The internet is abuzz over the recent updates to CPR guidelines from the American Heart Association (AHA), specifically the statement: “The routine use of mechanical CPR devices is not recommended for adult cardiac arrest.” Many agencies use mechanical CPR devices, such as the LUCAS-3, and many of us in the field have seen improvements in return of spontaneous circulation (ROSC). So, what are we supposed to do now?
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First, let’s look at context. The data used to measure effectiveness of CPR and, specifically, mechanical CPR, vary. What are we using as the benchmark? Is it survival-to-hospital discharge? That would be the end goal — that our field procedures and protocols lead to a successful outcome through the hospital, and that the patient is returned home neurologically intact. The issue here is there are a lot of steps along the way as the patient goes through cardiac arrest and then through the hospital stay — and any of those steps could impact the outcome. For instance:
- Patient downtime. Downtime affects survival rates. How long was the patient unresponsive without interventions?
- EMS response time. How long did it take for responders to arrive and begin interventions?
- Check compressions effectiveness. Are we pushing at the right rate and depth?
- Patient history. How many co-morbidities does the patient have? How old are they? A 95-year-old patient has a lower chance for survival than a 25-year-old.
Perhaps the metric is measuring how often ROSC is achieved. In that case, again, there are myriad factors in play. What was the timing of ALS medications? What was the patient’s initial heart rhythm? What was the patient history?
The new guidelines also offer significant updates to pediatric life support and adult life support — and they are worth considering. For instance, the guidelines mention having enough resources on scene to adequately manage the arrest — good idea (and common sense). The guidelines changed ventilations to 10 breaths a minute, something I’ve been preaching for years. They’ve also added recommendations for treating adults who are conscious and are choking — back blows alternating with abdominal thrusts.
When it comes to cardiac arrest management, the guidelines say the most definitive treatment is high-quality chest compressions and early defibrillation. This is nothing new. So where does this mechanical device nonsense come from? If we look at the data, and know that high-quality CPR is what saves people, why would we eliminate the LUCAS? Allow me to theorize.
Is there any measurable difference between a responder pushing on the chest at the appropriate rate and depth, and a machine that does the same thing? In theory, no, there shouldn’t be.
Is there any measurable difference between responders rotating chest compressions and assessing for pulses and shockable rhythms every two minutes? Again, in theory, no, there shouldn’t be.
What the science can’t capture is the reality on the street. The LUCAS frees up one or two responders, especially in systems that are already strapped for resources. The LUCAS allows for continuous chest compressions in the back of an ambulance, allowing for safer transports when the patient may re-arrest after ROSC. And, in those instances, the LUCAS is still indicated, even by the AHA.
Many of our agencies have purchased these machines, and we have seen their value firsthand. My department’s ROSC cases are through the roof (five in the last three months), and some of that is likely due to the LUCAS machine, but more so, the professionalism and training of our responders.
The LUCAS is not meant to be, nor was it designed to be, a first-line intervention. Once on scene of a cardiac arrest, responders must begin high-quality, manual chest compressions. Then they must tackle the airway and get defibrillation going. Only when it is reasonable to do so, likely within the first few minutes, should the LUCAS go on, and the placement must not interrupt CPR or blood flow for longer than 10 seconds. If that cannot be achieved, then we are working against ourselves, not helping the patient. That is what the guidelines and the science state.
The point is, there are too many factors to say definitively what does and does not contribute to surviving a cardiac arrest. The new 2025 guidelines have some great information, and they shouldn’t be discarded. I don’t work for the AHA Fire Department, but we aren’t going to disregard scientific studies or data-driven decision-making. We also aren’t going to blindly accept changes. The beautiful thing about medicine is that it is a practice, and we are always learning and evolving. We are not abandoning LUCAS machines, but we are refocusing our priorities to what we know works — high-quality compressions. If that is via a bunch of responders (if you’re that lucky), then great. If that is achieved through mechanical CPR because of staffing, safety or some other reason, awesome. In the end, it is about the patient and their survival, not the tools we use.
Keep training and learning, and keep the compressions flowing — lives depend on it.
What’s your biggest takeaway from the updated guidelines?
