CAT FOR TREATMENT

Clinical Question:
P: Adult with out of hospital cardiac arrest
E: Continuous chest compressions
O: Mortality
A. Study Characteristics
1. Patients included
Adults with nontrauma-related out-of-hospital cardiac arrest.
2. Interventions compared
Intervention: Continuous chest compressions at a rate of 100 compressions per
minute, with asynchronous positive-pressure ventilations delivered at a rate of
10 ventilations per minute
Control: Compressions that were interrupted for ventilations at a ratio of 30
compressions to two ventilations; ventilations were to be given with positive
pressure during a pause in compressions of less than 5 seconds in duration
3. Outcomes monitored
Primary Outcome: Rate of survival to hospital discharge
Secondary Outcome: Neurologic function at discharge (Modified Rankin scale)
B. Validity Criteria
1. Were the patients randomly assigned to treatment groups?
No. Cluster randomization with crossovers was used.
The 114 participating EMS agencies across the eight participating ROC sites were
grouped into 47 clusters. Clusters of agencies were randomly assigned, in a 1:1
ratio, to perform continuous chest compressions or interrupted chest
compressions during all the out-of-hospital cardiac arrests to which they
responded. Twice per year each cluster was crossed over to the other
resuscitation strategy.
2. Was allocation concealed?
Uncertain, method of randomization not known. However, there was a crossover
done so twice which will lower risk of bias.
3. Were baseline characteristics similar at the start of the trial
Yes. As seen in table 1, the patient baseline characteristics are similar.
4. Were the patients blinded to treatment assigned
Yes. Low Risk
5. Were the caregivers blinded to the treatment assigned
Not possible.

6. Were the outcome observers blinded to the treatment

assigned
Does not matter for primary outcome as it is not subjective. For secondary
outcome, uncertain as there was no mention on who made the assessment of
the Modified Rankin Scale.
7. Were all the patients analysed in the groups in which they
were originally randomized
Yes, they were analysed based on the group they were originally randomized to.
8. Was follow-up adequate
Yes. Assuming the 40 in the intervention group where vital data was not available
had adverse outcomes, Rt would be 1129/12613 which would be 8.9%. In the
control group, in which 23 had lost vital data had good outcomes, Rc will be
1095/11058 = 9.9%. RR is then 0.9 and RRR is 10%.ARR is 1% and the NNT is
100.
The author noted that the overall difference in the survival rate between the
treatment groups in the effectiveness population was still not significant.

C. Results
Outcome

Rc

Rt

RR

RRR

AR
R

NNT

1. Surviv
al to
Discha
rge

1072/110
35 =
9.7%

1129/12613
= 9.0%

9/9.
7=
0.9
3

(9.79.0)/9
.7 =
0.7/9.
7=
0.07

1/0.0
07 =
143

2. Modif
ed
Rankin
Scale
Score
</= 3

844/1099
5 = 7.7

883/12560 =
7.0

7/7.
7=
0.9
1

0.7 /
7.7 =
0.091

0.7
%
(1.5

0.1
)
0.7
%
(1.4

0.1
)

Outcome
1. Modifed
Rankin Scale
Score

Mean (c)

Mean (I)

5.6 +/1.35

5.63 +/1.29

D. Applicability Issues
1. Sex
2. Co-morbids

Mean
dif
0.04

1/0.0
07 =
143

pval
ue
0.0
7

0.0
9

95% CI

p-value

0 0.08

0.04

3. Race
4. Age
5. Pathology
The only concern may be with respect to the race as the study is
conducted in a North America and therefore the ethnicity of the
population may result in the study being not directly applicable to our
local population.
E. Reviewers Conclusion
This studys directness is a good fit with our clinical question. The study is
reliable and not biased. The results show that there is no statistically
significant improvement in the mortality and neurological outcome. However
through observation of the CI, the intervention does seem to indicate an
improvement as compared to the control. The clinical significance of this
improvement can be explored further. The study is robust and is mostly
applicable to our local context, though it is important to note potential
ethnicity differences and its impact on the ability to generalize study results
to our population.