CPR during transport (BLS): Scoping Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable.

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: None applicable.

Task Force Scoping Review Citation

Smyth M, Chung S, Mancini MB, Avis S, Brooks S, Castren M, Considine J, Hung K, Kudenchuk P, Nishiyama C, Perkins GD, Ristagno G, Semeraro F, Smith C, Morley PT, Olasveengen TM -on behalf of the International Liaison Committee on Resuscitation Basic Life Support Task Force. Pad size, orientation and placement for Cardiac Arrest - Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2020 Jan 2^nd. Available from: http://ilcor.org

Methodology

The continuous evidence evaluation process started with a scoping review of basic life support during ambulance transport conducted by the ILCOR BLS Task Force Scoping Review team. Evidence for adult and pediatric literature was sought, however no studies addressing the paediatric population were identified. The task force insights are provided by the Basic Life Support Task Force.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults and children receiving CPR in the out-of-hospital setting

Intervention: Transport to hospital

Comparators: Completing CPR on scene

Outcomes: Critical: Survival with good neurological function (i.e. at hospital discharge, 1 month, 6 months, 1 year), Critical: survival (i.e. hospital discharge, 1 month, 6 months, 1 year survival), Important: short term survival (return of spontaneous circulation – ROSC, hospital admission), Important: CPR quality parameters (i.e. compression fraction rate, depth, leaning etc).

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to July 27th, 2019.

Search Strategy

MEDLINE and EMBASE combined, via the OVID interface. Initial search completed on 26/11/2018, with follow-up search completed on 27/07/2019

Inclusion and Exclusion criteria

• Inclusion criteria – Adult or paediatric, out of hospital cardiac arrest, transported to hospital
• Exclusion criteria – ROSC prior to arrival at hospital

Data Tables

See separate attached document: BLS 1509 Scoping Review Data Tables

Task Force Insights

1. Why this topic was reviewed.

This topic has not been reviewed since before 2005.

2. Narrative summary of evidence identified

There was significant heterogeneity among study populations, study methodologies, outcome measures utilised and outcomes reported. Findings are grouped into themes and a narrative analysis is provided.

Studies reporting survival among OOHCA patients transported with CPR in progress (arriving at hospital without a pulse)

There were no randomised controlled trials and 8 non-randomised studies (Drennan 2014 1488; Gray 1991 1393; Kellerman 1993 1433; Lewis 1990 118; Lim 2002 96; Schoenenberger 1994 2433; Yates 2018 133; Zive 2011 277) reporting survival outcomes for OOHCA patients transported with CPR in progress and arriving at hospital without a pulse. All 8 studies reported on patients who achieved ROSC in the ED as well as survival to discharge, however only 3 studies reported neurologic outcome (Kellerman 1993 1433, Schoenenberger 1994 2433, Yates 2018 133).

The included studies comprised 12,072 patients of whom 1,146 (9.5%) achieved ROSC in the ED and 361 (2.9%) survived to hospital discharge. One study planned to report neurologic status at discharge (Kellerman 1993, 1433, n=1,068) however no patients survived. Two studies (Schoenenberger 1994 2433; Yates 2018 133) comprising 368 patients reported 19 (5.2%) patients had a favourable neurologic outcome (defined as CPC 1 or 2) at 1 year. However, the distribution of survivors with favourable neurologic outcome between these studies was uneven. In the study by Yates (Yates 2017 133) 3 out of 227 patients (1.3%) survived with favourable neurologic outcome, while in the study by Schoenenberger (Schoenenberger 1994 2433) 16 of 141 patients (11.3%) survived with favourable neurologic outcome

Studies reporting quality of manual CPR on scene versus during transport – human studies

There were no randomised controlled trials and 5 non-randomised studies (Cheskes 2017 34; Odegaard 2009 843; Olasveengen 2008 185; Roosa 2013 592; Russi 2016 634) comparing quality of CPR on scene versus quality of CPR during transport to hospital among patients suffering OOHCA and who failed to achieve ROSC on scene. The included studies comprised 1,219 patients, of whom, 9 received mechanical CPR (Olasveengen 2008 185).

Two studies (Cheskes 2017 34; Roosa 2013 592) comprising 899 patients conclude quality of CPR during transport is no worse than quality of CPR on scene. Cheskes (Cheskes 2017 34) further suggests that it is possible to deliver high performance CPR during transport. Two studies (Olasveengen 2008 185; Russi 2016 634) comprising 215 patients conclude quality of CPR was poorer during transport than on scene, while one study (Odegaard 2009 843) (n=105) concluded CPR quality was poor both on scene and during transport.

Various metrics were used to assess quality of CPR across the included studies including median compression rate, median compression depth, chest compression fraction, no flow duration, ventilation rate, variation in chest compression rate/depth. Both studies concluding quality of CPR during transport was no worse than quality of CPR on scene reported means for variables measured and note that CPR quality metrics were variable during transport.

Studies reporting quality of manual CPR on scene versus during transport – manikin studies

There were 4 randomised controlled trials (Braunfels 1997 128; Havel 2010 59; Lipman 2013 162; Sunde 1997 235) and 4 non-randomised studies (Chung 2010 841; Roberts 1979 30; Stapleton 2017 63; Stone 1995 121) comparing quality of CPR on scene versus quality of CPR during transport using manikins. Two studies (Roberts 1979 30; Sunde 1997 235) additionally contrasted CPR quality metrics between manual and mechanical CPR. In the randomised controlled trials quality of CPR was variously reported as % correct compressions, variation in compression rate, variation in compression depth, correct hand placement and adequate recoil. In the 4 non-randomised studies quality of CPR measures included compression rate, compression depth, ventilation rate and ventilation volume. Manikin studies suggest CPR quality is poorer during transport than when on scene.

Studies comparing manual vs mechanical CPR during transport - ROSC and survival outcomes

There were 3 randomised controlled trials (Axelsson 2009 1099; Dickinson 1998 289; Hallstrom 2006 2620) and 3 non-randomised studies (Axelsson 2006 47; Casner 2005 61; Ong 2006 2629) comparing survival outcomes for OOHCA patients transported with manual CPR versus mechanical CPR. The 3 RCTs comprising 900 patients showed no benefit from mechanical CPR with respect to ROSC or survival to discharge. One of the studies (Hallstrom 2006 2620) suggested functional neurologic outcomes may be worse when mechanical CPR is provided. The 3 non-randomised studies comprising 1,273 patients report conflicting results. The largest study (Ong 2006 2629) (n=783) suggests mechanical CPR is associated with increased ROSC, survival to hospital admission and survival to hospital discharge, however there was no difference in functional neurologic outcome. The two smaller studies (Axelsson 2006 47) (n=328) and Casner 2005 61) (n=162) suggest no significant difference in important survival outcomes.

Studies comparing manual vs mechanical CPR during transport – physiologic outcomes and CPR quality CPR metrics

There were 2 randomised controlled trials (Axelsson 2009 1099; Dickinson 1998 289) and 3 non-randomised studies (Kim 2017 636; Lyon 2015 102; Wang 2007 453) comparing physiologic outcomes and CPR quality metrics among OOHCA patients transported with manual CPR versus mechanical CPR. The 2 RCTs comprising 143 patients reported conflicting results with 1 study (Axelsson 2009 1099) (n=126) indicating improved EtCO2 when mCPR is provided and the other (Dickinson 1998 289) (n=17) suggesting there was no difference. The 3 non-randomised studies were also not equivocal 1 study (Kim 2017 636) (n=17) suggested CCF was improved by implementing mCPR. Lyon (Lyon 2015 102) reported that the median time interruption from last manual CPR compression to first mCPR compression was 39s (Range 14-118 sec IQR 29s-47s). This may partially explain why Wang (Wang 2007 453) (n=20) reported that the no compression (hands off) interval was similar in both groups and mCPR patients received a lower mean compression rate.

Studies comparing manual vs mechanical CPR during transport – manikin studies

There were 4 randomised controlled trials (Kim 2016 1604; Lipman 2013 162; Putzer 2013 201; Sunde 1997 235) and 3 non-randomised studies (Fox 2013 1; Gassler 2013 589; Roberts 1979 30) comparing manual versus mechanical CPR during ambulance transport using manikins. Mechanical CPR provided consistent CPR whereas several studies suggested quality of manual CPR declined during transport.

Studies addressing survival among out of hospital cardiac arrest patients transported without prehospital ROSC where a TOR advocated transport

We identified no randomised controlled trials and 2 non-randomised studies ¹³⁶ (Drennan 2014, 1488; Yates 2018, 133) addressing survival among out of hospital cardiac arrest patients transported without prehospital ROSC where a TOR advocated transport.

Among 20,207 OHCA treated by EMS, Drennan et al (Drennan 2014 1488) identified 3,374 (16.4%) cases where prehospital ROSC was not achieved and the Universal TOR guideline recommended transport to hospital with ongoing resuscitation. Of these patients, 122 (3.6%) survived to hospital discharge. A smaller study by Yates et al (Yates 2018 133) identified 227 cardiac arrest cases, not eligible for prehospital termination of resuscitation (per the UK ambulance TOR guideline) who were transported with ongoing CPR. Of these only patients 7 (3.1%) had a potentially reversible cause of cardiac arrest. Most patients (n = 210, 92.5%) died in the emergency department, although 17 were admitted (14 to intensive care). Only 3 (1.3%) survived to hospital discharge. Among those transported with CPR, the universal TOR guideline would have recommended resuscitation be stopped without transport in 89 (39.2%) cases. There were no survivors (0%) among patients eligible for the universal TOR guideline.

Studies addressing duration and or distance of transport on outcomes

We identified no randomised controlled trials and 5 non-randomised studies (Cudnik 2010 518; Geri 2017 96; Spaite 2008 61; Spaite 2009 248; Zive 2011 277) addressing duration and or distance of transport on outcomes.

In a moderately sized logistic analysis (n=7,540) Cudnik et al (Cudnik 2010 518) determined that transport distance was not associated with survival (OR 1.00; 95% CI 0.99 to 1.01). A systematic review and meta-analysis by Geri et al (Geri 2017 96) similarly reported no significant relationship between transport distance and survival to discharge (mean diff -0.05 [95% CI -0,86 to 0.76]). Two studies by Spaite et al (Spaite 2008 61; Spaite 2009 248) similarly concluded that Survival was not significantly impacted by transport interval OR 1.2 (95% CI 0.77 to 1.8) and OR 1.01 (95% CI 0.99 to 1.05) respectively. In an analysis of the ROC epistry Zive et al (Zive 2011 277) reported that among 4,586 cases where transport was initiated without achieving ROSC on scene, 386 achieved ROSC before arriving at the ED and 198 survived to hospital discharge.

Other

We identified 1 randomised controlled trial (Lei 2010 1562) and 1 non-randomised study (Hung 2017 398) where alternative approaches to the provision of manual CPR received by patients was compared during transport. Lei (Lei 2010 1562) compared two different approaches to manual CPR during transport (standard vs straddling the stretcher). They were unable to identify a significant difference between these two approaches. Hung (Hung 2017 398) compared quality of CPR when 1 versus 2 EMTs were attending the patient during transport. Quality of CPR was improved when there were 2 EMTs vs only 1 EMT.

A study by Kurz (Kurz 2012 1085) identified the forces applied to EMTs while performing CPR in a moving ambulance as a result of accelartion, deceleration and turning. They identified that these forces impacted the EMTs ability to provide adequate CPR and theorised that this would have significant adverse impact on achieving/maintaining the minmum coronary perfusion pressure required to achieve ROSC (15mmHg).

3. Narrative Reporting of the task force discussions

There was considerable Task Force debate concerning the appropriate outcome for this PICOST:

• Is quality of CPR quality during transport better/no different/worse than quality of CPR on scene?
• Are clinical outcomes impacted by the decision to transport with CPR?
• When should the decision to transport with ongoing CPR be made?
• Does distance of transport affect outcomes?
• Can we identify which patient groups will/will not benefit form transport with ongoing CPR?
• Should we recommend the use of mechanical CPR during transport?

The Task Force acknowledges several confounding factors when interpreting evidence e.g. use of feedback devices to improve CPR quality during transport or the implementation of high performance CPR within EMS systems. In addition, the Task Force noted that studies reporting quality of CPR metrics reported mean outcome measures and acknowledge that quality of CPR may have fluctuated considerably.

This topic has not been addressed by ILCOR for many years. This scoping review has identified new evidence addressing this topic. The BLS Task Force recognizes that it may be appropriate to undertake more than one systematic review based on our findings. The BLS Task Force will seek public feedback to prioritize which questions to explore in the coming year. In the first instance the BLS Task Force will commence a systematic review comparing quality of CPR metrics on scene versus during transport.

Knowledge Gaps

There is a paucity of evidence addressing the impact of transport on quality of CPR and subsequent clinical outcomes. EMS crews would benefit from guidance addressing:

• Which patient groups might benefit from resuscitation on scene?
• Which patient groups might benefit from early initiation of transport?
• When transport should be initiated, including timing and in relation to procedures/interventions?
• What is the most appropriate form of CPR (e.g. mechanical vs manual) during transport?
• Do feedback devices help ensure quality of CPR during transport?
• Risk to EMS providers performing CPR on scene versus in a moving vehicle.

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