Strategies to improve out-of-hospital cardiac arrest outcomes in the pre-hospital environment – Part B: non-pharmaceutical strategies


heart arrest
emergency medical service
advanced life support

How to Cite

Pemberton KE, Franklin RC, Watt K. Strategies to improve out-of-hospital cardiac arrest outcomes in the pre-hospital environment – Part B: non-pharmaceutical strategies. Australasian Journal of Paramedicine [Internet]. 2019Nov.4 [cited 2022Jan.23];160. Available from:



Out-of-hospital cardiac arrest (OHCA) historically has low survival rates. Higher rates of survival have recently developed in some small geographical areas, which pre-empted an increase in the volume of research in this field. The aim of this paper is to consolidate the findings of the strategies that do not focus on drugs.


This is a systematic search and review, rather than a systematic review. A search of four databases (MEDLINE, CINAHL, Informit, Scopus) was undertaken in February 2017. Papers published between 2007 and 2017 containing strategies that may be used by paramedics when resuscitating adult patients in OHCA from presumed cardiac aetiology were identified.


Twenty-eight studies were included in the review, comprising six separate strategies. This manuscript reports on the four non-pharmaceutical strategies (use of a modified resuscitation protocol; use of a mechanical chest compression device; intra-thoracic pressure regulation and application of therapeutic hypothermia).


Use of a modified resuscitation protocol to improve the quality of cardiopulmonary resuscitation, was the only strategy showing evidence to warrant a recommendation for immediate implementation. Future studies should focus on strategy specific patient subsets.


Berdowski J, Berg RA, Tijssen JGP, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 2010;81:1479-87.

Pemberton K, Franklin R, Watt K. Strategies to improve outcomes from out-of-hospital cardiac arrest - Part A. Australasian Journal of Paramedicine 2019;16.

Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J 2009;26:91-108.

Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. J Am Med Assoc 2008;299:1158-65.

Kellum MJ, Kennedy KW, Barney R, et al. Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest. Ann Emerg Med 2008;52:244-52.

Garza AG, Gratton MC, Salomone JA, et al. Improved patient survival using a modified resuscitation protocol for out-of-hospital cardiac arrest. Circulation 2009;119:2597-605.

Nichol G, Leroux B, Wang H, et al. Trial of continuous or interrupted chest compressions during CPR. N Engl J Med 2015;373:2203-14.

Bobrow BJ, Vadeboncoeur TF, Stolz U, et al. The influence of scenario-based training and real-time audiovisual feedback on out-of-hospital cardiopulmonary resuscitation quality and survival from out-of-hospital cardiac arrest. Ann Emerg Med 2013;62:47-56.e1.

Hopkins CL, Burk C, Moser S, et al. Implementation of pit crew approach and cardiopulmonary resuscitation metrics for out-of-hospital cardiac arrest improves patient survival and neurological outcome. J Am Heart Assoc 2016;5:11.

Pearson DA, Darrell Nelson R, Monk L, et al. Comparison of team-focused CPR vs standard CPR in resuscitation from out-of-hospital cardiac arrest: results from a statewide quality improvement initiative. Resuscitation 2016;105:165-72.

Jennings PA, Harriss L, Bernard S, et al. An automated CPR device compared with standard chest compressions for out-of-hospital resuscitation. BMC Emerg 2012;12:8.

Wik L, Olsen JA, Persse D, et al. Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation 2014;85:741-8.

Smekal D, Johansson J, Huzevka T, Rubertsson S. A pilot study of mechanical chest compressions with the LUCAS device in cardiopulmonary resuscitation. ibid. 2011;82:702-6.

Axelsson C, Herrera MJ, Fredriksson M, Lindqvist J, Herlitz J. Implementation of mechanical chest compression in out-of-hospital cardiac arrest in an emergency medical service system. Am J Emerg Med 2013;31:1196-200.

Rubertsson S, Lindgren E, Smekal D, et al. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA 2014;311:53-61.

Perkins GD, Lall R, Quinn T, et al. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet 2015;385:947-55.

Zeiner S, Sulzgruber P, Datler P, et al. Mechanical chest compression does not seem to improve outcome after out-of hospital cardiac arrest. A single center observational trial. Resuscitation 2015;96:220-5.

Aufderheide TP, Alexander C, Lick C, et al. From laboratory science to six emergency medical services systems: new understanding of the physiology of cardiopulmonary resuscitation increases survival rates after cardiac arrest. Crit Care Med 2008;36(11 Suppl):S397-404.

Aufderheide TP, Nichol G, Rea TD, et al. A trial of an impedance threshold device in out-of-hospital cardiac arrest. N Engl J Med 2011;365:798-806.

Aufderheide TP, Frascone RJ, Wayne MA, et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial. Lancet 2011;377:301-11.

Bernard SA, Smith K, Cameron P, et al. Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation 2010;122:737-42.

Bernard SA, Smith K, Cameron P, et al. Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest. Crit Care Med 2012;40:747-53.

Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: a randomized clinical trial. J Am Med Assoc 2014;311:45-52.

Garrett JS, Studnek JR, Blackwell T, et al. The association between intra-arrest therapeutic hypothermia and return of spontaneous circulation among individuals experiencing out of hospital cardiac arrest. Resuscitation 2011;82:21-5.

Schenfeld EM, Studnek J, Heffner AC, et al. Effect of prehospital initiation of therapeutic hypothermia in adults with cardiac arrest on time-to-target temperature. Can J Emerg Med 2015;17:240-7.

Bernard SA, Smith K, Finn J, et al. Induction of therapeutic hypothermia during out-of-hospital cardiac arrest using a rapid infusion of cold saline: the RINSE Trial (Rapid Infusion of Cold Normal Saline). Circulation 2016;134:797-805.

Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen MP. Estimating effectiveness of cardiac arrest interventions. ibid. 1997;96:3308.

Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. ibid. 2013;128:417-35.

Christenson J, Davis D, Aufderheide TP, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. ibid. 2009;120:1241-7.

Edelson DP, Becker LB, Abella BS, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation 2006;71:137-45.

Idris AH, Guffey D, Aufderheide TP, et al. Relationship between chest compression rates and outcomes from cardiac arrest. Circulation 2012;125:3004-12.

Rea T, Olsufka M, Yin L, Maynard C, Cobb L. The relationship between chest compression fraction and outcome from ventricular fibrillation arrests in prolonged resuscitations. Resuscitation 2014;85:879-84.

Stiell IG, Brown SP, Christenson J, et al. What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation? Crit Care Med 2012;40:1192-8.

Vadeboncoeur T, Stolz U, Panchal A, et al. Chest compression depth and survival in out-of-hospital cardiac arrest. Resuscitation 2014;85:182-8.

Fernandez Castelao E, Russo SG, Riethmuller M, Boos M. Effects of team coordination during cardiopulmonary resuscitation: a systematic review of the literature. J Crit Care 2013;28:504-21.

Hunziker S, Tschan F, Semmer NK, Marsch S. Importance of leadership in cardiac arrest situations: from simulation to real life and back. Swiss Med Wkly 2013;143:w13774.

Clarke S, Lyon RM, Short S, Crookston C, Clegg GR. A specialist, second-tier response to out-of-hospital cardiac arrest: setting up TOPCAT2. Emerg Med J 2013.

Gates S, Quinn T, Deakin CD, et al. Mechanical chest compression for out of hospital cardiac arrest: systematic review and meta-analysis. Resuscitation 2015;94:91-7.

Li H, Wang D, Yu Y, Zhao X, Jing X. Mechanical versus manual chest compressions for cardiac arrest: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2016;24(1).

Tang L, Gu WJ, Wang F. Mechanical versus manual chest compressions for out-of-hospital cardiac arrest: a meta-analysis of randomized controlled trials. Sci Rep 2015;5:15635.

Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation 2015;86:88-94.

Belohlavek J, Kucera K, Jarkovsky J, et al. Hyperinvasive approach to out-of hospital cardiac arrest using mechanical chest compression device, prehospital intraarrest cooling, extracorporeal life support and early invasive assessment compared to standard of care. A randomized parallel groups comparative study proposal. Prague OHCA study. J Transl Med 2012;10:163.

Lamhaut L, Hutin A, Puymirat E, et al. A pre-hospital extracorporeal cardio pulmonary resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: an observational study and propensity analysis. Resuscitation 2017;117:109-17.

Lafuente-Lafuente C, Melero-Bascones M. Active chest compression-decompression for cardiopulmonary resuscitation. Cochrane Database Syst Rev 2013;9:CD002751.

Segal N, Parquette B, Ziehr J, Yannopoulos D, Lindstrom D. Intrathoracic pressure regulation during cardiopulmonary resuscitation: a feasibility case-series. Resuscitation 2013;84:450-3.

Arrich J, Holzer M, Havel C, Müllner M, Herkner H. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev 2016;2016(2).

Arrich J, Holzer M, Havel C, Warenits AM, Herkner H. Pre-hospital versus in-hospital initiation of cooling for survival and neuroprotection after out-of-hospital cardiac arrest. ibid. 2016;2016(3).

Castren M, Nordberg P, Svensson L, et al. Intra-arrest transnasal evaporative cooling: a randomized, prehospital, multicenter study (PRINCE: Pre-ROSC IntraNasal Cooling Effectiveness). Circulation 2010;122:729-36.

Nordberg P, Taccone F, Truhlar A, et al. Pre-hospital Resuscitation INtra-arrest Cooling Effectiveness Survival – The PRINCESS Study. Resuscitation 2015;96:45.

Nordberg P, Taccone FS, Castren M, et al. Design of the PRINCESS trial: pre-hospital resuscitation intra-nasal cooling effectiveness survival study (PRINCESS). BMC Emerg 2013;13:21.

Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med 2013;369:2197-206.