Resuscitation 96 (2015) 220225

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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Clinical paper

Mechanical chest compression does not seem to improve outcome

after out-of hospital cardiac arrest. A single center observational trial
Sebastian Zeiner a,1 , Patrick Sulzgruber a,1 , Philip Datler a , Markus Keferbck a ,
Michael Poppe a , Elisabeth Lobmeyr a , Raphael van Tulder a , Andreas Zajicek b ,
Angelika Buchinger b , Karl Polz b , Georg Schrattenbacher b , Fritz Sterz a,
a
b

Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria

Municipal Ambulance Service of Vienna, Vienna, Austria

a r t i c l e

i n f o

Article history:
Received 16 April 2015
Received in revised form 29 July 2015
Accepted 30 July 2015
Keywords:
Out-of-hospital cardiac arrest
Cardiopulmonary resuscitation
Mechanical chest compression
Mortality
Survival

a b s t r a c t
Aim: Recently three large post product placement studies, comparing mechanical chest compression (cc)
devices to those who received manual cc, found equivalent outcome results for both groups. Thus the
question arises whether those results could be replicated using the devices on a daily routine.
Methods: We prospectively enrolled 948 patients over a 12 months period. Chi-Square test and
MannWhitney-U test were used to assess differences between manual and mechanical cc subgroups. Uni- and multivariate Cox regression hazard analysis were used to assess the inuence of cc
type on survival.
Results: A mechanical cc device was used in 30.1% (n = 283) cases. Patients who received mechanical cc
had a signicantly worse neurological outcome measured in cerebral performance category (CPC)
than the manual cc group (56.8% vs. 78.6%, p = 0.009). Patients receiving mechanical cc were signicantly
younger, more were male and were more likely to have bystander CPR and an initially shock-able ECG
rhythm. There was no difference in the quality of CPR that might explain the worse outcome in mechanical
cc patients.
Conclusion: Even with high quality CPR in both, manual and mechanical cc groups, outcome in patients
who received mechanical cc was signicantly worse. The anticipated benets of a higher compression
ratio and a steadier compression depth of a mechanical cc device remain uncertain. In this study selection
for mechanical cc was not standardized, and was non-random. This merits further investigation. Further
research on how mechanical cc is chosen and used should be considered.
Clinical trial registration: https://ekmeduniwien.at/core/catalog/2013/ (EK-Nr:1221/2013)
2015 Elsevier Ireland Ltd. All rights reserved.

Introduction
The number of patients suffering cardiac arrest (CA) is continuously rising within the western society. Despite many efforts in
the eld of resuscitation science survival rates after out of hospital CA (OHCA) still remain unsatisfying low. However a large
variety of factors improving outcome in patients suffering OHCA
are well established. A prompt administration of sufcient chest

A Spanish translated version of the abstract of this article appears as Appendix

in the nal online version at http://dx.doi.org/10.1016/j.resuscitation.2015.07.051.
Corresponding author.
1

E-mail address: fritz.sterz@meduniwien.ac.at (F. Sterz).

These authors are contributed equally in this work.

http://dx.doi.org/10.1016/j.resuscitation.2015.07.051
0300-9572/ 2015 Elsevier Ireland Ltd. All rights reserved.

compressions is known to be the most benecial factor for outcome

in patients suffering CA.15
Current guidelines recommend a target compression rate
between 100 and 120 compressions per minute, a minimization
of interruptions, constant compression depth of at least 5 cm and
overall high compression ratios.6,7 To assess these target guidelines,
great hopes were recently set upon automated chest compression
devices to support or even replace manual chest compression (cc).
In the 2010 guidelines of both, the American Heart Association
and the European Resuscitation Council LUCASTM (Physio-Control
Incorporation, Lund, Sweden) which is an automated mechanical piston device and AutoPulse (ZOLL Medical Corporation; MA
Chelmsford, USA), a load-distributing band device are specically
mentioned. Both guidelines pointed out that at the time the consensus was found that there was neither certain prove for these
devices to improve nor to worsen outcome and that future study

S. Zeiner et al. / Resuscitation 96 (2015) 220225

results were to be awaited.7,8 A recent meta-analysis of Westfall

et al. comprising eight studies about load distribution devices and
four about piston driven devices concluded that mechanical chest
compression devices achieved signicantly more returns of spontaneous circulation (ROSC).9
Furthermore the mechanical versus manual cc for OOHCA
(PARAMEDIC), Circulation Improving Resuscitation Care (CIRC) trial
and LUCASTM in CA study (LINC) study produced results depicting
that mechanical cc deliver results comparable to manual cc but
were not able to demonstrate superiority. However both devices
are currently established and widely used although post-product
placement data on outcome of the mentioned devices remain scare
and inconclusive.2,3,1014
Therefore we aimed to verify these results for the everyday use
of mechanical cc devices by emergency medical technicians (EMT)
and emergency medical physicians in an OHCA setting. Moreover
we aimed analyzed whether mechanical cc impacts on 30-day survival with favorable neurological outcome.15,16
Methods
Study population
Patients suffering OHCA and receiving resuscitative efforts by
EMTs or physicians of the Municipal Ambulance Service of Vienna,
between July 2013 and August 2014 were enrolled. To address the
study goals, patients were stratied into two groups according to
mechanical cc and manual cc. Mechanic cc was dened as actual
chest compressions administrated by LUCAS or AutoPulse to the
patients. If the device was brought to the scene, or prepared for
use, but was not put in operation, it was not dened as a mechanic
cc. The study protocol complies with the declaration of Helsinki and
was approved by the local ethics committee of the Medical University of Vienna (EK 1221/2013) with waiver of informed consent.
There are more than 40 ambulance cars, manned by EMTs as
well as 16 emergency physician vehicles that can be dispatched
in Vienna. Eight of the emergency physician vehicles are equipped
with a LUCASTM and eight are equipped with an AutoPulse . So
called eld-supervisor staffed vehicles specialized in quality
management, data gathering and assistance in extreme scenarios
were dispatched in addition to the scene in numerous cases. They
often assist in OHCAs and are equipped with LUCASTM devices; they
are trained to immediately bring the device to the patient contrary to the standard emergency physician vehicle teams, which
are trained to bring an emergency backpack and a debrillator.
After an emergency call concerning a possible OHCA is made, an
EMT staffed ambulance car as well as an emergency physicians
car are dispatched to the location of the incident. In most cases
regular ambulances which are not equipped with a mechanical
cc device arrive earlier at the patient. Another possibility is that
a patients condition worsens during transport or on the scene so
that an emergency physician was not primarily present at the scene
but secondarily dispatched by the EMTs request.
Data acquisition and follow-up
Patient data were gathered from run-reports and written event
recordings according to the Utstein criteria.48 ECG leads, thoracic
impedance data as well as vital parameters were recorded from the
moment the debrillator-electrodes were placed at the patient. The
aforementioned data were extracted from the EMS debrillators
used (LifePak 500, 12, or 15, Physio-Control, Redmond, WA, USA)
by trained personal and forwarded for evaluation. Impedance data
were analyzed using CODE-STATTM Reviewer (Version 8.0, PhysioControl, Redmond, WA, USA). Thoracic impedance measurements

221

were used to evaluate cc and ventilation. Furthermore dispatchtimes and emergency call records as well as hospital records were
obtained. Outcome data and the patients CPC were obtained via
the hospital records and discharge letters as well via contacting
the afliated physician at the admitting department. CPC has been
dened according to established guidelines.17 CPC 1 and 2 being
good cerebral performance and moderate cerebral disability in
comparison to CPC 3 and 4 being severe cerebral disability and coma
or vegetative state.16,18
During the whole study period and beyond an individual
feedback for each case was issued to the EMS team. Feedback and debrieng are known to improve CPR-performance
in hospitals1921 and out-of-hospital.22 It has been shown that
the data collected with debrillators are sufcient to provide
feedback.2325
Statistical analysis
Discrete data are shown as counts and percentages and
were analyzed using Chi-Square test. Continuous variables are
shown as mean and interquartile-range (IQR) and analyzed using
MannWhitey-U test or KruskalWallis test for comparison within
the subgroups. Uni- and multivariable Cox-regression hazard analysis reecting a multiplicatively association of covariates on the
hazard were used to assess the inuence of cc type on mortality.
Results were presented as hazard ratio (HR) and the respective 95%
condence interval (CI) per one standard deviation (1-SD) increase
for continuous variables. The multivariate model was adjusted
for other variables associated with in-hospital mortality including: age, female gender, cardiovascular etiology of CA, initially
shock-able ECG rhythm, witnessed CA, bystander BLS, handson fraction and larynx-tube. Statistical signicance was dened
by two-sided p-values <0.05. Statistical analyses were performed
using the STATA 11 software package (StataCorp LP, USA) and PASW
18.0 (IBM SPSS, USA).
Results
Overall 938 patients were enrolled. Patients were stratied into
two groups according to mechanical cc (n = 283) and manual cc
(n = 655; see Fig. 1), because of the very low number of cases with
mechanical CPR only, a separation in three subgroups would not
yield signicance. The mean age of the total cohort was 68 11
years and 343 (36.6%) of the patients were female.
The group that received manual cc was overall older with
70 10 years compared to 63 9 years (p 0.001). Signicantly
less female patients receive CPR with a mechanical cc device (n = 78,
27.6%) compared to male patients (n = 205, 72.4%) (p 0.001).
Interestingly in patients where the decision was made to use a
mechanical cc device the rate of patients with an initially shockable ECG rhythm (33.7% vs. 22.1%; p < 0.001) was higher. Moreover
patients had more often a witnessed CA (55.8% vs. 54.0%; p = 0.614)
and were more likely to receive bystander BLS (54.1% vs. 44.7%;
p = 0.008). This gives the impression that patients with an objectively more favorable initial position for good outcome are more
likely to receive a mechanic cc device. Within the total study collective a high quality of cc was achieved with 108 (102115) mean
chest compressions per minute and a compression ratio of 82%
(7887). There was no signicant difference between the compression ratios of the two groups with 82% (7787) in the manual
only group and 82% (7986) in the group receiving also mechanical resuscitation (p = 0.959). Even the percentage of minutes in
which the compression ratio was higher than 75% did not reveal
a difference with 78% (6489) overall, 79% (6389) in the manual
and 78% (6787) in the mechanical group (p = 0.360). The groups

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S. Zeiner et al. / Resuscitation 96 (2015) 220225

differed in duration of CPR with 12.7 min (6.419.7) in the manual and 21.6 min (14.730.7) in the mechanical group (p < 0.001)
(Table 1).
Outcome parameters
Any ROSC was achieved in 341 (36.3%) of all patients and
sustained ROSC in 266 (28.3%) patients. There were 153 (16.3%)
survivors at 30 days after the initial event of which 113 (73.4%) had
a CPC of 1 or 2. The patients receiving manual resuscitation were
more likely to attain sustained ROSC (n = 201, 30.6%) compared to
those receiving mechanical cc (n = 65, 23.0%) (p = 0.017). Though
the 30 day survival did not signicantly differ between the groups,
the neurological outcome did. There was a signicant difference in
favorable neurological outcome detectable. The 30 day survivors
had a CPC 1 or 2 in the manual cc subgroup in 113 (73.4%) patients
compared to the group with mechanical cc with 21 (56.8%) patients
(p = 0.009) (Table 1).

Compression ratio and CPR duration

The compression ratios stayed high even in long (>20 min)
resuscitation efforts. In the group with manual cc the compression ratio after 20 min was 83% (7887) and the same as in the
shorter resuscitations (82%(7587) in resuscitations shorter than
10 min and 82% (7787) in resuscitations that took between 10 and
20 min) and as high as in the group resuscitated with mechanical
cc for more than 20 min with 82% (7986) (Tables 2 and 3).
Comparing devices
Within the mechanical cc subgroup, LUCASTM was used in 239
(84.5%) and AutoPulse in 44 (15.5%) cases. Comparing the two
devices used for mechanical cc there was no difference in the quality of CPR or outcome. The mean compression ratio for the LUCASTM
group was 82% (7986) and for the AutoPulse group 82% [7787]
(p = 0.895). In patients receiving mechanical cc with LUCASTM sustained ROSC was achieved in 82 (34.3%) patients as compared to 13
patients treated with AutoPulse (29.5%) (p = 0.539). A CPC of 1 or 2
was reached by19 patients (7.9%) that received CPR with LUCASTM

Fig. 1. Patient ow diagram.

Table 1
Baseline characteristics.

Age, years (IQR)

Male gender, n (%)
Location of CA, n (%)
Home
Public
Transport
Witnessed CA, n (%)
Bystander BLS, n (%)
Cardiac etiology of CA, n (%)
Initial shock-able ECG rhythm, n (%)
Time CA until rst medical contact (IQR)
Ventilation-rate/minute, (IQR)
Compression-rate/minute, (IQR)
Compression ratio, (IQR)
% of CPR Minutes >75% CR, (IQR)
Duration of CPR, minutes (IQR)
Time to sustained ROSC, minutes (IQR)
Time to death, minutes (IQR)
ROSC, n (%)
sROSC, n (%)
Survival until discharge, n (%)
CPC 1 + 2 at discharge, n (%)

Total cohort

Manual CC

Mechanical CC

p-Value

68 (5779)
595 (63.4)

70 (6081)
390 (59.5)

63 (5473)
205 (72.4)

<0.001
<0.001
0.020

640 (69.5)
268 (29.1)
13 (1.4)
512 (54.5)
446 (47.5)
497 (51.0)
226 (25.7)
7 (59)
7 (49)
108 (102115)
82 (7887)
78 (6489)
14.9 (8.523.6)
11.3 (5.519.3)
18.1 (10.428.3)
341 (36.3)
266 (28.3)
153 (16.3)
113 (73.4)

458 (71.8)
169 (26.5)
11 (1.7)
354 (54.0)
293 (44.7)
323 (50.5)
133 (22.1)
7 (59)
7 (410)
108 (102115)
82 (7787)
79 (6389)
12.7 (6.419.7)
9.1 (4.417.5)
14.1 (8.322.4)
246 (37.5)
201 (30.6)
117 (17.8)
92 (78.6)

182 (64.3)
99 (35.0)
2 (0.7)
158 (55.8)
153 (54.1)
156 (55.1)
93 (33.7)
6 (48)
7 (59)
107 (102115)
82 (7986)
78 (6787)
21.6 (14.730.7)
16.3 (10.428.4)
26.1 (19.534.5)
95 (33.6)
65 (23.0)
36 (12.7)
21 (56.8)

0.614
0.008
0.200
<0.001
0.218
0.723
0.654
0.959
0.360
<0.001
<0.001
<0.001
0.250
0.017
0.052
0.009

Categorical data are presented as counts and percentages, continuous as median and IQR (interquartile range). CC = chest compression, CA = cardiac arrest,
CPR = cardiopulmonary resuscitation, ROSC = return of spontaneously circulation, sROSC = sustained return of spontaneously circulation, CPC = cerebral performance category.

S. Zeiner et al. / Resuscitation 96 (2015) 220225

223

Table 2
Compression ratio stratied within CPR duration.
Manual CC
sROSC

No sROSC

Total cohort
<10 min
1020 min
>20 min

82 (7686)
81 (7285)
84 (7887)
82 (7782)

83 (7888)
82 (7788)
82 (7787)
83 (7987)

Manual CC

Total cohort
<10 min
1020 min
>20 min

Survival

No survival

81 (7487)
80 (7186)
85 (7788)
85 (7788)

83 (7887)
82 (7688)
82 (7787)
83 (7987)

Manual CC

Total cohort
<10 min
1020 min
>20 min

CPC 1 2

CPC 3 4

80 (7386)
80 (7185)
80 (7185)
79 (7691)

85 (7788)
81 (7393)
87 (8088)
87 (7989)

p-Value

Mechanical CC

sROSC

No sROSC

0.030
0.065
0.675
0.591

82 (7786)
77 (7381)
77 (7381)
84 (8089)

p-Value

Mechanical CC

82 (7986)
87 (7989)
82 (7786)
82 (7886)

Survival

No survival

0.031
0.043
0.321
0.800

81 (7787)
80 (7781)
80 (7488)
85 (8088)

82 (7986)
83 (7488)
82 (7985)
82 (7886)

p-Value

Mechanical CC

0.067
0.427
0.503
0.637

CPC 1 2

CPC 3 4

80 (7785)
80 (7781)
79 (7487)
81 (7984)

84 (7588)
64 (6464)
84 (7488)
87 (8488)

p-Value

p-Value*

0.402
0.015
0.716
0.061

0.704
0.248
0.434
0.361

p-Value

p-Value*

0.432
0.358
0.475
0.338

0.503
0.936
0.278
0.810

p-Value

p-Value*

0.387
0.250
0.955
0.073

0.760
0.900
0.456
0.755

Compression ratio is presented as median and IQR (interquartile range). sROSC = sustained return of spontaneously circulation, CPC = cerebral performance category.
*
p-Value for comparison of manual and mechanical chest compression subgroups
Table 3
Compression ratio-development over time-periods.
Manual CC

Total cohort
sROSC
Survival
CPC 1 + 2

p-Value

10 min

1020 min

20 min

82 (7587)
81 (7285)
80 (7186)
80 (7185)

82 (7787)
84 (7887)
85 (7788)
80 (7185)

83 (7887)
82 (7782)
85 (7788)
79 (7691)

0.169
0.082
0.091
0.145

Mechanical CC

p-Value

10 min

1020 min

20 min

81 (7687)
77 (7381)
80 (7781)
80 (7781)

82 (7985)
77 (7381)
80 (7488)
79 (7487)

82 (7986)
84 (8089)
85 (8088)
81 (7984)

0.687
0.011
0.293
0.703

Compression ratio is presented as median and IQR (interquartile range). sROSC = sustained return of spontaneously circulation, CPC = cerebral performance category.

Table 4
Comparison of mechanical CPR devices.

Age, years (IQR)

Compression-rate/minute, (IQR)
Compression ratio, (IQR)
% of CPR minutes >75% CR, (IQR)
ROSC, n (%)
sROSC, n (%)
Survival until discharge, n (%)
CPC 1 + 2 at discharge, n (%)

LUCAS

Autopuls

p-Value

63 (5473)
108 (102115)
82 (7986)
78 (6887)
82 (34.3)
37 (17.0)
31 (13.0)
19 (7.9)

63 (5071)
105 (100110)
82 (7787)
77 (6489)
13 (29.5)
7 (10.8)
5 (11.4)
2 (4.5)

0.515
0.020
0.895
0.854
0.539
0.250
0.769
0.416

Categorical data are presented as counts and percentages, continuous as median and IQR (interquartile range). ROSC = return of spontaneously circulation, sROSC = sustained
return of spontaneously circulation, CPC = cerebral performance category.

compressions per minute (102115) in the LUCASTM and 105

(100110) in the AutoPulse group (p = 0.020).

Table 5
Unadjusted and adjusted effects of Mechanical CC on cardiac mortality.

Unadjusted Effects
Adjusted Effects*

Crude HR

p-Value

1.59 (1.212.09)
1.38 (1.041.84)

0.010
0.026

Cox proportional hazard model for Mechanical CC. Hazard ratios (HR) for continuous
variables refer to a 1-SD increase.
*
The multivariate model 2 was adjusted for age, female gender, cardiovascular
etiology of CA, initially shock-able ECG rhythm, witnessed CA, bystander BLS, handson fraction, larynxtube application.

and 2 (4.5%) that received CPR with AutoPulse (p = 0.416)

(Table 4).
The compression rate before administration of the automated
cc device differed signicantly between the subgroups with 108

Survival analysis
A total of 785 (83.7%) patients consisting of 538 (82.1%)
patients who received manual and 247 (87.3%) patients who
received mechanical cc did not survive until hospital discharge.
Mechanical cc had a strong, direct association with in-hospital
mortality in the entire study cohort with an HR per one standard
deviation (1-SD) of 1.59 (95% CI 1.212.09, p = 0.01). Moreover after
adjustment for potential cofounders, within the multivariate model
mechanical cc still remained signicantly and directly associated
with in-hospital mortality with an adjusted HR per one standard
deviation (1-SD) of 1.38 (95% CI 1.041.84p = 0.026) (Table 5).

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S. Zeiner et al. / Resuscitation 96 (2015) 220225

Discussion
Our prospective observational study revealed a signicant difference in neurological outcome between manual only and manual
cc followed by the administration of mechanical cc or automated
cc only. Both, sustained ROSC as well as favorable neurological outcome were signicantly more common in patients receiving only
manual cc. In addition, we were able to demonstrate an overall
satisfyingly high compression ratio, even for longer resuscitations.
Surprisingly also in the group of resuscitations that took more than
20 min the mechanical devices did not seem to make a difference
in compression ratio.
We were able to show that the use of mechanical cc devices
was directly associated with mortality even after adjustment for
potential cofounders. With regard to selection of patients, we found
that patients with an apparently favorable presentation for good
outcome (younger, initially shock-able ECG rhythm, witnessed CA
receiving bystander BLS) were more likely to receive mechanical cc.
The worse outcome in such patients is therefore difcult to explain.
The difference in neurological outcome may be due to the difference
in duration of CPR between the two groups. We cannot verify why
there is such a distinct difference. One possible explanation could
be a bias in the decision making of ambulance crews concerning the
question of when to use a mechanical cc device. Another possible
explanation might be a later pronunciation of death by the present
emergency physician when such a device was in use.
The strong point of this study is that the focus was laid on the
everyday use of the mechanical cc devices. Only emergency physician manned response vehicles are equipped with an automated cc
device whereas regular EMT-manned ambulances do not have such
a device available on board. There was no recommendation issued
to the emergency physicians when their vehicles were equipped
with the devices whether or not or in what specic settings to use
them. This freedom of choice, allowed us to reect its impact on
the patients outcome in the everyday use in out of hospital critical
care medicine.
The high variation in cases in which an AutoPulse (n = 44) was
used compared to a LUCASTM (n = 239) device might be explained
by the procedures of the Vienna ambulance service. The routineprocedure for the emergency physicians and their teams is to bring
an emergency backpack as well as a debrillator to the patient.
Moreover three of the so called eld-supervisor vehicles specialized in quality management, data gathering and assistance in
extreme scenarios are dispatched to the scene in several cases
(see Methods section). They assist in most OHCAs and are all three
equipped with LUCASTM and trained to immediately bring the
device to the patient. If the physician wants to use an AutoPulse
instead of the LUCASTM or no eld supervisor vehicle is present, he
needs to order one of the paramedics to get the automated cc device
via an ambulance equipped either with AutoPulse or LUCASTM .
Furthermore in the past the ambulance service of Vienna had problems concerning the batteries of the AutoPulse devices and even
though the manufacturer took care of the issue there still are some
resentments against AutoPulse devices by the emergency physicians and EMTs. Unfortunately we cannot determine the factors
that lead to the deviation in sustained ROSC and neurological outcome comparing manual only and mechanical cc because the key
gures (such as mean cc rate, minutes with cc between 100 and
120, hands on fraction minutes with hands on fraction higher than
75%, hands off time and more) we collected to assess cc quality did
not differ signicantly.
Additionally the demographic differences in those groups,
namely the groups receiving mechanical cc being younger and
containing more males, are typically linked with better outcome
and survival, and cannot explain the worse outcome in patients
undergoing mechanical CPR.26,27 Unfortunately due to lack of data

concerning the patients BMI we cannot determine if the BMI

affected the choice of a mechanical device being used.
Furthermore we want to point out that our study is not able
to detect any problems the devices might have concerning compression depth. Greater chest compression depth is known to
improve outcome.28 Some research indicates a lack of CPR-quality
in mechanical chest compression that could possibly render their
potential benets void. Mistakes concerning the positioning of the
devices and delayed reaction to earlier mistakes in the handling
of the devices were described.29 Also several case reports exist
in which insufcient blood ow is reported, in two of them, the
authors note that switching to manual cc, allowing for a deeper
compression, leads to an improved blood ow.30,31
Another downside of our study is the low number of resuscitations in which a load-distributing band device is being used.
Therefore we are not able to detect any differences in outcome
these devices might have themselves or any differences concerning
their use and decision making for using the device. This would be
interesting particularly given their completely different mechanical approach to cc. Concerning the possible harm of mechanical cc
devices no cases of adverse events were reported to us from the
hospitals to which the patients were administered.
The LINC study found no signicant difference in survival to
discharge between the manual and the mechanical arm with 6.4%
and 7.5%, respectively. Similar ndings were reported within the
PARAMEDIC study with only 5% in the mechanical and 6% in the
manual group. In contrast to previous ndings, within our study
population, patients receiving solely manual cc demonstrated a
higher rate of both survival until discharge and favorable neurological outcome with 14% compared to merely 7.4% in the mechanical
cc group.
As mentioned earlier, during and before the LINC and the CIRC
trial, the EMTs and emergency physicians received additional training for not only conventional but also mechanically assisted CPR.
Maybe this lack of constant practice in handling the devices lead
to a less ideal use of the devices in comparison to the observation
periods of CIRC and LINC.
Unfortunately not much data about chest compression ratio
over time is available. Only the CIRC trial points out that the 20 min
CPR fraction was 80.4% for mechanical cc group and 80.2% for manual cc group which is comparable to our results, namely overall 82%
in both groups.
The major limitation of the current study is, that is was performed in a single urban area. However we might overcome a
potential selection bias by analyzing all OHCA cases within the
observation period. Furthermore there was no standardized postCA treatment due to different hospital admissionsthis might lead
to differences in outcome.

Conclusion
Within the current study we were able to demonstrate, that
there was a high quality of CPR in both manual and mechanical subgroup detectable. However the outcome in patients who received
mechanical cc was signicantly worse than in the manual cc subgroup. While 73.4% of the 30 day survivors reached a CPC 1/2 within
the manual cc subgroup, only 56.8% of the patients within the
mechanical cc subgroup had good neurological outcome. Maybe the
indication for using a mechanical chest compression device should
be set stricter. The anticipated benets of a higher compression
ratio and a steadier compression depth of a mechanical cc device
remain uncertain. In this study selection for mechanical cc was not
standardized, and was non-random. This merits further investigation. Further research on how mechanical cc is chosen and used
should be considered.

S. Zeiner et al. / Resuscitation 96 (2015) 220225

Conict of interest statement

Funding sources
None.

15.

Disclosures
None.
16.

Acknowledgements

17.

We are indebted to the EMTs and physicians of the Vienna

Ambulance Service for their support and indulgence.
References
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