Synchronous CPR in Pseudo-PEA
Date First Published:
April 10, 2020
Last Updated:
April 23, 2020
Report by:
Peter Hulme, Consultant Emergency Medicine (Manchester Royal Infirmary)
Search checked by:
Jack Ingham, Manchester Royal Infirmary
Three-Part Question:
[In patients with pseudo-PEA] does [synchronous CPR] [improve mortality]
Clinical Scenario:
A 70 year old man presents in PEA cardiac arrest. An ED echocardiogram shows cardiac activity but no pulse is palpable. Pseudo-PEA is diagnosed. You wonder whether CPR timed to systole may improve his chances of survival.
Search Strategy:
AMED (Allied and Complementary Medicine) <1985 to March 2020>(0)Embase <1974 to 2020 April 09>(21)
HMIC Health Management Information Consortium <1979 to March 2020>(0)
Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R) <1946 to April 09, 2020>(9)
30
HMIC Health Management Information Consortium <1979 to March 2020>(0)
Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R) <1946 to April 09, 2020>(9)
30
Search Details:
1. pseudo pea.mp. [mp=ab, hw, ti, tn, ot, dm, mf, dv, kw, fx, dq, nm, kf, ox, px, rx, an, ui, sy]
2. pseudo emd.mp. [mp=ab, hw, ti, tn, ot, dm, mf, dv, kw, fx, dq, nm, kf, ox, px, rx, an, ui, sy]t
3. synchronised.mp. [mp=ab, hw, ti, tn, ot, dm, mf, dv, kw, fx, dq, nm, kf, ox, px, rx, an, ui, sy]t
4. CPR.mp. [mp=ab, hw, ti, tn, ot, dm, mf, dv, kw, fx, dq, nm, kf, ox, px, rx, an, ui, sy]
5. cardiopulmonary resucitation.mp. [mp=ab, hw, ti, tn, ot, dm, mf, dv, kw, fx, dq, nm, kf, ox, px, rx, an, ui, sy]
6. 1 or 2
7. 3 or 4 or 5
8. 6 and 7
2. pseudo emd.mp. [mp=ab, hw, ti, tn, ot, dm, mf, dv, kw, fx, dq, nm, kf, ox, px, rx, an, ui, sy]t
3. synchronised.mp. [mp=ab, hw, ti, tn, ot, dm, mf, dv, kw, fx, dq, nm, kf, ox, px, rx, an, ui, sy]t
4. CPR.mp. [mp=ab, hw, ti, tn, ot, dm, mf, dv, kw, fx, dq, nm, kf, ox, px, rx, an, ui, sy]
5. cardiopulmonary resucitation.mp. [mp=ab, hw, ti, tn, ot, dm, mf, dv, kw, fx, dq, nm, kf, ox, px, rx, an, ui, sy]
6. 1 or 2
7. 3 or 4 or 5
8. 6 and 7
Outcome:
14 papers of which three were relevant to the clinical question
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Synchronized Chest Compressions for Pseudo-PEA: Proof of Concept and a Synching Algorithm Marill et al 2019 USA | Single pig MAP went from 55 mm Hg (time 7,017 seconds) to 60 mm Hg (7,027 seconds) to 83 mm Hg (7,056 seconds) durin |
Proof of concept study | Blood pressure | Synchronized, but not unsynchronized, chest compressions were associated with increased blood pressure. MAP went from 55-60 mm Hg to 83 mm Hg | Single pig. No human evidence. |
| Coronary perfusion pressure | Synchronized, but not unsynchronized, chest compressions were associated with increased coronary perfusion pressure. CPP went from 32-38 mm Hg to 60 mm Hg. | ||||
| Synchronization of chest compressions with residual systolic cardiac activity during cpr is associated with improved cerebral perfusion pressures in a swine model of pseudo-pulseless electrical activi Larabee et al 2011 USA | 7 pigs | A partial-asphyxial swine model of pseudo-PEA arrest was used. Cerebral perfusion pressure was measured over 2 minutes of chest compressions in either systole or diastole. | Cerebral perfusion pressure | Mean Cerebral perfusion pressure was significantly higher for systolic compressions compared to diastolic compressions (13.4+/-7.9 vs. 10.1+/-5.5 mmHg; p<0.001). | Pig models. No human evidence. |
| Coronary perfusion pressure during external chest compression in pseudo-EMD, comparison of systolic versus diastolic synchronization Paradis et al 2012 USA | 8 pigs | A porcine asphyxial model of pseudo PEA comparing coronary perfusion pressure during chest compression synchronized with residual systole and diastole. | Aortic pressure | Systolic synchronization was association with increases in the relaxation phase aortic pressure (41.7 ± 8.9 mmHg vs. 36.9 ± 8.2 mmHg) p=0.0009 | Pig models. No human evidence. |
| Coronary perfusion pressure | Systolic synchronization was association with increases in coronary perfusion pressure (37.6 ± 11.7 mmHg vs. 30.2 ± 9.6 mmHg) p=0.0001 |
Author Commentary:
The only available evidence is in pigs. The limited evidence shows no mortality benefit but the studies weren't designed to show a benefit in mortality. The studies showed benefits in cerebral and coronary perfusion pressure during chest compressions in systole.
Bottom Line:
There is no human evidence of mortality benefit for synchronous chest compressions in pseudo PEA but the limited evidence in pig models shows improved cerebral and coronary perfusion pressure. Further research should be performed in humans to see if these benefits are transferable and lead to improved survival rates.
References:
- Marill et al. Synchronized Chest Compressions for Pseudo-PEA: Proof of Concept and a Synching Algorithm
- Larabee et al. Synchronization of chest compressions with residual systolic cardiac activity during cpr is associated with improved cerebral perfusion pressures in a swine model of pseudo-pulseless electrical activi
- Paradis et al. Coronary perfusion pressure during external chest compression in pseudo-EMD, comparison of systolic versus diastolic synchronization