Hands Down, Manual is Better

450642795Man or machine?  This debate increasingly occurs in many venues as computers and other devices created for our convenience, comfort and ease continue to be invented and disseminated.  But there's one area where the machine remains inferior to the efforts of man, as Rick and I discuss on PodMed this week: CPR or cardiopulmonary resuscitation. That's as featured in the Lancet this week and also presented at the American Heart Association meeting taking place concurrently.

This trial is unique in that it is pragmatic.  Rather than being conducted under ideal clinical or laboratory conditions, instead this trial randomized actual patients who had experienced out-of-hospital myocardial infarction (MI) or heart attack being transported from the field via ambulance.  The subjects were randomized in a 1:2 ration, respectively, to either mechanical CPR using a device known as a LUCAS-2, or manual CPR. A total of 4471 subjects who experienced cardiac arrest not as a result of trauma were included, with randomization taking place depending on which response vehicle arrived on the scene first, one equipped with the mechanical device or not. Sixty percent of those in the mechanical group actually received CPR using the device while 11 (less than 1%) of the manual group did so.

The primary outcome was survival at 30 days post-MI, with secondary outcomes event survival, survival to 3 months, survival to 12 months, and survival with favorable neurological outcome at 3 months. Clearly the favorable neurological data is very important as this is compromised in many survivors.

There was no significant difference in 30 day survival among those who received mechanical CPR versus those who received manual: 6% versus 7% respectively. Longer term survival was also similar between groups, but those who received mechanical CPR had worse neurological outcomes than those who had manual CPR. A low rate of adverse events was also seen in those treated with the LUCAS-2:  three patients with chest bruising, two with chest lacerations, and two with blood in mouth. 15 device incidents while the LUCAS-2 was employed.

The authors conclude, and we agree, that the results of this trial argue against use of mechanical devices to perform CPR.  They're expensive, personnel using them require training, and they don't achieve the desired objective of improving survival odds for those having an out-of-hospital cardiac arrest.  Since almost half a million such events occur each year in the US alone, getting our arms around the best way to conduct CPR is clearly important.  Rick and I agree that we're glad this study was done.  In a real world environment, under conditions where the expectation would be that the machine would perform better while jostling around in the back of an ambulance, it didn't.  Yet one more example of assumptions disproved, so kudos to the authors.

Rick makes the point that out-of-hospital CPR is very simple, consisting of chest compressions only, and that more efforts need to undertaken to simply convince the public that they're the best chance someone who's experienced an MI has to make it alive to the hospital.  Other topics this week on our heart-only issue include a better understanding of HDL cholesterol in NEJM, appropriate duration of dual antiplatelet therapy after stenting in the same journal, and police work and sudden cardiac death in the BMJ.  Until next week, y'all live well.

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Caleb December 18, 2014 at 3:58 pm

I just personally believe that the human element will always have a significant advantage than mechanical in this and other related areas.

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