CPR is less effective than we think

I don’t know how many of you readers are old enough to remember the frequent use of open chest cardiac massage, first successfully performed in 1901. It began as a way to resuscitate suddenly dead people, assuming that their hearts had arrested or fibrillated.

The surgeon would open the chest between ribs 5 and 6 and rhythmically squeeze the heart to move the blood and re-establish life. Sometimes it worked; usually it did not.

Then, in a 1960 landmark article in JAMA, Kouwenhoven, Jude, and Knickerbocker at Hopkins described closed chest cardiac massage and everything changed. Suddenly, patients who were observed dying could be brought back to life without an open thoracotomy.

Great, or so it seemed.

Big organizations taught the procedure; new categories of emergency medical workers were created; ordinary people were educated to save lives dramatically; medical associations sponsored research and published papers, even entire theme issues in JAMA every several years.

A mass of television shows taught the public that codes were called and enacted with teams of beautiful male and female doctors breathing and beating the dead back to life. It became such a pervasive cultural phenomenon that any person who did not wish this effort to bring them back to life after they died the first time would have to file a predeath Do Not Resuscitate order and hope that it would be followed.

After the performance science was solid and positively enacted to create a culture of resuscitation, then came the hard data.

Judged on favorable outcomes (meaning a well functioning body and brain at 30 days) after the drama ended and the TV cameras went elsewhere, the whole schmear was found to hardly ever work to the patient’s or the family’s advantage.

But the culture was already ingrained.

Now we see a huge Japanese study of more than 400,000 people who experienced out-of-hospital cardiac arrest, published in the JAMA on March 21, 2012. Approximately 18% of those who were administered CPR and epinephrine did achieve spontaneous circulation but fewer than 5% survived 1 month and fewer than 2% survived 1 month with good or moderate cerebral performance.

So, if an average adult keels over in the street, is found unresponsive and pulseless by a bystander, and is administered CPR while a 911 call is made, the odds that such a person will emerge from the eventualities of the resuscitation effort healthy and with a normally functioning brain are about 2%.

The other outcomes are death — soon, or within 30 days — after lots of cost and much suffering for many, or being discharged from a hospital, alive but mentally impaired, presumably lifelong.

So, I don’t know about you, but if I drop dead on the street, observed or unobserved, I suppose the observer will feel obligated to call 911, but please do not administer closed chest cardiac massage to me.

I don’t want my rib caged collapsed and I don’t want to live with iatrogenic squash rot, only to have to die all over again sometime later.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

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  • Brian L

    Speak for yourself, I’ll take the CPR, please.

    Hinchey PR, Myers JB, Lewis R, et al. Improved Out-of-Hospital Cardiac Arrest Survival After the Sequential Implementation of
    2005 AHA Guidelines for Compressions, Ventilations, and Induced Hypothermia: The Wake County Experience. Annals of Emergency Medicine. 2010;56(4):348-357.

    Wake EMS honored as heart attack survival rates rise, http://www.newsobserver.com/2012/05/18/2071575/wake-ems-honored-as-heart-attack.html

  • marykparker

    I love this phrase “iatrogenic squash rot.” So apt. I’m with you in the desire to avoid resuscitation, something that seems endemic to health professionals. Just let me go.

  • http://www.thisistrue.com Randy Cassingham

    “So, if an average adult keels over in the street, is found unresponsive and pulseless by a bystander, and is administered CPR while a 911 call is made, the odds that such a person will emerge from the eventualities of the resuscitation effort healthy and with a normally functioning brain are about 2%.”

    Nope.

    You’re confusing overall percentages with specific situations where the liklihood of survival is MUCH higher.

    The problem is, the overall number is pushed down toward 2% because most cardiac arrests are NOT witnessed, and CPR is NOT initiated within minutes of their collapse. It’s the classic scenario: someone finds gramps lifeless in his easy chair, calls 911, waits 5-15 minutes for an ambulance (or fire truck) to arrive, and THEN someone starts CPR. Obviously the save percentage here is almost exactly zero. That skews the “average” dramatically.

    Yes, CPR is started on WAY too many people — those who cannot possibly be brought back, including terminally ill patients (for the love of the Flying Spaghetti Monster: WHY?!), trauma-induced arrests, those who have clearly been dead for more than a few minutes (including those with obvious lividity, or even rigor mortis), etc. Of course those MANY zero-percentage cases are going to drive down the overall percentage.

    But younger, otherwise healthy people whose arrest is witnessed and good CPR started immediately, with defibrillation within a reasonable amount of time? The odds are a LOT higher than 2%. Just ask my patient from June 2009, who dropped in his bedroom. His daughter, a nursing student, was visiting, and performed proper compressions on her 50-year-old father for about 12 minutes (with NO respirations given) before I arrived and defibrillated him. And you CAN ask him about it, because he is 100% recovered with NO cognitive deficits whatever. He shook my hand in gratitude AGAIN at the post office this week. He gets to see his grandchildren grow up.

    The problem with a doctor saying “CPR doesn’t work” is that people will shrug and say “What’s the point?” and not bother. That, sir, is causing harm for the many people who COULD be saved. Didn’t you take some kind of oath not to do that?

    • http://www.facebook.com/cb.horner Cb Horner

      I’ll take the 100% success rate here at McKinney Schools with a portable defib. 6 cases within the past 2 years, from kids to older adults. All are doing fine.

    • http://www.facebook.com/sliderk9 Darryl Kenney

      Randy, I agree with all of your statements here (long time True subscriber). The one paragraph about “WAY too many people” is a statement about the US legal system. Where a lawyer will ask, “Did you do everything you could to save his life?” If CPR is not administered then the witness/defendant would have to say no. Therefore, it makes it a “I did it just to say that I tried everything”.

  • James deMaine

    Actually if you have witnessed out of hospital cardiac arrest and have CPR, you have about an 11% chance of survival to hospital discharge. See Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C. : 2002) 2011 Jul 29; 60(8): 1-19. The average age was 64. Obviously CPR is not indicated for the sick elderly or those near the end of life, but let’s not pull the plug too soon on ourselves!

  • http://www.facebook.com/profile.php?id=1088829873 Skip Kirkwood

    I’ll take the CPR. Dr. Kevin needs to read more studies.

  • Hexanchus t

    Kudos to you for shedding a little light on this subject.

    The fact is that even for in hospital cardiac arrest, the odds of survival to discharge are well under 20%, and half of those that do survive suffer major disabilities as a result.

    I don’t understand why some people think that a treatment that only benefits 10-15% of those it is used on is such a miracle. To me, statistically, it is an exercise in futility.

    Yes there are some instances such as drowning or electrical shock where the survival odds are better for an otherwise healthy individual, but when the cause is underlying cardiovascular disease the odds are pretty dismal as Dr. Lundberg points out.

    This is why, even though I am in good health, I have a POLST that says, DNR, DNI, no IV’s, do not transport to hospital and allow natural death.

    • http://www.facebook.com/jack.lewis.334 Jack Lewis

      Hmm. I’ve worked hard enough keeping this beat-up (but basically sound) body going that I have no problem with accepting “the kindness of strangers” should someone happen to be available to resuscitate me in the event of cardiac arrest. My father in law’s been resusc’ed more than once; he’s pretty good company and I like having him around.

      A treatment that changes my odds of survival from “all dead now” to a 10-15 percent chance of full recovery is absolutely a miracle. I’m grateful to live in an age where such miracles are manifest, and I earnestly pray (if “pray” is even the right term) for human ingenuity, compassion and hope to continue to outweigh the dismal flavor of cynicism displayed above.

      My glass feels much more than half-full. Sorry that you seem to have spilled so much of yours, Hexanchus t.

  • Roger Heath

    As the inventor making possible the Automatic External Defibrillator (AED), I find this article interesting, and brave. I have been involved in analyzing research for 40 years and attending many of the early conferences on CPR and Defibrillation at Purdue, there were those few who emerged very concerned about the effects of CPR on the brain. One concerned physician pointed out that pressures in the brain are increased substantially and this could contribute to substantially greater use of oxygen, thus you might resuscitate the heart, but the effects on the brain could be very very adverse.

    Dr. Paul Zoll, considered by most as the Father of Modern Cardiac Electrophysiology, the first to do an external defibrillation in man, also a good friend, thought that noninvasive pacing held much greater hope for returning a subject to a normal or sustaining state. He stated that if prompt pacing can be effective, then there can be great hope for survival.

    Data is better for CPR than represented here, however there are still many things that are not known about this subject. CPR is relatively new in the long history of mankind. Prompt defibrillation, on the other hand, does show substantial survival rates, if applied during the first moments of arrest. No question that the prospects for survival are greater with very fast countershock using defibrillation.

    Was Dr. Zoll right? To view references to some of his and other studies on this subject here is the link on my web site: http://www.defib.us.com/original-bibliography/

    Roger Heath

  • http://www.facebook.com/dbquach Dat Quach

    I do believe we read the same article, but I don’t think it was a study on the effectiveness of CPR. I wouldn’t throw out CPR just yet. The article may have significant affects on the way epinephrine may be used for out-of-hospital cardiac arrest.

    The objective of the study as stated by the researchers was to “evaluate the effectiveness of epinephrine in CPR…”p 1161. Dr. Hagihara and colleges don’t even breakout the OUTCOME data on those who received chest compressions, rescue breathes only and AED even though they have the data. They did find that, “that the use of (prehospital) epinephrine might be related to decreased 1-month survival.” p. 1166.

    The editorial by Dr. Callaway provides an interesting explanation of why this may be the case that patients who receive epinephrine have end up with “iatrogenic squash rot.” JAMA. 2012;307(11):1198-1200. doi:10.1001/jama.2012.313

  • http://twitter.com/sisvivian92 Vivian Schaefer

    Some years ago, a man had a heart attack in our church and the 2 nurses there brought him back with CPR and he lived many years. I, on the other hand have been required in my job to do CPR on people who are dead because they do not have a DNR.

  • Mike Evans

    If you are going to end with such a melodramatic term as “iatrogenic squash rot”, you might want to define it. The only references I can find regarding that term are links back to this article.
    WTF is “iatrogenic squash rot”?

    • http://www.facebook.com/profile.php?id=1465552766 Craig D Bersak

      I believe that he’s referring to his brain (figuratively) turning to mush due to the administered CPR.
      IATROGENIC
      : induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures

    • Facebook User

      I had to break down his flip term myself, Mike. Iatrogenic refers to illness caused by medical examination or treatment. If the doc is making a gardening allusion, “squash rot” is what happens when young squash fruit shrivels up and falls off the vine before maturation. So, he’s saying he’d rather not have his brain shrivel up and become useless due to the medical treatment provided in the form of CPR. That said, I’m in the other camp — bring it on if it’s timely!

  • Bill Dearmore

    I remember bringing my own uncle back after he drowned in a swimming accident more than fifty years ago. And that was long before modern CPR was even invented. I used the “Artificial Respiration” that was being taught then. He is still living now, healthy and active. If you see me fall and my heart is not beating, please do resuscitate me. I enjoy living, and would like to live as long as I can.

  • http://www.facebook.com/ThePir8 Matt Wilson

    Five years ago I had to perform CPR on a child who had collapsed at an indoor sports centre. Tragically neither my efforts, nor the efforts of the ambulance officers who attended was successful. Was I aware of the low survival rate before I tried to help this young life? Absolutely. Would I try if I was in the same position again? Absolutely. I gave him every opportunity to live and can hold my head up high. without any intervention you are guaranteeing failure.

  • http://www.facebook.com/denise51781 Yvonne Denise Roche

    Aside from the faulty logic, I think 2% is better than 0%, as far as odds go. Life is precious. If CPR saves anyone, then it is worth doing.

  • John from Detroit

    So, on the average CPR works 100% in 2% of the cases.. Now consider this… 98 people who have had CPR performed on them have just died when you collspe (Patient # 99) Right in front of a trained administrator of CPR (Best case scenaro) and you personally become one of the 2 percent.

    My brother is one of those 2 Percent
    My mother, who is since decased was one of those 2 percent for many many y ears.
    I have a few friends who are among the same 2 percent.

    I’ll take a 2 percent improvement over certain death any day.