medtigo Journal of Emergency Medicine

|Literature Review

| Volume 2, Issue 3

Mechanical Vs Manual CPR Data from the States of Jersey Ambulance Service

  • 1

Author Affiliations

medtigo J Emerg Med. |
Date - Received: May 13, 2025,
Accepted: May 16, 2025,
Published: Jul 03, 2025.

https://doi.org/10.63096/medtigo3092231

Abstract

Background: Performing high-quality chest compressions can be considered a difficult task. Some ambulance services in the United Kingdom (UK) have mechanical cardiopulmonary resuscitation (CPR) devices available for use in out-of-hospital cardiac arrest (OHCA), which aim to deliver continuous chest compressions to eliminate problems that affect the delivery of high-quality CPR. Some examples include situations where only a limited number of rescuers are available, prolonged CPR, hypothermic cardiac arrest, during extrication from confined places, or in a moving ambulance. This study aims to clarify whether mechanical CPR is more effective than manual CPR. Three well-known trials were considered: the Autopulse Assisted Prehospital International Resuscitation (ASPIRE) trial, the Circulation Improving Resuscitation Care (CIRC) trial, and the Mechanical versus Manual Chest Compression for Out-of-Hospital Cardiac Arrest (PARAMEDIC) trial. It also identified one Cochrane systematic review, covering eleven randomized controlled trials (RCT) and data from 12,944 adult participants who suffered either OHCA or intra-hospital cardiac arrest (IHCA). High-quality chest compressions to achieve ROSC have a high recommendation and high evidence, but it is considered a difficult task. Some ambulance services in the UK have available mechanical CPR devices to be used in OHCA, aiming to deliver continuous chest compressions to eliminate problems that affect the delivery of high-quality CPR.

Keywords

Mechanical Cardio-Pulmonary Resuscitation, Manual Cardio-Pulmonary Resuscitation, Out-of-hospital cardiac arrest, Return of spontaneous circulation, High-quality chest compressions.

Introduction

Working as a paramedic involves having contact with patients in cardiac arrest. According to Perkins et al, the National Health Service (NHS) ambulance services in the UK attempted resuscitation in approximately 30,000 people in OHCA each year, with half of these events being witnessed by a bystander. Of these 30,000 OHCA, 70% received bystander CPR and 10% CPR with the use of an automatic external defibrillator (AED). When resuscitation is attempted, only 9% of the people survive to hospital discharge.[1] According to the cardiac arrest registry to enhance survival (CARES), in 2020, there were 356,361 OHCA in the United States of America (USA). OHCA was witnessed by a layperson in 37.7% of cases, or by emergency medical services (EMS) providers in 12.7% of cases. Survival to hospital discharge after EMS-treated cardiac arrest was 10.4%.[2]

Applying the class of recommendation and level of evidence to clinical strategies, interventions, treatments, or diagnostic testing in patient care, Merchant et al., confirms the importance of the high-quality of chest compression as follows: during manual CPR, rescuers should perform chest compressions to a depth of at least 5cm (class of recommendation 1, level of evidence B-NR); at a rate of 100 to 120/min (class of recommendation 2a, level of evidence B-NR).[3] Performing high-quality chest compressions can be considered a difficult task. According to Huseyin et al, only continuous chest compressions performed for one minute can maintain a high level of effectiveness.[4] Longer periods of chest compressions should be discouraged due to fatigue, regardless of the gender, age, weight, and height of the provider.[5]

Some ambulance services in the UK have available mechanical CPR devices that are being used in OHCA, which aim to deliver continuous chest compressions to eliminate problems that affect the delivery of high-quality CPR. Some examples include situations where limited rescuers are available, prolonged CPR, hypothermic cardiac arrest, during extrication from confined places, in a moving ambulance, or during the preparation of extracorporeal membrane oxygenation (ECMO) equipment to perform extracorporeal CPR (ECPR).[6] The aim of this study is to clarify whether mechanical CPR is more effective than manual CPR.

Methodology

To obtain an answer, the Population, Intervention, Comparison, and Outcome (PICO) format, considered a widely known strategy to frame a research question, was produced:[8] “While treating patients in cardiac arrest, is a mechanical CPR device a more effective procedure than manual CPR?” Three well-known trials were considered: The conclusions of the ASPIRE trial go against the use of mechanical CPR, suggesting a lower survival and worse neurological outcomes in comparison with traditional manual CPR.[9] However, the design of the CIRC trial and the PARAMEDIC trial suggests that mechanical CPR and manual CPR resulted in statistically equivalent survival to hospital discharge.[10,11]

To obtain further evidence to underpin the PICO question, a literature search was undertaken using the Cochrane Library due to its reviews being considered of higher quality and less biased on average than other systematic reviews.[12].  It was identified in 1 Cochrane systematic review, covering 11 RCT and data from 12,944 adult participants who suffered either OHCA or IHCA. Sixty-two articles were also identified. From these 62, 9 were excluded due to it being exclusively related with endotracheal intubation success; 5 were excluded due to it being exclusively related to ventilated patients; 1 was excluded due to it being exclusively related with the use of a mechanical feedback device; 3 were excluded due to it being identified as a repeat; other three were excluded due it being more than 20 years old; 1 was removed due to it being related to chest compressions in infants; and one was removed due to it being specifically related to backboards.

The Cochrane systematic review concluded that mechanical CPR devices are not superior to conventional manual CPR. However, the systematic review also concluded that mechanical CPR can be a reasonable alternative to manual CPR in settings where consistent high-quality CPR is not possible or dangerous to be performed by providers.[6] Data from the States of Jersey Ambulance Service was also analysed.

The States of Jersey ambulance service
The Jersey Channel Islands are a self-governing Crown Dependency of the UK. With an area of 120Km2, the Island of Jersey is divided into twelve parishes, with an estimated population of 99,000 at the end of 2019.[13,14] According to the States of Jersey ambulance service, in 2021, Jersey paramedics responded to 137 cardiac arrests. Of 137 cardiac arrests, 19 had do-not-attempt-CPR (DNACPR), 47 were confirmed dead on scene by Jersey paramedics using the recognition of life extinct (ROLE) guideline, and 51 received Advanced Life Support (ALS) interventions. From those 51 cardiac arrests, 38 received ALS with manual CPR and 13 received ALS with manual CPR and mechanical CPR (Physio-Control LUCAS 3 chest compression system) afterwards; 12 achieved return of spontaneous circulation (ROSC) (23.5%), 8 were with manual CPR and 4 with manual CPR and mechanical CPR afterwards.

The treatment of a cardiac arrest, including the execution of CPR during basic life support (BLS), advanced life support (ALS), and reversible causes in the context of an OHCA, was analysed:

BLS
Arriving on scene, the paramedic crew first must initiate BLS or take over BLS already initiated by a first responder or bystander (class of recommendation 2b, level of evidence C-LD).[3]

Defibrillation
The paramedic crew applies the monitor defibrillator to recognise the current rhythm in manual mode, and defibrillate if appropriate (class of recommendation 1, level of evidence B-NR).[3] Although the use of an AED to confirm a shockable rhythm led to a significant reduction in survival outcomes compared with manual mode, the AEDs do not consistently advise a shock for pulseless monomorphic ventricular tachycardia or pulseless polymorphic ventricular tachycardia.[15,16] If the patient has an implanted pacemaker showing pacemaker spikes on the ECG, it might limit the recognition of a ventricular fibrillation by the AED.[17,18] AEDs also take longer to recognise a shockable rhythm. Tomkins et al concluded that AEDs take a median of 14 seconds in comparison with an ALS provider (median of 7 seconds), affecting ROSC (18.49% ALS provider vs 8.33% AED).[17-20]

Airway
The paramedic crew will secure the airway with one oropharyngeal tube and/or two nasopharyngeal tubes (class of recommendation 2b, level of evidence C-EO) and ventilate with bag-valve-mask (BVM) (class of recommendation 2a, level of evidence C-EO).[3] However, to immediately secure the airway, paramedics normally insert a supraglottic device (I-Gel) (class of recommendation 2b, level of evidence B-R), an end tidal carbon dioxide (EtCO2) sensor (class of recommendation 2b, level of evidence C-LD), and connect the I-Gel to a mechanical ventilator. The use of a mechanical ventilator delivers consistent and controlled tidal volume (Vt) (class of recommendation 2a, level of evidence C-LD) and Respiratory rate (RR) (class of recommendation 2b, level of evidence C-LD), freeing the paramedic to perform vascular access.[21,22]

Ventilation
The use of a mechanical ventilator is not currently seen by paramedics. Nevertheless, according to Saru et al, the six-dial strategy is the recommended setting for mechanical ventilation use during CPR: Positive end-expiratory pressure (PEEP) of 0cmH2O, Vt of 8ml/kg, fraction of inspired oxygen (FiO2) of 100%, RR of 10 breaths per minute, maximum peak inspiratory pressure (Pmax Alarm) of 60cmH2O, ventilator trigger off, inspiratory time (TI) of 1 second, and inspiratory to expiratory time (I: E ratio) of 1:5. Such strategy supports the use of PEEP of 0cmH2O aiming to reduce the intra-thoracic pressure, improving venous return.[22]

Vascular access
The paramedic introduces an intravenous (IV) (class of recommendation 2a, level of evidence B-NR) or intra-osseous (IO) access (class of recommendation 2b, level of evidence B-NR) to administer ALS drugs while the other provider assures manual CPR.[3] It is expected that the result of the PARAMEDIC-3 will be used to determine which access is more effective.[23]

Mechanical CPR device
The mechanical CPR device is normally introduced when a second crew arrives on scene (class of recommendation 2b, level of evidence C-LD). Taking into consideration the data available from the States of Jersey ambulance service, 2/3 of the cardiac arrests achieved ROSC before the arrival of the second crew.

As mentioned before, the Cochrane systematic review concluded that the use of mechanical CPR devices is not superior to manual CPR. However, it can be a reasonable alternative where consistent high-quality manual compressions are not possible or dangerous for the provider, such as limited rescuers available, prolonged CPR, hypothermic cardiac arrest, during extrication from confined places, or in a moving ambulance.[24] Following the European Resuscitation Council Guidelines 2021, these situations must be considered by the paramedics while performing ALS, including the following reversible causes:

Hypoxia
Supraglottic devices (I-Gel) occasionally fail to carry out its purpose due to the influence of temperature on volume, weight and density, due to the presence of bronchospasm when the airway pressure of ventilation exceeds 40cmH2O and the BVM pop-off valve normally releases at about 60cmH2O, due to its use beyond 4 hours, due to risk of gastric distention such as hiatus hernia, sepsis, morbid obesity, pregnancy or upper gastro-intestinal surgery, due to presence of burns or anaphylaxis, and drowning.[24-28] Presently, if the supraglottic device fails to carry out its purpose, most paramedics in the UK can no longer perform endotracheal intubation due to the conclusions of the Airways-2 trial.[29] In a situation of “can’t ventilate, can’t intubate”, paramedics can perform needle cricothyroidotomy.[30] Nevertheless, needle cricothyroidotomy should not be performed in an out-of-hospital setting because the ventilation via a cannula becomes totally inadequate within 60 seconds if a low-pressure self-assembled ventilation system is used.[31] Although not supported by the JRCALC, surgical cricothyroidotomy is currently a paramedic skill in some ambulance services in the UK and is considered far superior to needle cricothyroidotomy.

Hypovolaemia
Paramedics can deliver sodium chloride 0.9% IV/IO if hypovolaemia is present secondary to diarrhoea and vomiting, heat stroke, etc. However, it is no longer recommended for its administration in the presence of a major haemorrhage. The American College of Surgeons Committee on Trauma from the USA and the European Task Force for Advanced Bleeding Care in Trauma from Europe recommend using fresh frozen plasma (FFP) and packed red blood cells (PRBC) at a rate of at least 1:2 for the initial resuscitation of haemorrhaging trauma patients. The National Institute for Health and Care Excellence (NICE) from the UK recommends a 1:1 ratio.[32-34] Presently, the UK paramedics normally don’t carry FFP or PRBC.

Hypo/hyperkalemia/metabolic
Paramedics can correct hypoglycaemia by administering glucose 10% IV/IO. However, they cannot correct metabolic acidosis, hypomagnesemia, or hyperkalemia because they don’t carry sodium bicarbonate, magnesium (class of recommendation 1, level of evidence C-LD), or calcium chloride/gluconate (class of recommendation 1, level of evidence C-LD).[3]

Hypo/hyperthermia
Paramedics can try to correct hypothermia with chemical blankets, blizzard blankets, and warm fluids, taking into consideration the core temperature after drop and the rewarming acidosis.[35] Paramedics can also try to correct hyperthermia with cold fluids, a cold-water bath, cooling blankets, and ice packs.[36] In 2017, Schell-Chaple et al suggested that Paracetamol IV decreases temperature, blood pressure, and heart rate when administered to febrile critically ill patients.[37] Currently, paracetamol is available for paramedics and supported by JRCALC to administer as an analgesic and not as an antipyretic.[30]

Coronary thrombosis and pulmonary thrombosis
Despite being supported by JRCALC, most of the paramedics in the UK don’t have access to Tenecteplase and heparin. The definitive treatment is to transport the patient to the nearest Primary Percutaneous Coronary Intervention (PPCI). Paramedics in the UK also cannot administer thrombolysis if a pulmonary embolism is suspected (class of recommendation 2v, level of evidence C-LD).[3] Jersey Channel Islands don’t have PPCI available. So, Jersey paramedics need to transport the patient to Jersey General Hospital using a mechanical CPR device. On arrival, and if appropriate, the patient will receive heparin and Tenecteplase if coronary thrombosis is suspected, or alteplase if pulmonary embolism is suspected, aiming to achieve ROSC.[38] If ROSC is achieved, the patient will then be transferred via air ambulance to a PPCI facility in England.

Tension pneumothorax
Paramedics can correct a tension pneumothorax by performing needle thoracentesis.[39]

Nevertheless, if needle decompression is not producing the desired effect, finger thoracostomy should be performed. Although it is not part of the scope of practice of a paramedic working in the UK, according to Hanno et al, finger thoracostomy is more effective than needle decompression and should be the preferred approach for chest decompression.[40]

Cardiac tamponade
Paramedics cannot perform pericardiocentesis or clamshell thoracotomy in order to correct cardiac tamponade.[41,42]

Toxins
Paramedics can administer naloxone for opioid overdose; atropine and pralidoxime for organophosphates, carbamates, and for anti-cholinesterase intoxication; and administer activated charcoal for non-specific poisons.[30] However, if the patient is in cardiac arrest, activated charcoal should be administered via nasogastric tube.[43] Although I-Gel has a gastric port to insert a gastric tube, paramedics working in the UK are not trained to perform such a procedure.

Currently, glucagon is supported by JRCALC to be administered in case of hypoglycaemia, but paramedics cannot administer glucagon for beta-blocker overdose (class of recommendation 2a, level of evidence C-LD)3 and/or calcium channel blocker overdose (class of recommendation 2b, level of evidence C-LD). Paramedics also cannot administer sodium bicarbonate 8.4% for sodium channel blockers overdose and/or tricyclic antidepressants overdose (class of recommendation 2a, level of evidence C-LD).

Results & Discussion

Manual Vs Mechanical CPR
On scene, paramedics can only fully resolve 2 of the 8 reversible causes. Meaning, at the present of the remaining 6 reversible causes, the patient will be conveyed to the hospital while receiving ALS. Only a few ambulance services in the UK have available mechanical CPR devices, meaning that in most cardiac arrests, paramedics will have to wait on scene for a helicopter emergency medical service (HEMS), critical care teams, or hazardous area response team (HART) to arrive. Despite having a mechanical CPR device, HEMS operations are restricted to weather and time of the day and are not always trained or equipped to respond to the remaining six causes of cardiac arrest on scene (e.g., double paramedic crew). Critical care teams, such as the British Association for Immediate Care (BASICS), are not always available, and HART is only suitable to be deployed if the event is closer to their location. Such a lack of availability leads paramedics to perform conventional manual CPR in a moving ambulance, which, according to Chew et al, substantially reduces the quality. During the PARAMEDIC trial, CPR quality and feedback technology were not available to assess the effectiveness of manual CPR during transport. In comparison, the States of Jersey ambulance service uses a monitor defibrillator, Zoll X-Series, which has CPR quality and feedback technology.[44-50]

Although mechanical CPR cannot be used on patients where it is not possible to apply it correctly, such as paediatric patients due to being too small, or bariatric patients due to being too large, Magliocca et al.[7] and Corral et al.[42] proved that a piston-based mechanical CPR allowed for significantly greater hemodynamic support and systemic perfusion, as represented by higher coronary perfusion pressure (CPP), higher EtCO2, higher arterial blood pressure, and lower arterial lactate compared with manual CPR in a moving ambulance. Mechanical CPR also accounted for a better quality of chest compressions, with a lesser rescuer’s physical effort requirements, compared with manual CPR.[7] Mechanical CPR is also advocated to be used in cardiac arrests according to the European Resuscitation Council Guidelines 2021.[1]

ROSC Rate
According to Perkins et al, only 9% survive to OHCA in the UK1, and 10.4% in the USA2. However, there are exceptions. In 2016, the Rialto Fire Department from California, USA, implemented a toolbox with the following procedures to add to ALS intervention:

  • Continuous uninterrupted compressions utilizing a mechanical CPR device (class of recommendation 2b, level of evidence C-LD), following the concept of the Hands-on Defibrillation.[44]
  • Apnoeic oxygenation. Despite not being mentioned, nasal cannula oxygenation appears to prevent or delay desaturation.[45]
  • Use of an Impedance Threshold Device (ITD) (class of recommendation 2b, level of evidence C-LD).[3]
  • Heads-up CPR, mentioned by Merchant et al.[3] But there is not enough evidence to make a recommendation. Nevertheless, Pepe et al concluded that the head-up/torso-up cardiopulmonary resuscitation bundle is feasible and associated with an immediate, steady rise in resuscitation rates.[46]
  • Delaying defibrillation for a certain subset of patient presentations.
  • Expanded utilization of waveform capnography (class of recommendation 2b, level of evidence C-LD).[3]
  • Deprioritizing adrenaline in the order of interventions.

When applying the toolbox to an estimated population of 102,555, the Rialto Fire Department achieved a 60% ROSC for all non-traumatic adult arrests.[51]

Only performing continuous uninterrupted compressions utilizing a mechanical CPR device, the States of Jersey Ambulance Service has a ROSC of 23.5%, far behind the 60% from Rialto Fire Department, but ahead of the 9% average in the UK.

Organ donation
According to Perkins et al, one in ten OHCA and one in twenty-five IHCA admitted to critical care go to gift organs for transplantation and Merchant et al recommend that all patients who are resuscitated from cardiac arrest but who subsequently progress to death should be evaluated for organ donation (class of recommendation 1, level of evidence B-NR).[1,3] Merchant et al also recommend that patients who do not have ROSC after resuscitation efforts and who would otherwise have the termination of resuscitative efforts may be considered candidates for donation in settings where such a program exists (class of recommendation 2b, level of evidence B-NR).[3]

On the 20th of May 2020, the law around organ donation in the UK was modified so that all adults are now considered organ donors when they die unless they have recorded a decision not to donate48, have Creutzfeldt-Jakob disease, Ebola virus disease, active cancer, or human immunodeficiency virus.[49] Such a recommendation suggests that, despite appearing to be futile, paramedics could maintain ALS with a mechanical CPR device and with a mechanical ventilator while conveying the patient to a hospital with a transplant unit. A harvest team could then collect the following organs: heart, lungs, liver, kidneys, pancreas, small bowel, tissue, cornea, and bones.

Conclusion

In the UK and the USA, OHCA has a survival rate of 9% and 10.4% respectively. High-quality chest compressions to achieve ROSC have a high recommendation and high evidence, but it is considered a difficult task. Some ambulance services in the UK have available mechanical CPR devices to be used in OHCA, aiming to deliver continuous chest compressions to eliminate problems that affect the delivery of high-quality CPR. Although the Cochrane systematic review concluded that mechanical CPR devices are not superior to conventional manual CPR, the review also concluded that mechanical CPR can be a reasonable alternative to manual CPR in settings where consistent high-quality CPR is not possible or dangerous to be performed by providers.

The States of Jersey ambulance service uses mechanical CPR. It is normally applied when a second crew arrives on the scene and, despite 2/3 of the cardiac arrest achieving ROSC before the arrival of the second crew, the States of Jersey ambulance service had a 23.5% ROSC rate in 2021. However, in 2016, the Rialto Fire Department from California, USA, implemented a toolbox that includes mechanical CPR and achieved 60% ROSC for all non-traumatic adult arrests. Taking into consideration that OHCA is preferred to be an organ donor in comparison with IHCA, with 1/10 and 1/25, respectively, and the change of the British organ donation law on the 20th of May 2020, mechanical CPR could also be used in ALS while conveying the patient to a transplant unit.

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Acknowledgments

I would like to express my gratitude to the States of Jersey Ambulance Service for providing me with the required data to produce this article.

Funding

No funding bodies/grants supported this research or contributed to the author’s salary.

Author Information

Alfredo Manuel da Silva Leal
Independent Researcher
College of Remote and Offshore Medicine, Portugal
Email: a.leal@corom.edu.mt

Author Contribution

The author contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles and was involved in the writing – original draft preparation and writing – review & editing to refine the manuscript.

Ethical Approval

Not applicable

Conflict of Interest Statement

I, Alfredo Manuel da Silva Leal, declare that I have no conflict of interest relating to this article. I have no personal, financial, or other relationships that could influence my work or decisions in this matter.

Guarantor

None

DOI

https://doi.org/10.63096/medtigo3092231

Cite this Article

Leal AMS. Mechanical vs Manual CPR Data from the States of Jersey Ambulance Service. medtigo J Emerg Med. 2025;2(3):e3092231. doi:10.63096/medtigo3092231 Crossref

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