Kardiopulmonale Reanimation durch einen professionellen Helfer

Background

The 2005?guidelines for cardiopulmonary resuscitation (CPR) do not define the rescuer’s position while performing basic life support (BLS) by one single rescuer with a bag-valve mask device. Three different methods are possible: chest compressions and ventilations from over the head of the casualty (over-the-head CPR), from the side of the casualty (lateral CPR) and chest compressions from the side and ventilations from over-the-head of the casualty (alternating CPR). The aim of this study was to compare the quality of BLS of these three methods.

Methods

After a standardized theoretical introduction and hands-on training 117?medical students with limited knowledge and training in CPR participated in this study. Students were randomized in a cross-over design and performed a 2?min CPR test for each position on a manikin.

Results

Over-the-head CPR led to significantly more chest compressions (median 139 per 2?min), significantly higher number of inflations (8 per 2?min) and significantly shorter hands-off time (41?s) compared to lateral (136; 8; 42?s) and alternating CPR (125; 7; 46?s). Over-the-head CPR resulted in significantly more correctly performed ventilations (4 per 2?min) and non-significantly fewer correct chest compressions (61 per 2?min) compared to lateral (3; 82) and alternating CPR (3; 80).

Conclusions

Even though the statistical differences between the positions might not be of clinical relevance, according to the data over-the-head CPR is a good option for a single rescuer equipped with a bag-valve mask device and who is familiar with bag-valve-mask ventilation.     

Quality of cardiopulmonary resuscitation on manikins: on the floor and in the bed

Background: In general, in-hospital resuscitation is performed in a bed and out-of-hospital resuscitation on the floor. The surface under the patient may affect the cardiopulmonary resuscitation (CPR) quality; therefore, we evaluated CPR quality (the percentage of chest compressions of correct depth) and rescuer's fatigue (the mean compression depth minute by minute) when CPR is performed on a manikin on the floor or in the bed.
Methods: Forty-four simulated cardiac arrest scenarios of 10 min were treated by intensive care unit (ICU) nurses in pairs using a 30 : 2 chest compression-to-ventilation ratio. The rescuer who performed the compressions was changed every 2 min. CPR was randomly performed either on the floor or in the bed without a backboard; in both settings, participants kneeled beside the manikin.
Results: A total number of 1060 chest compressions, 44% with correct depth, were performed on the floor; 1068 chest compressions were performed in the bed, and 58% of these were the correct depth. These differences were not significant between groups. The mean compression depth during the scenario was 44.9±6.2 mm (mean±SD) on the floor and 43.0±5.9 mm in the bed ( P =0.3). The mean chest compression depth decreased over time on both surfaces ( P <0.001), indicating rescuer fatigue, but this change was not different between the groups ( P =0.305).
Conclusions: ICU nurses perform chest compression as effectively on the floor as in the bed. The mean chest compression depth decreases over time, but the surface had no significant effect.     

Chest compression-only CPR

Background

The literature related to the rationale of cardiopulmonary resuscitation (CPR) including chest compressions combined with ventilations or compression-only CPR without ventilations is reviewed.

Results

The conclusion is that the evidence in favor of compression-only CPR is of limited level of evidence and does not convincingly support the superiority of compressions without ventilations, nor does it prove its non-inferiority. Theoretical and practical considerations favor continued education in the combined application of chest compressions and ventilations with a compression:ventilation ratio of 30:2.

Conclusion

Compression-only CPR should be recommended only if the rescuer is not willing or able to deliver mouth-to-mouth ventilation or when CPR is instructed by the dispatcher to untrained rescuers by telephone. For all other circumstances, trained rescuers should combine chest compressions with ventilations.     

Mechanische Reanimationshilfen

In Germany 100,000–160,000 people suffer from out-of-hospital cardiac arrest (OHCA) annually. The incidence of cardiopulmonary resuscitation (CPR) after OHCA varies between emergency ambulance services but is in the range of 30–90 CPR attempts per 100,000 inhabitants per year. Basic life support (BLS) involving chest compressions and ventilation is the key measure of resuscitation. Rapid initiation and quality of BLS are the most critical factors for CPR success. Even healthcare professionals are not always able to ensure the quality of CPR measures. Consequently in recent years mechanical resuscitation devices have been developed to optimize chest compression and the resulting circulation. In this article the mechanical resuscitation devices currently available in Germany are discussed and evaluated scientifically in context with available literature. The ANIMAX CPR device should not be used outside controlled trials as no clinical results have so far been published. The same applies to the new device Corpuls CPR which will be available on the market in early 2014. Based on the current published data a general recommendation for the routine use of LUCAS? and AutoPulse® CPR cannot be given. The preliminary data of the CIRC trial and the published data of the LINC trial revealed that mechanical CPR is apparently equivalent to good manual CPR. For the final assessment further publications of large randomized studies must be analyzed (e.g. the CIRC and PaRAMeDIC trials). However, case control studies, case series and small studies have already shown that in special situations and in some cases patients will benefit from the automatic mechanical resuscitation devices (LUCAS?, AutoPulse®). This applies especially to emergency services where standard CPR quality is far below average and for patients who require prolonged CPR under difficult circumstances. This might be true in cases of resuscitation due to hypothermia, intoxication and pulmonary embolism as well as for patients requiring transport or coronary intervention when cardiac arrest persists. Three prospective randomized studies and the resulting meta-analysis are available for active compression-decompression resuscitation (ACD-CPR) in combination with an impedance threshold device (ITD). These studies compared ACD-ITD-CPR to standard CPR and clearly demonstrated that ACD-ITD-CPR is superior to standard CPR concerning short and long-term survival with good neurological recovery after OHCA.     

Thoraxkompression ohne Beatmung bei der Laienreanimation?

Basic life support (BLS) refers to maintaining airway patency and supporting breathing and the circulation, without the use of equipment other than infection protection measures. The scientific advisory committee of the American Heart Association (AHA) published recommendations (online-first) on March 31 2008, which promote a call to action for bystanders who are not or not sufficiently trained in cardiopulmonary resuscitation (CPR) and witness an adult out-of-hospital sudden collapse probably of cardiac origin. These bystanders should provide chest compression without ventilation (so-called compression-only CPR). If bystanders were previously trained and thus confident with CPR, they should decide between conventional CPR (chest compression plus ventilation at a ratio of 30:2) and chest compression alone. However, considering current evidence-based medicine and latest scientific data both the European Resuscitation Council (ERC) and the German Resuscitation Council (GRC) do not at present intend to change or supplement the current resuscitation guidelines "Basic life support for adults". Both organisations do not see any need for change or amendments in central European practice and continue to recommend that only those lay rescuers that are not willing or unable to give mouth-to-mouth ventilation should provide CPR solely by uninterrupted chest compressions until professional help arrives. It is also stressed that the training of young people especially teenagers as lay rescuers should be promoted and the establishment of training programs through emergency medical organizations and in schools should be encouraged.     

Überkopfreanimation

Many German paramedic schools are teaching a so-called “over head CPR” for the management of cardiac arrest with two healthcare providers on the scene. One person performs resuscitation and chest compressions at the head of the patient, while the other one prepares the equipment. In contrast, standard CPR consists of resuscitation and preparation of the equipment (during chest compressions) administered by the person at the head of the patient and chest compressions performed by the second rescuer at the side of the patient. A study conducted in Mainz proved that during over head CPR significantly fewer chest compressions were performed than during standard CPR. New studies now emphasize the major importance of chest compressions. After prolonged ventricular fibrillation, it seems to be better to perform chest compressions before defibrillation instead of immediate defibrillation.Over head CPR cannot be recommended in general, but it might be a method for special situations.     

Spontanatmung – Schnappatmung – Beatmung?

The value of mouth-to-mouth ventilation is currently discussed because of a wide-spread fear of transmission of infectious diseases. An expert committee of the American Heart Association even considered to recommend chest compressions. In paralyzed volunteers, however, ventilation induced by chest compressions was not able to provide a sufficient gas exchange. Laboratory investigations studying ventilation during CPR showed controversial results. Animal models that prevented gasping during cardiac arrest favored ventilation during CPR, whereas gasping animals seemed to be satisfactorily ventilated with chest compressions alone. The question whether spontaneous gasping after a cardiac arrest in humans may be sufficient for oxygenation and carbon dioxide elimination remains unanswered at this point in time. Therefore, mouth-to-mouth ventilation remains the therapy of choice during basic life. If a rescuer chooses to not perform mouth-to-mouth ventilation, at least chest compressions should be administered. The value of cricoid pressure during ventilation with an unprotected airway has to be emphasized to all healthcare professionals to avoid disastrous stomach inflation. If intubation can not be performed right away, the airway may be secured with the laryngeal mask airway, combitube, larynx tube, or intubating laryngeal mask airway. Rapid intubation and ventilation with oxygen remains the state-of-the-art therapy during CPR.     

Kardiopulmonale Reanimation „oben ohne“

A decade after the onset of a discussion whether ventilation could be omitted from bystander basic life support (BLS) algorithms, the state of the evidence is reevaluated. Initial animal studies and a prospective randomized patient trial had suggested that omission of ventilation during the first minutes of lay cardiopulmonary resuscitation (CPR) did not impair patient outcomes. More recent studies demonstrate, however, that this may hold true only in very specific scenarios, and that the chest compression-only technique was never superior to standard BLS. Instead of calling basics of BLS training and practice into question, more and better training of lay persons and professionals appears mandatory, and targeted use of dispatcher-guided telephone CPR should be evaluated and, if it improves outcome, it should be encouraged. Future studies should focus much less on the omission but on the optimization of ventilation under the specific conditions of CPR.     

Blitzschlagverletzung und kardiopulmonale Reanimation

The mainstay of management of lightning-induced respiratory and cardiac arrest is provision of basic life support (BLS) by bystanders. Attention should focus on adequate artificial ventilation and thoracic compressions. Cardiopulmonary resuscitation (CPR) may be effective after delayed onset and even after prolonged resuscitative attempt. In case of numerous victims struck simultaneously, standard triage principles must be modified. Highest priority is given to the unconscious patient with no spontaneous breathing and circulation. When exposure to lightning is still ongoing and conditions of rescuer safety remain limited, it is acceptable to rescue the patient prior to initiation of CPR. Once spontaneous circulation is re-established, intravenous fluid therapy must be restricted. Regular CPR refresher courses should emphasize on effective bystander CPR and primary prevention of lightning casualties.     

Neue mechanische Methoden der kardiopulmonalen Reanimation (CPR) Literaturstudie und Analyse der Effektivität

In a recent German multicenter study, 25% of the patients who suffered a witnessed cardiac arrest outside the hospital were resuscitated successfully and were discharged from the hospital. Approximately 100000 people suffer a fatal cardiac arrest in Germany annually, which is about ten times more than deaths resulting from motor vehicle accidents. New devices and techniques for cardiopulmonary resuscitation (CPR) have been developed in order to enhance the efficacy of chest compressions during CPR. The purpose of the present article is to review mechanisms of blood flow during CPR, to discuss CPR devices and techniques (vest CPR, CPR with interposed abdominal compressions, active compression-decompression (ACD) CPR, phased chest and abdominal compression-decompression CPR, and to further evaluate results from subsequently published laboratory and clinical studies. Vest CPR performs chest compressions with a pneumatic pump, which is able to compress the entire thorax with great force while minimizing injury. This device was developed to achieve an optimal driving force of the thoracic-pump mechanism during CPR. After promising results in laboratory studies and further technical development, vest CPR increased coronary perfusion pressure (CPP) in a clinical study even after 45?min of unsuccessful advanced cardiac life support. Currently, this device is being evaluated in an international multicenter study in Europe and the United States. A vest for employment by the emergency medical service (EMS) is in preparation. Interposed abdominal compressions during relaxation of the chest may augment artificial blood flow. In some laboratory studies, this mechanism resulted, in part, in promising data, and in another did not achieve better survival rates in comparison with standard CPR. No benefit of abdominal compressions was shown in an investigation in an EMS, whereas in a clinical study patients who were treated with interposed abdominal compressions were more likely to survive and be discharged from the hospital. However, in a follow-up study of in-hospital patients with asystole or pulseless electrical activity, abdominal compressions resulted in higher 24-h survival, but not hospital discharge rate, when compared with standard CPR. In animal studies ACD CPR produced increased CPP, end-tidal carbon dioxide, minute ventilation, and short-term survival. Subsequently performed clinical studies confirmed the data from the laboratory investigations; however, the hemodynamic advantage of ACD CPR did not result in increased long-term survival and a better neurological outcome in both in- and out-of-hospital cardiac arrest patients. To date, the reason why better hemodynamic variables did not result in better outcomes is unknown. A combination of ACD CPR with interposed abdominal compressions raised cerebral blood flow by approximately 60%, but did not augment myocardial blood flow in comparison with standard CPR. Recently, a device was developed to administer phased chest and abdominal compression-decompression CPR; this technique has been tested in an animal study and showed significant hemodynamic advantages and better survival compared with standard CPR. Clinical investigations of this device are being performed. In summary, since the rediscovery of chest compressions more than 35 years ago, this intervention has not changed significantly. Objective data from laboratory and clinical studies such as systolic blood pressure, CPP, and the gold standard for the efficacy of CPR, long-term survival and neurorlogical outcome, will determine if a new device or technique can replace standard-CPR. Despite the new developments, it is mandatory to perform standard CPR correctly with a chest compression rate of 80–100/min and a depth of 38–50?mm.     

Pro cardiopulmonary resuscitation before defibrillation

Background

The medical dogma has always been to defibrillate a patient discovered to be in ventricular fibrillation (VF), and automatic electric defibrillators (AED) drove this standard into widespread cardiopulmonary resuscitation (CPR) guidelines. Slow AED operation and three stacked shocks added several minutes of not providing blood flow generated by chest compressions. Investigators questioned the practice of providing defibrillation first for patients with longer down time compared to providing chest compressions prior to defibrillation. Human and experimental literature in addition to the interplay between chest compression, defibrillation, and saving lives are discussed.

Materials and methods

The experimental and human literature published regarding chest compression prior to defibrillation is reviewed, the importance of providing chest compressions that generate adequate blood flow to vital organs is highlighted, and the scientific evidence for CPR before defibrillation was performed is explored.

Results

Our review documented that in experimental animal studies of cardiac arrest there is a pooling of blood on the venous side of the heart during VF and that chest compression before defibrillation serve two purposes: (1) high quality chest compressions preserve brain function and (2) perfusing the heart with blood,“primes it” for successful restoration of spontaneous circulation. In clinical practice, the time interval of CPR before defibrillation is unknown. One randomized trial of 3?min of CPR before defibrillation found a significant increase in survival for those who were reached more than 5?min after cardiac arrest, and this was supported by a study based on historic controls. Other studies have not found any benefit but we may speculate that this was due to the quality of the CPR. Delaying defibrillation attempts is meaningless, if quality of chest compressions is suboptimal.

Conclusion

High quality CPR before defibrillation is the treatment of choice for those patients who will not receive a defibrillation attempt shortly after VF started. Regarding survival, it has not been documented that CPR first is inferior to defibrillation first. CPR first is safe and effective for most prehospital cardiac arrest patients.     

Atemwegsmanagement in der Initialphase der Reanimation

Background

The revised 2005 guidelines of the ERC emphasised the importance of uninterrupted chest compressions. However, airway management is frequently associated with interruptions and errors in cardiopulmonary resuscitation (CPR). Additionally CPR within the first minutes is often performed under conditions of manpower shortage. In this study the airway management as well as the incidence and causes of interruptions of chest compressions during resuscitation were analysed.

Materials and methods

Fire department two-rescuer teams with standard ambulance equipment responded to a simulated cardiac arrest scenario. Data collection with respect to management and chronology was performed by two independent observers and with the integrated software of a manikin (Resusci Anne Simulator).

Results

A total of 52 rescue teams each consisting of 2 paramedics were evaluated during the first 5 cycles of CPR (12.6±0.7 min). The overall no flow fraction (NFF) was 41.7±6.7%, whereby 16% were caused by bag-mask-ventilation (BMV). Of the teams, 30 attempted endotracheal intubation with a primary failure rate of 30.0%. In 65.7% of intubation attempts interruption of thorax compressions occurred for 45±17 s. Additional measures included over-the-head CPR which was carried out by 28.8% of the teams and resulted in increased intervals from 6±2 s up to 10±5 s (p=0.032) per BMV cycle.

Conclusions

During early CPR airway management seems to be difficult under conditions of limited manpower. Especially endotracheal intubation is associated with an increased NFF and high failure rate. Over-the-head CPR led to a significant lengthening of interruptions in chest compression.     

Cardiopulmonary resuscitation: effect of CPAP on gas exchange during chest compressions

BACKGROUND: Conventional cardiopulmonary resuscitation (CPR) includes 80-100/min precordial compressions with intermittent positive pressure ventilation (IPPV) after every fifth compression. To prevent gastric insufflation, chest compressions are held during IPPV if the patient is not intubated. Elimination of IPPV would simplify CPR and might offer physiologic advantages, but compression-induced ventilation without IPPV has been shown to result in hypercapnia. The authors hypothesized that application of continuous positive airway pressure (CPAP) might increase CO2 elimination during chest compressions. METHODS: After appropriate instrumentation and measurement of baseline data, ventricular fibrillation was induced in 18 pigs. Conventional CPR was performed as a control (CPR(C)) for 5 min. Pauses were then discontinued, and animals were assigned randomly to receive alternate trials of uninterrupted chest compressions at a rate of 80/min without IPPV, either at atmospheric airway pressure (CPR(ATM)) or with CPAP (CPR(CPAP)). CPAP was adjusted to produce a minute ventilation of 75% of the animal's baseline ventilation. Data were summarized as mean +/- SD and compared with Student t test for paired observations. RESULTS: During CPR without IPPV, CPAP decreased PaCO2 (55+/-28 vs. 100+/-16 mmHg) and increased SaO2 (0.86+/-0.19 vs. 0.50+/-0.18%; P < 0.001). CPAP also increased arteriovenous oxygen content difference (10.7+/-3.1 vs. 5.5+/-2.3 ml/dl blood) and CO2 elimination (120+/-20 vs. 12+/-20 ml/min; P < 0.01). Differences between CPR(CPAP) and CPR(ATM) in aortic blood pressure, cardiac output, and stroke volume were not significant. CONCLUSIONS: Mechanical ventilation may not be necessary during CPR as long as CPAP is applied. Discontinuation of IPPV will simplify CPR and may offer physiologic advantage.     

Increasing compression depth during manikin CPR using a simple backboard

BACKGROUND: The quality of external chest compressions (ECC) is influenced by the surface supporting the patient. The aim of this study was to compare chest compression depth with and without a rigid backboard. The authors hypothesized that the presence of a backboard would result in an increased depth of chest compressions. METHODS: A randomized, double-blinded, cross-over trial. We simulated in-hospital cardiac arrest using a resuscitation manikin placed in a standard hospital bed. In total, 23 hospital orderlies were randomly assigned to perform ECC for 2 min on two identical ResusciAnne manikins, under one of which a rigid backboard had been placed. Data were recorded using the Laerdal PC-Skill Reporting System. RESULTS: Mean chest compression depth increased from 43 to 48 mm (P < 0.0001) when a backboard was present (mean difference 5 mm, 95% CI 3.6-7.5 mm, SD 4.6). There was a significant increase in mean proportion of compressions >40 mm when using a backboard Mean 92% vs. 69%, P= 0.0007). No difference was found between the two groups in the following variables: duty cycle, compression rate, mean proportion of compressions of correct depth (40-50 mm) or proportion of compressions with incomplete release. CONCLUSIONS: Applying a backboard significantly increases depth of chest compressions during cardiopulmonary resuscitation when performed on a manikin model.     

Cardiopulmonary Resuscitation: Effect of CPAP on Gas Exchange during Chest Compressions

Background: Conventional cardiopulmonary resuscitation (CPR) includes 80-100/min precordial compressions with intermittent positive pressure ventilation (IPPV) after very fifth compression. To prevent gastric insufflation, chest compressions are held during IPPV if the patient is not intubated. Elimination of IPPV would simplify CPR and might offer physiologic advantages, but compression-induced ventilation without IPPV has been shown to result in hypercapnia. The authors hypothesized that application of continuous positive airway pressure (CPAP) might increase CO2 elimination during chest compressions.

Methods: After appropriate instrumentation and measurement of baseline data, ventricular fibrillation was induced in 18 pigs. Conventional CPR was performed as a control (CPRC) for 5 min. Pauses were then discontinued, and animals were assigned randomly to receive alternate trials of uninterrupted chest compressions at a rate of 80/min without IPPV, either at atmospheric airway pressure (CPRATM) or with CPAP (CPRCPAP). CPAP was adjusted to produce a minute ventilation of 75% of the animal's baseline ventilation. Data were summarized as mean +/- SD and compared with Student t test for paired observations.

Results: During CPR without IPPV, CPAP decreased PaCO2 (55 +/- 28 vs. 100 +/- 16 mmHg) and increased SaO2 (0.86 +/- 0.19 vs. 0.50 +/- 0.18%; P < 0.001). CPAP also increased arteriovenous oxygen content difference (10.7 +/- 3.1 vs. 5.5 +/- 2.3 ml/dl blood) and CO2 elimination (120 +/- 20 vs. 12 +/- 20 ml/min; P < 0.01). Differences between CPRCPAP and CPRATM in aortic blood pressure, cardiac output, and stroke volume were not significant.     

Herzdruckmassage im Rahmen der Laienreanimation

Background

The quality of chest compressions and early defibrillation are paramount in cardiopulmonary resuscitation (CPR). Whether real-time feedback devices may improve CPR efforts in lay person CPR is unclear.

Material and methods

Prospective randomized studies were carried out to test the influence of the electronic real-time feedback device PocketCPR? on the quality of chest compression by lay person CPR training in a mock-up cardiac arrest scenario. Altogether 42 inexperienced lay persons were randomized into 2 groups (groups A and B). The quality of chest compressions was analyzed with respect to depth and frequency in a cross-over design.

Results

PocketCPR? improved mean chest compression depth significantly (p=0.029) solely in one of both groups (44±7 versus 41±10 mm). However, both groups achieved recommended compression depths between 38–51 mm independent of device application. Also mean chest compression frequency was improved significantly (p=0.001) in one group only (100±21 versus 115±21 per min). There was no demonstrable significant potential learning effect through the application of the feedback device.

Conclusion

Real-time feedback devices do not ensure a consistent improvement of chest compression quality during mock-up lay person CPR training. Additional studies are needed to investigate potential effects for trained health care professionals.     

Beurteilung der Effizienz eines Audioplayers für Ersthelfer in der Behandlung eines Atem-Kreislauf-Stillstands

Background

Bystander first aid is important for survival in cases of cardiac arrest. Acoustic first aid instructions could increase the quality of cardiopulmonary resuscitation (CPR), however, insufficient studies have been performed.

Material and methods

In this study 110 participants were confronted with a manikin-based situation of sudden cardiac arrest. The participants were randomly assigned to a test group and a control group. The participants of the test group received an audioplayer with first aid instructions for performing CPR.

Results

The audioplayer had no effect on the primary endpoint and the hands-off time was 59% in both groups. The participants of the test group controlled consciousness and tilt of the head to check for a free airway significantly more often (93% versus 33% and 44% versus 15%, respectively). No significantly different results were found in the number of performed calls for help (53% versus 55%), compressions (100% versus 100%) and ventilation (98% versus 96%). The control group started chest compression significantly earlier (38?s versus 67?s; p?<?0.001). Furthermore the control group performed significantly deeper chest compressions (39?mm versus 34?mm; p?=?0.008).

Conclusion

The use of an audioplayer did not improve the effectiveness of bystander first aid in simulated cases of cardiac arrest.     

Thoraxkompressionsqualität

Background

The outcome of cardiopulmonary resuscitation (CPR) depends on the quality of chest compressions. Current European Resuscitation Council (ERC) guidelines promote the development of feedback systems. However, no studies presenting satisfactory results of feedback use have been published.

Methods

A total of 60 patients with cardiac arrest (≥18 years of age) received resuscitation attempts using an automated external defibrillator (AED) with real-time feedback by the ambulance service of the City of Münster. The frequency of chest compressions, no-flow time (NFT) and depth of chest compressions were analyzed for the first three cycles of CPR and compared to the ERC guidelines 2005.

Results

Chest compression frequency did not differ significantly from the ideal as set out in the guidelines. Analysis of NFTs showed significantly longer NFT for the first cycle but NFT for the second and third cycles did not differ significantly from the ideal. The target depth of 4-5 cm was achieved in 80% of all chest compressions in the first 3 cycles.

Conclusion

With the AED real-time feedback technology used in this study standardized performance of chest compressions could be maintained in a professional ambulance service. Implementation of a feedback system requires training of ambulance staff.     

Could we use abdominal compressions rather than chest compression in patients who arrest after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether abdominal cardiopulmonary resuscitation (CPR) could be used instead of external cardiac massage either to protect the recent sternotomy or while chest compressions are not possible whilst a sternotomy is being performed. Altogether 386 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Patients who arrest after cardiac surgery and require chest reopening will have a period of no external chest compression and therefore, no cerebral or coronary perfusion. In addition, if a patient arrests prior to cardiac surgery there will be a period of time performing the sternotomy during which there will be no external compressions. We found only one paper in a porcine model that looked at the effectiveness of abdominal only CPR although it did show that abdominal CPR was actually 60% better than chest CPR. Interposed abdominal and chest compressions has been much more extensively studied and has been shown to be significantly better in return of spontaneous circulation than chest compressions alone. We conclude that currently there is very little evidence to support abdominal only CPR although these studies may support the concept that it may potentially increase the coronary and cerebral perfusion pressure.