We have demonstrated in simulation that the guidance of the CC delays the deterioration of the overall quality of the CC and its components (frequency, depth, and release) related to fatigue during an extended CC beyond the 2-min CC relay currently recommended. There is evidence that CC guidance improves adequacy to recommendations and allows closer alignment with the CC frequency, depth, and release objectives. Mechanical CC devices have not proven their superiority over manual CC, and manual CC remains the gold standard. The outcome of out-of-hospital cardiac arrest (OHCA) is significantly, positively, and independently correlated with the suitability for different CCF targets, CC frequency, CC depth, and brief predefibrillation pause (< 10 s). The recommendations state that the CCF must be greater than 60%, and some experts estimate that a CCF of 80% is possible. Reducing these interruptions and improving CC is therefore a major goal of improving CPR. Third, CC interruptions automatically decrease the CC rate per minute, and difficulty in reaching the upper target of the guidelines’ CC rate has been linked to a significantly higher ratio of ROSC. Second, the quality of the cardiac output generated by CC drops when resuming after an interruption of more than 30 s, the cutoff below which several CC can restore the best cardiac output possible. First, they are a source of direct stoppage of cerebral and coronary perfusions, potentially altering the neurological prognosis and the probability of return of spontaneous circulation (ROSC). CC interruptions are deleterious in at least three ways. During CPR, minimizing CC interruptions, and therefore increasing the CCF, is essential, as this is an independent factor of cardiac arrest (CA) survival. The ratio of the time during which the CC are performed (low-flow) to the total time of resuscitation is referred to as the chest compression fraction (CCF). The latest recommendations emphasize the importance of professionals applying the highest possible quality of CPR and chest compressions (CC). The quality of cardiopulmonary resuscitation (CPR) is at the heart of the last three 5-year recommendations. With an incidence between 5 and 15 per 10,000 and a survival rate of only 6 to 11%, there is still room for improvement in care to reduce the morbidity and mortality of these patients. Out-of-hospital cardiac arrest (OHCA) remains a challenge for prehospital rescue. It will also provide insight into the feasibility of extending the relay rhythm between two rescuers from the currently recommended 2 to 4 min. This study will contribute to assessing the impact of real-time feedback on CC quality in practical conditions of OHCA resuscitation. Secondary outcomes are the depth, frequency, and release of CC length (care, no-flow, and low-flow) rate of return of spontaneous circulation characteristics of advanced CPR survival at hospital admission survival and neurological state on days 1 and 30 (or intensive care discharge) and dosage of neuron-specific enolase on days 1 and 3. Patients will be randomized in a 1:1:1:1 distribution receiving advanced CPR as follows: 2-min blind, 2 min with guidance, 4-min blind, or 4 min with guidance. Five hundred adult nontraumatic OHCAs will be included over 2 years. Primary outcomes (i) CCF and (ii) correct compression score will be recorded by a real-time feedback device. Using a 2 × 2 factorial design in a multicenter randomized trial, two hypotheses will be tested simultaneously: (i) a 4-min relay rhythm improves the CCF (reducing the no-flow time) compared to the currently recommended 2-min relay rate, and (ii) a guiding tool improves the quality of CC. The possibility of improving CCF by lengthening the time between two CC relays and the effect of real-time feedback on the quality of the CC must be investigated. CC guidance improves adherence to recommendations and allows closer alignment with the CC objectives. Survival is significantly and positively correlated with the suitability of CCF targets, CC frequency, CC depth, and brief predefibrillation pause. It is essential to minimize CC interruptions, and therefore increase the chest compression fraction (CCF), as this is an independent factor for survival. The guidelines emphasize the highest possible quality of cardiopulmonary resuscitation (CPR) and chest compressions (CC). With a survival rate of 6 to 11%, out-of-hospital cardiac arrest (OHCA) remains a healthcare challenge with room for improvement in morbidity and mortality.
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