Delaying Defibrillation to Give Basic Cardiopulmonary Resuscitation to Patients With Out-of-Hospital Ventricular Fibrillation A Randomized Trial Context Defibrillation as soon as possible is standard treatment for patients with ven-
tricular fibrillation. A nonrandomized study indicates that after a few minutes of ven-
tricular fibrillation, delaying defibrillation to give cardiopulmonary resuscitation (CPR)first might improve the outcome. Objective To determine the effects of CPR before defibrillation on outcome in pa-
tients with ventricular fibrillation and with response times either up to or longer than
Design, Setting, and Patients Randomized trial of 200 patients with out-of-
hospital ventricular fibrillation in Oslo, Norway, between June 1998 and May 2001.
Patients received either standard care with immediate defibrillation (n=96) or CPR first
ARLY DEFIBRILLATION IS CRITICALfor survival from ventricular fi-
with 3 minutes of basic CPR by ambulance personnel prior to defibrillation (n=104). If initial defibrillation was unsuccessful, the standard group received 1 minute of CPR
before additional defibrillation attempts compared with 3 minutes in the CPR first group. Main Outcome Measure Primary end point was survival to hospital discharge. Sec- ondary end points were hospital admission with return of spontaneous circulation (ROSC),
1-year survival, and neurological outcome. A prespecified analysis examined sub-
(CPR) is performed.1,2 Another major fac-
groups with response times either up to or longer than 5 minutes. Results In the standard group, 14 (15%) of 96 patients survived to hospital dis-
charge vs 23 (22%) of 104 in the CPR first group (P=.17). There were no differences
in ROSC rates between the standard group (56% [58/104]) and the CPR first group
a defibrillator is available.1 It has been as-
(46% [44/96]; P=.16); or in 1-year survival (20% [21/104] and 15% [14/96], re-
spectively; P=.30). In subgroup analysis for patients with ambulance response times
of either up to 5 minutes or shorter, there were no differences in any outcome vari-
of the heart and brain cells,3 but is in-
ables between the CPR first group (n=40) and the standard group (n=41). For pa-
sufficient to improve the state of the tis-
tients with response intervals of longer than 5 minutes, more patients achieved ROSC
in the CPR first group (58% [37/64]) compared with the standard group (38% [21/
55]; odds ratio [OR], 2.22; 95% confidence interval [CI], 1.06-4.63; P=.04); survivalto hospital discharge (22% [14/64] vs 4% [2/55]; OR, 7.42; 95% CI, 1.61-34.3; P=.006);
and 1-year survival (20% [13/64] vs 4% [2/55]; OR, 6.76; 95% CI, 1.42-31.4; P=.01).
Thirty-three (89%) of 37 patients who survived to hospital discharge had no or minor
reductions in neurological status with no difference between the groups.
energy phosphates,3 severe acidosis,4 and
Conclusions Compared with standard care for ventricular fibrillation, CPR first prior
a ventricular fibrillation frequency spec-
to defibrillation offered no advantage in improving outcomes for this entire study popu-
trum indicating a low chance of defibril-
lation or for patients with ambulance response times shorter than 5 minutes. How-
ever, the patients with ventricular fibrillation and ambulance response intervals longer
than 5 minutes had better outcomes with CPR first before defibrillation was at-
tempted. These results require confirmation in additional randomized trials. Author Affiliations are listed at the end of this
PhD, Institute for Experimental Medical Research, Ul-
leval University Hospital, N-0407 Oslo, Norway (e-mail:
For editorial comment see p 1434. Corresponding Author and Reprints: Lars Wik, MD, 2003 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 19, 2003-Vol 289, No. 11 1389
not given before the first defibrillation
ences in survival were detected (PϽ.05),
were also included in the monitoring.
minutes prior to the first defibrillation
after, it was given for 3 minutes both for
ventricular fibrillation/ventricular tachy-
refractory ventricular fibrillation or re-
were identical on all units including the
ing to the guidelines of the European Re-
pressions and ventilation) prior to a de-
sent for inclusion in the study was waived
Utstein style.11 Out-of-hospital data were
Utstein data collection sheets. These data
men and 16% were older than 65 years.
culated from time of dispatch of the first
trolled trial involving patients older than
18 years with ventricular fibrillation or
ately. If unsuccessful, defibrillation was
witnessed the cardiac arrest. On-site ran-
domization after defibrillator electrocar-
diogram verification of ventricular fibril-
lance personnel to log the time of arrival
tal personnel were blinded, including the
physician not involved in the care of any
arrival at the patient's location until direct
patients or in data collection. This phy-
sealed randomization list after 6, 18, and
synchronized with the other time points. 1390 JAMA, March 19, 2003-Vol 289, No. 11 (Reprinted) 2003 American Medical Association. All rights reserved. Figure 1. Flow Diagram of CPR First and
Inc) provided a power of 80 for ␣ of.05
1357 Patients Found Lifeless and Assessed for Eligibility
test. We calculated the odds ratios (ORs)
SPSS statistical software. PϽ.05 was
groups, a logistic regression analysis was
discharged alive was regressed on the in-
(Version 11.0, SPSS Inc, Chicago, Ill).
CPR indicates cardiopulmonary resuscitation. Aster-isk indicates emergency medical service personnel failed
to enroll patients even though they met study crite-
ria; the randomization envelope was missing for 2patients.
bystander, location of cardiac arrest, and
interval was also included. This term rep-
shown in TABLE 1. There were no sig-
spect to probability of survival to hospital
discharge as a function of response time,
sponse times, location of the cardiac ar-
and it may specifically be used to test the
tients in the standard treatment group.
pulseless electrical activity. Of 260 car-
ization envelope was missing in 2 cases.
96]; P =.17); ROSC rates (56% [58/
104] vs 46% [44/96]; P=.16); or 1-year
96]; P =.30) (TABLE 2). Of 37 patients
met study criteria (FIGURE 1). 2003 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 19, 2003-Vol 289, No. 11 1391
had been in the interval of Յ5 minutes).
tients in the CPR first group than in the
[37/64] vs 38% [21/55]; P =.04); sur-
(TABLE 3). As of May 2002, 29 pa-
64] vs 4% [2/55]; P =.006); and 1-year
tients were still alive and 27 patients or
In logistic regression analysis, both for-
Table 1. Baseline Characteristics of Patients
with the predictor variables of age (OR,0.97; 95% CI, 0.94-0.99), CPR per-
CPR First Standard P Characteristic
present (OR, 1.41; 95% CI, 1.03-1.94).
significant (P =.03). The term group is
results. FIGURE 2 shows the estimated
charge plotted against response time.
Abbreviations: CI, confidence interval; CPR, cardiopulmonary resuscitation; ROSC, restoration of spontaneous circu-
shapes of the curves are significantly dif-
ferent. The estimated survival with CPRfirst vs standard therapy is a functionof the response time interval formula
Table 2. Rates of Discharge From Hospital, ROSC, and 1-Year Survival* CPR First Standard P OR (95% CI)† Value‡
In this study, there were no overall dif-
prior to defibrillation. However, for pa-
Abbreviations: CI, confidence interval; CPR, cardiopulmonary resuscitation; OR, odds ratio; ROSC, return of sponta-
*Patients received ventricular fibrillation posthospitalization and 3 minutes of CPR before defibrillation vs standard treat-
†ORs and 95% CIs were calculated by logistic regression.
pital discharge and 1-year survival rates
‡Calculated from the Fisher exact test. 1392 JAMA, March 19, 2003-Vol 289, No. 11 (Reprinted) 2003 American Medical Association. All rights reserved. Table 3. Overall Performance Categories and Cerebral Performance Categories of Patients at Hospital Discharge and at 1-Year Survival No. Received Treatment, No. Received Treatment, No. Received Treatment, All Patients CPR First Standard CPR First Standard CPR First Standard Discharge Discharge Discharge Year* Discharge Discharge Discharge
Abbreviation: CPR, cardiopulmonary resuscitation. *There are no differences between the groups when comparing patients surviving (overall performance category and cerebral performance category 1 through 4) to either hospital
discharge or 1 year after cardiac arrest. In both the CPR first and the standard treatment group, 1 patient with response time of 5 minutes or less failed to answer the question-naire. The other patients with unknown scores lived longer than 1 year, but died before the questionnaire was sent out in May 2002.
of defibrillation first was questioned as
Figure 2. Estimated Probability of Survival
tricular fibrillation demonstrate that CPR
rate.7,17,18 In dogs with 7.5 minutes of ini-
response times of 4 minutes or longer.
tially untreated ventricular fibrillation,
the defibrillation success was higher af-
brillation.7 The same laboratory later re-
fibrillation than CPR first in swine with
Average fraction of surviving patients for each 2-minute
5 minutes of initially untreated ventricu-
interval. Lines indicate logistic regression models withtime as independent variable fitted separately for each
lar fibrillation.19 In a study of dogs, im-
these rates along with the fact that car-
episodes of fibrillation if it was limited
we did not find a higher survival rate with
patients below which defibrillation first
search15) is unlikely to specifically affect
this could be due to a type II error, and
average cut-off time for CPR first vs de-
2003 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 19, 2003-Vol 289, No. 11 1393
fibrillation first is therefore not pres-
tients with ventricular fibrillation, with
vorably with previous research.8,26 In the
outcome (PϽ.11) in the group who re-
(Figure 2), but the fall-off rate with time
studies have indicated that the effects of
guidelines for reporting results after car-
this study, the findings are based on non-
on the quality.25 In a study from Oslo,13
pital discharge, and the accuracy of this
quire confimation in future clinical trials.
of life later after discharge has been chal-
a CPC score of 1 at hospital discharge had
factor for survival.1,23,24 In those stud-
a sensitivity of 78% and a specificity of
ies, defibrillation was attempted as soon
43% for predicting that quality of life at
a later date was the same as or better than
evaluated. Also, the response time in the
ration of the cardiac arrest and the qual-
defibrillation was an important factor for
ity of CPR performed by a bystander.
survival, but the analysis indicates that
physicians appear to be inaccurate judges
performed defibrillation prior to CPR.
of patient function.27 In the present study,
The delay before defibrillation is still im-
we are reporting 1-year follow-up and the
basis of the scores is the patient or rela-
fibrillation is better with response times
tive's own evaluation of function, mood,
of 3 minutes than of 7 or 10 minutes.
prior to cardiac arrest. In May 2002 when
the follow-up questionnaire was sent out,
judged from spectral analysis of the elec-
trocardiogram appears to deteriorate rap-
seven patients or their relatives answered
troshock of prolonged ventricular fibril-
ventricular fibrillation to a more resus-
citation-refractory rhythm, such as asys-
tion6 seems related to the relatively high
1394 JAMA, March 19, 2003-Vol 289, No. 11 (Reprinted) 2003 American Medical Association. All rights reserved.
termine the optimal duration of CPR first
tion of current resuscitation guidelines,
in patients with ventricular fibrillation. Author Affiliations: Norwegian Competence Center
and our data, signal the need for reevalu-
for Emergency Medicine, Institute for Experimental
Medical Research (Dr Wik), Division of Surgery (DrsT. Steen and P. A. Steen, and Messrs Hansen and
Fylling), Ulleval University Hospital, Oslo, Norway; Nor-
wegian Defense Research Establishment Division ofProtection and Material, Kjeller, Norway (Dr Vaa-
treatment of ventricular fibrillation. An
genes); and Department of Technology and Natural
While defibrillation is the essential in-
Science, Stavanger University College, Stavanger, Nor-way (Dr Auestad).
tervention in ventricular fibrillation, de-
Author Contributions: Study concept and design: Wik, Acquisition of data: Wik, T. Steen, Vaagenes. Analysis and interpretation of data: Wik, Vaagenes,
Drafting of the manuscript: Wik, Hansen, Fylling,Auestad. Critical revision of the manuscript for important in-
yond the factors of the local ischemia. tellectual content: Wik, T. Steen, Vaagenes, Auestad,
shock for ventricular fibrillation is not
P. A. Steen. Statistical expertise: Wik, Vaagenes, Auestad, P. A.
sidered useful to apply CPR to "coarsen
Obtained funding: Wik, P. A. Steen. Administrative, technical, or material support: Wik,
ventricular fibrillation." However, that
been several minutes' delay before defi-
Study supervision: Vaagenes, P. A. Steen. Funding/Support: This study was supported by grants
brillation as soon as possible for all pa-
from the Norwegian Air Ambulance and Laerdal Foun-
tients with ventricular fibrillation.30,31
with out-of-hospital ventricular fibrilla-
tion. Further trials are needed to evalu-
Acknowledgment: We thank the paramedics, Mona Monsen, and the physicians of Oslo EMS for their work
ate this resuscitation strategy and to de-
REFERENCES 1. European Resuscitation Council. Part 4: the auto- 12. Safar P, Bircher NG. Cardiopulmonary cerebral re-
diopulmonary resuscitation: survival in 1 hospital and
mated external defibrillator: key link in the chain of
suscitation. In: Basic and Advanced Cardiac and Trauma
literature review. Medicine. 1995;74:163-175.
survival. Resuscitation. 2000;46:73-91. Life Support: An Introduction to Resuscitation Medicine.23. Stueven HA, Waite EM, Troiano P, Mateer JR. Pre- 2. Larsen MP, Eisenberg MS, Cummins RO, Hall-
3rd ed. London, England: WB Saunders; 1988:267.
hospital cardiac arrest-a critical analysis of factors af-
strom AP. Predicting survival from out-of-hospital car-
13. Wik L, Steen PA, Bircher NG. Quality of by-
fecting survival. Resuscitation. 1989;17:251-259.
diac arrest: a graphic model. Ann Emerg Med. 1993;
stander cardiopulmonary resuscitation influences out-
24. Weaver WD, Cobb LA, Hallstrom AP, et al. Con-
come after prehospital cardiac arrest. Resuscitation.
siderations for improving survival from out-of-
3. Kern KB, Garewal HS, Sanders AB, et al. Deple-
hospital cardiac arrest. Ann Emerg Med. 1986;15:
tion of myocardial adenosine triphosphate during pro-
14. Sunde K, Eftestol T, Askenberg C, Steen PA. Qual-
longed untreated ventricular fibrillation: effect on de-
ity assessment of defibrillation and advanced life sup-
25. Van Hoeyweghen RJ, Bossaert LL, Mullie A, et al,
fibrillation success. Resuscitation. 1990;20:221-229.
port using data from the medical control module of
for the Belgian Cerebral Resuscitation Study Group. 4. Maldonado FA, Weil MH, Tang W, et al. Myocar-
the defibrillator. Resuscitation. 1999;41:237-247.
Quality and efficiency of bystander CPR. Resuscita-
dial hypercarbic acidosis reduces cardiac resuscitabil-
15. Campbell JP, Maxey VA, Watson WA. Haw-
ity. Anesthesiology. 1993;78:343-352.
thorne effect: implications for prehospital research. Ann26. Graves JR, Herlitz J, Bang A, et al. Survivors of out 5. Brown CG, Dzwonczyk R. Signal analysis of the hu-
of hospital cardiac arrest: their prognosis, longevity and
man electrocardiogram during ventricular fibrillation:
16. Robinson JS, Davies MK, Johns BM, Edwards SN.
functional status. Resuscitation. 1997;35:117-121.
frequency and amplitude parameters as predictors of
"Out-of-hospital cardiac arrests" treated by the West
27. Hsu JW, Madsen CD, Callaham ML. Quality-of-
successful countershock. Ann Emerg Med. 1996;27:
Midlands Ambulance Service over a 2-year period. Eur
life and formal functional testing of survivors of out-
J Anaesthesiol. 1998;15:702-709.
of-hospital cardiac arrest correlates poorly with tra-
6. Eftestol T, Sunde K, Steen PA. Effects of interrupt- 17. Yakaitis RW, Ewy GA, Otto CW, Taren DL, Moon
ditional neurologic outcome scales. Ann Emerg Med.
ing precordial compressions on the calculated prob-
TE. Influence of time and therapy on ventricular de-
ability of defibrillation success during out-of-hospital
fibrillation in dogs. Crit Care Med. 1980;8:157-163. 28. Dybvik T, Strand T, Steen PA. Buffer therapy dur-
cardiac arrest. Circulation. 2002;105:2270-2273. 18. Idris AH, Becker LB, Fuerst RS, et al. Effect of ven-
ing out-of-hospital cardiopulmonary resuscitation. Re-7. Niemann JT, Cairns CB, Sharma J, Lewis RJ. Treat-
tilation on resuscitation in an animal model of cardiac
ment of prolonged ventricular fibrillation: immediate
arrest. Circulation. 1994;90:3063-3069. 29. Holmberg M, Holmberg S, Herlitz J, Gardelov B.
countershock versus high-dose epinephrine and CPR pre-
19. Niemann JT, Cruz B, Garner D, Lewis RJ. Imme-
Survival after cardiac arrest outside hospital in Swe-
ceding countershock. Circulation. 1992;85:281-287.
diate countershock versus cardiopulmonary resusci-
den: Swedish Cardiac Arrest Registry. Resuscitation.8. Cobb LA, Fahrenbruch CE, Walsh TR, et al. Influ-
tation before countershock in a 5-minute swine model
ence of cardiopulmonary resuscitation prior to defi-
of ventricular fibrillation arrest. Ann Emerg Med. 2000;
30. Kloeck W, Cummins RO, Chamberlain D, et al. The
brillation in patients with out-of-hospital ventricular
universal advanced life support algorithm: an advisory
fibrillation. JAMA. 1999;281:1182-1188. 20. Weaver WD, Cobb LA, Hallstrom AP, Fahren-
statement from the Advanced Life Support Working
9. World Medical Association. Declaration of Hel-
bruch C, Copass MK, Ray R. Factors influencing sur-
Group of the International Liaison Committee on Re-
sinki. Helsinki, Finland: World Medical Association; 1964.
vival after out-of-hospital cardiac arrest. J Am Coll Car-
suscitation. Circulation. 1997;95:2180-2182. 10. European Resuscitation Council guidelines for ad- 31. Automated external defibrillators and ACLS: a new
vanced life support. Resuscitation. 1998;37:81-90. 21. Stults KR, Brown DD, Schug VL, Bean JA. Pre-
initiative from the American Heart Association. Am J11. Cummins RO, Chamberlain DA, Abramson NS,
hospital defibrillation performed by emergency medi-
et al. Recommended guidelines for uniform report-
cal technicians in rural communities. N Engl J Med.32. Weisfeldt ML, Becker LB. Resuscitation after car-
ing of data from out-of-hospital cardiac arrest: the Ut-
diac arrest: a 3-phase time-sensitive model. JAMA.
stein style. Circulation. 1991;84:960-975. 22. Saklayen M, Liss H, Markert R. In-hospital car- 2003 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 19, 2003-Vol 289, No. 11 1395
In July of 1968, Pope Paul VI issued a very important letter: "Humanae Vitae"(latin for Human Life). How many Catholics today know, love, live, and teach others it's truths? The New Universal Catechism calls contraception "intrinsically evil"(p.570) Contraception is against life. It goes against the natural design of God for sexuality, changing it into something it was never inten
CONFERENCE DRAFT 20030313 DESCRIPTIVE CATALOGING OF RARE MATERIALS A Statement of Objectives and Principles This statement grows out of deliberations of the Bibliographic Standards Committee of the Rare Books and Manuscripts Section of the Association of College and Research Libraries and the work of a special conference on DCRM hosted by the Beinecke Library at Yale University,