.86%, 95% CI -1.2% to 3.0%) survival with a good
neurologic outcome.
These findings are further supported by the results of a systematic review and metaanalysis
of 24 studies which found no significant difference in ROSC (OR: 0.90; 95%
CI 0.79 to 1.03; P = .13; I2 = 88%), 24-hour survival (OR: 0.77; 95% CI 0.49 to 1.20; P
= .24; I2 = 88%), survival to discharge (OR: 1.12; 95% CI 0.89 to 1.40; P = .34; I2 =
80%), or survival beyond 30 days (OR: 1.05; 95% CI 0.84 to 1.32; P = .65; I2 = 0%).
Patients undergoing manual compression demonstrated significantly higher rates of
a favorable neurological outcome when compared to mechanical compression (OR:
3
1.41; 95% CI 1.07 to 1.84; P = .01; I2 = 84%). This meta-analysis was limited by a
high degree of heterogeneity between study results, but also by the inclusion of
studies of very disparate methodology, including randomized controlled trials, a
prospective non-randomized trial, cohort studies, and case-control studies.
These data suggest that mechanical compression devices offer no short-term
survival benefit in patients with OHCA, with a strong suggestion that they may
worsen long-term functional outcomes. While there may be some circumstances in
which mechanical compression devices may offer benefit—including intra-arrest
transport, patients requiring extra-corporeal membrane oxygenation (ECMO), and
limited personnel precluding performance of manual compression—routine
prehospital use is not ideal and these devices should not be applied doing so will
result in prolonged time off the chest or suboptimal compressions.