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Thursday, February 28, 2013

New research that will NOT help you.

There is a lot of discussion about different approaches to CPR these days: Cardiocerebral resuscitation, minimizing the peri-shock pause, "pit crew" CPR, etc. These are great topics, with some interesting research backing them up. This post isn't about those topics!
 
(CEMSMAC) who voted unanimously (5-0) to back the draft document - See more at: http://medicscribe.com/2013/02/in-praise-of-cemsmac/#sthash.2mwVR64E.dpuf
(CEMSMAC) who voted unanimously (5-0) to back the draft document - See more at: http://medicscribe.com/2013/02/in-praise-of-cemsmac/#sthash.2mwVR64E.dpuf
Instead, there were two recent publications that describe methods in CPR that I don't want to see anybody use in the foreseeable future. This is not a case of "needs to be tested in a large clinical trial," and it also isn't the case that "CEMSMAC voted unanimously to back the draft document," and we're still waiting for regional guidelines.

Now, perhaps one day, far in the future, there will be some evidence for the methods the authors are describing. But given the quality of these publications, I'm guessing that that day is still a ways off.

"Should we squeeze people's belly and legs during CPR?"
Even though MAST pants have gone the way of the dodo, and Trendelenburg position is going that way as well, the appeal of "auto-transfusion" persists.


To be fair, the look never went out of style! (YouTube)
A letter from a group of Chinese physicians was recently published in the American Journal of Emergency Medicine. The actual title of the letter is "Improvement of cardiopulmonary resuscitation by bending and pressing the lower extremities." In this letter (which does not contain any actual research), they make the modest claim that they have developed an "improved" CPR. 

This improved method? One picture is worth a thousand...

I think this could get this blog banned in my own hospital.

What the heck is that? The authors explain: 
Bending and pressing both lower extremities is based on the premise that bending and pressing the lower limbs during CPR will increase blood flow to the heart. As the patient's hemodynamic status improves, the blood flow to the coronary and cerebral arteries increases.
They go on to provide exactly zero references to support this idea, and no original evidence of their own. But they've got some great illustrations!


So, press at exactly 45°, because... Because why exactly? They don't explain, but they drop some pearls of wisdom like:
By reestablishing blood circulation, the hemodynamics of the [cardiac arrest] patient further improve, and ultra-early return of spontaneous circulation could be expected.
As a goal, it's hard to beat "ultra-early" ROSC. How about adverse effects though? 
If the steps are followed properly, there will be no further damage to the patient.
No further damage?

"The salutory effect of leg flinging during CPR"
 Not the actual title, but close enough. 

"Cardiac arrest: Vascular resuscitation by leg elevation" goes further than the paper above, and is written as a case report with a brief literature review. Like the paper above, it intends to describe a new technique to augment CPR, namely passive leg elevation (PLE). Given that PLE was recently shown to have some mild but indirect benefits, this a valid topic for a literature review.

The case report, however, raises a few questions, and the conclusion the author reaches are potentially dangerous. 
One late afternoon at a large gathering everyone stood up. Soon there were calls for help. A 40-year-old man was found on the floor. He was not breathing and was unresponsive. Two other doctors and I checked him serially but found no pulse. I checked his carotid for more than 30s without feeling any pulse. About 3 min had passed since the call for help, and I was about to start CPR when I remembered that some people were fasting that day.
I quickly lifted up his legs by putting my arm under his thighs. He was flaccid and his back came up off the ground, and the legs flew up into the air and then onto his abdomen.
The legs were placed on top of a chair pulled from nearby. He immediately became pink in color, opened his eyes, and started breathing. Asked if he was fasting, he answered yes. Water was brought and he drank. He lay supine with his legs up for 10 min, then he sat and stood. When paramedics arrived (at about 15 min), he felt fine and refused to go. When evaluated the next day, an ear infection was diagnosed and he was given antibiotics.
Just a fainting spell, right? We've all seen it. A moist, cool cloth on the forehead, a little air, and people perk up just fine on their own. 

Even Supergirl.
But instead of concluding that this was a simple faint, the author concludes that:
Amazing immediate and complete clinical improvement with leg raising was noted in a case of out of hospital cardiac arrest. 
Well, nothing's impossible. It may be the case that a patient who suffered a true cardiac arrest, after 3 minutes without CPR, completely recovered after having his legs propped up on a chair. But I doubt it.

The Bottom Line
As I said at the start, perhaps studies in the future will show I was all wrong in my impression of these papers. Maybe we'll find a benefit of leg-compression CPR, or even that the ABCs/CABs should be changed to the L-ABCs. 

In the meantime, though, I think it's harmful for the authors to try and push these ideas so strongly. While lifting or squeezing the legs is not likely harmful in itself, it has the potential to distract rescuers from other tasks. And suggesting that people avoid CPR to prop up the legs runs contrary to the available evidence, and delays the known benefits of CPR.

3 comments:

  1. Maybe they read it in a fortune cookie?

    Or is that insensitive?

    I'm glad to see that ED physicians are starting to abandon Trendelenberg. I'm hopeful that EMS teaching and practice will follow suit in another 20 or so years.

    I spent a lot of time in the field taking patients out of Trendelenberg over the objections of some of my co workers.

    ReplyDelete
    Replies
    1. Yeah, Trendelenburg is going to take some time to fade away!

      Delete
  2. Trendelenburg, "Don't use a tourniquet", traction splints, and so many other wrong things we teach and learn.

    ReplyDelete