• LINC trial: Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest

    by Alan Batt. Last modified: 06/03/14

    lucas

    Summary

    • Randomised, controlled, multi-centre study over 5 years
    • 2589 OHCAs enrolled
      • Control group (n=1289) received standard CPR as per ILCOR Guidelines
      • Intervention group (n=1300) received mechanical chest compressions combined with defibrillation during ongoing compressions (hands-on defibrillation)
      • Control group were defibrillated, intubated and transported earlier and faster than those in the intervention group.
    • No difference in 4 hour survival rate.
    • No significant difference in 6 months survival rate.
    • No significant difference in good neurological outcomes by 6 months (CPC 1 or 2).
    • Mechanical CPR did not result in improved effectiveness compared with manual CPR.
    • No data that supports the use of mechanical device over traditional compressions.

    So is this the end of mechanical CPR devices? A well designed trial, with a large international population shows no difference in mechanical v manual CPR. Some limitations of this study that need to be noted:

    • Different algorithms resulting in differences in mechanical v manual CPR and defibrillation delivery.
    • Intervention group had defibrillation performed at 90 seconds without rhythm check to reduce interruptions in compressions.
    • Algorithm adherence could not be quantified.
    • Patients with ROSC were also treated with mild hypothermia to 32°C to 34°C (89°F-93°F) for 24 hours, regardless of initial ECG rhythm.
    • Patients with ROSC also had PCI performed if indicated for ST-segment elevation on a 12-lead ECG.

    lincalgorithm

    Proponents of mechanical devices say they:

    1. Are safer in the prehospital setting because compressions can continue while the patient is being transported without interruption or harm to providers – yet a recent study [1] shows that of patients without ROSC in the field transported to the ED with compressions ongoing, only 0.49% had a good neurologic outcome. So do we really need compressions en-route when we shouldn’t be transporting anyone unless they have ROSC prehospital?
    2. Free up a provider to allow focus on airway management, medication administration etc. This study showed that those who had manual CPR performed were defibrillated, intubated and transported earlier and faster than those who had mechanical CPR.

    cpcscale

     
    Rubertsson S1, Lindgren E1, Smekal D1, Östlund O2, Silfverstolpe J3, Lichtveld RA4, Boomars R4, Ahlstedt B5, Skoog G6, Kastberg R6, Halliwell D7, Box M7, Herlitz J8, Karlsten R1. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA. 2014 Jan 1;311(1):53-61. PMID: 24240611.

    Abstract

    Importance

    A strategy using mechanical chest compressions might improve the poor outcome in out-of-hospital cardiac arrest, but such a strategy has not been tested in large clinical trials.

    Background

    To determine whether administering mechanical chest compressions with defibrillation during ongoing compressions (mechanical CPR), compared with manual cardiopulmonary resuscitation (manual CPR), according to guidelines, would improve 4-hour survival.

    Design, Setting & Participants

    Multicenter randomized clinical trial of 2589 patients with out-of-hospital cardiac arrest conducted between January 2008 and February 2013 in 4 Swedish, 1 British, and 1 Dutch ambulance services and their referring hospitals. Duration of follow-up was 6 months.

    Interventions

    Patients were randomized to receive either mechanical chest compressions (LUCAS Chest Compression System, Physio-Control/Jolife AB) combined with defibrillation during ongoing compressions (n = 1300) or to manual CPR according to guidelines (n = 1289).

    Main Outcomes and Measurements

    Four-hour survival, with secondary end points of survival up to 6 months with good neurological outcome using the Cerebral Performance Category (CPC) score. A CPC score of 1 or 2 was classified as a good outcome.

    Results

    Four-hour survival was achieved in 307 patients (23.6%) with mechanical CPR and 305 (23.7%) with manual CPR (risk difference, -0.05%; 95% CI, -3.3% to 3.2%; P > .99). Survival with a CPC score of 1 or 2 occurred in 98 (7.5%) vs 82 (6.4%) (risk difference, 1.18%; 95% CI, -0.78% to 3.1%) at intensive care unit discharge, in 108 (8.3%) vs 100 (7.8%) (risk difference, 0.55%; 95% CI, -1.5% to 2.6%) at hospital discharge, in 105 (8.1%) vs 94 (7.3%) (risk difference, 0.78%; 95% CI, -1.3% to 2.8%) at 1 month, and in 110 (8.5%) vs 98 (7.6%) (risk difference, 0.86%; 95% CI, -1.2% to 3.0%) at 6 months with mechanical CPR and manual CPR, respectively. Among patients surviving at 6 months, 99% in the mechanical CPR group and 94% in the manual CPR group had CPC scores of 1 or 2.

    Conclusions and Relevance

    Among adults with out-of-hospital cardiac arrest, there was no significant difference in 4-hour survival between patients treated with the mechanical CPR algorithm or those treated with guideline-adherent manual CPR. The vast majority of survivors in both groups had good neurological outcomes by 6 months. In clinical practice, mechanical CPR using the presented algorithm did not result in improved effectiveness compared with manual CPR.

    Trial Registration

    clinicaltrials.gov Identifier: NCT00609778.

    References

     
    1.

    Goto Y1, Maeda T, Nakatsu-Goto Y. Neurological outcomes in patients transported to hospital without a prehospital return of spontaneous circulation after cardiac arrest. Crit Care. 2013 Nov 20;17(6):R274. PMID: 24252433.

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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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