C ontinuous C hest C ompressions Trial

1. Continuous Chest Compressions Trial Final version 1, 03-30-2011

2. Training Objectives After this program you will be able to: • Describe the rationale for continuous chest compressions (CCC) & 30:2, as they integrate with the upcoming trial. • Demonstrate the ROC CCC/30:2 protocol including: • CAB assessment • Efficient application of the AED/defibrillator at the same time chest compressions started • Integrated responder approach and provision of care • Maintenance of compressions including depth, release & rate • Ventilation timing and volume

3. Continuous Chest Compressions (CCC) • Traditional CPR—30 chest compressions: 2 ventilations • Pauses in CPR chest compressions are associated with a decrease in coronary and cerebral perfusion pressure. • Many EMS agencies using CCC—an alternative style of CPR. • Unclear whether survival is higher with CCC or 30:2 CPR. • There are no randomized trials. • We do not know if CCC or 30:2 CPR is better. • A randomized controlled trial is the only way to know which approach is better.

4. Purpose of the Study To compare the effect of “CCC” CPR versus “30:2” CPR on outcomes following out-of-hospital cardiac arrest.

5. Interventions―Two Styles of Chest Compressions • “CCC” CPR • Alternative style of CPR • Continuous chest compressions with no pauses • Ventilation: One BVM ventilation every 10 chest compressions (10:1), with no pause in compressions • “30:2” CPR • Usual style of CPR • Chest compressions with pauses for ventilation • Ventilation: Two BVM ventilations every 30 chest compressions (30:2), with pause in compressions

6. Randomization • By agency groups, for fixed time period (e.g. CCC x 6 months) → cross-over to opposite arm (30:2) • Assigned CPR treatment arm (CCC or 30:2) will be the “standard of care” for all patients during study period except . . . • Peds • Obvious respiratory arrest • Afterward, ROC will determine patient eligiblity/ineligibility for inclusion in study • e.g. prisoners, pregnancy, oPt out, DNAR, EMS-witnessed arrest, trauma Modified final version 1, 09-19-2011

7. BLS On Scene Continue 30 CC’s as AED readied Standard ? ? ? ? ~ ~ ~ ~ ACLS BVM at 10 : 1 End of Study Protocol The CCC Protocol Continue same CPR protocol until placement of advanced airway Approximately 2 minutes Approximately 2 minutes Approximately 2 minutes 200 continuous chest compressions* 200 continuous chest compressions* 200 continuous chest compressions* If ALS on-scene IV/IO ASAP + epinephrine Advanced airway Modified final version 1, 09-19-2011 *200 continuous chest compressions (with 1 breath every 10 CC) given over 2 minutes

8. The 30:2 Protocol Continue same CPR protocol until placement of advanced airway BLS On Scene Approximately 2 minutes Approximately 2 minutes Approximately 2 minutes Continue 5 cycles at 30:2 5 cycles at 30:2 5 cycles at 30:2 30 CC’s as AED readied Standard ? ? ? ? ~ ~ ~ ~ ACLS BVM at 30 : 2 If ALS on-scene IV/IO ASAP + epinephrine Advanced airway End of Study Protocol Modified final version 1, 09-19-2011

9. CCC versus 30:2 Advanced Airway Approximately 2 minutes Approximately 2 minutes Approximately 2 minutes 200 200 200 CCC ? ? ? continuous chest ~ continuous chest ~ continuous chest ~ compressions compressions compressions Continue same CPR protocol until placement of advanced airway Turn on AED / monitor, Standard ACLS If ALS on-scene IV/IO ASAP + epinephrine give 30 compressions while AED is readied 30 : 2 5 cycles at 30:2 ? ? ? 5 cycles at 30:2 5 cycles at 30:2 ~ ~ ~ End of Study 30 : 2 IV / IO Epinephrine / Vasopressin ASAP Protocol Modified final version 1, 09-19-2011

10. Important Points ! • If ALS is early on scene . . . insert IV/IO early • Give epinephrine or vasopressin early • CCC gets BVM at 10:1 • One breath between every 10th chest compression • Deliver each rescue breath over 1 sec to produce chest rise • No break in chest compressions • 30:2 gets standard AHA BVM ventilation • 30 chest compressions—break for 2 ventilations • Deliver each rescue breath over 1 sec to produce chest rise Modified final version 1, 09-19-2011

11. Choreographing the Perfect Arrest Management Pit Stop • Work as a team. • Each team member has a pre-assigned responsibility.For example: • CPR • Manage airway/BVM • Attach and operate monitor/defibrillator • Insert IV/IO—give drugs • Mustrotate CPR compressor every2 minutes. • Assign someone to time compression cycles and record events. • Best to choreograph prior to arrival.

12. Questions & Answers ?

13. What should we do when we arrive on scene? • Assess CAB—confirmed arrest • Check time, assign documentation, and turn on monitor/defibrillator • Immediately start CPR (check and record time, or delegate timing) • Apply defibrillation pads as soon as possible during CPR • ASAP BVM at 10:1 or 30:2 • Coordinate 2-minute rotations, rhythm checks, and defibrillation (if shock indicated) • If ALS on-scene early, start IV/IO during CPR Modified final version 1, 09-19-2011

14. How do I know whether to do CCC or 30:2? • EMS agencies are randomized by cluster • Assigned treatment arm • Carry out for 3–6 months • Switch • Switch again

15. What if the patient arrested during my care? • Shock as required • If CPR required after shock, perform in accordance with assigned treatment arm (CCC or 30:2) • Afterward, ROC will determine patient eligiblity/ineligibility for inclusion in study Modified final version 1, 09-19-2011

16. More BLS Questions • What if another individual or agency arrives first and begins CPR? • INCLUDE and perform the protocol if:. • Law enforcement • Bystander • Other individuals or agencies that do not typically or regularly respond to cardiac arrest incidents(e.g., lifeguards, military, security, etc.) • EXCLUDE and continue with standard ACLS (local protocol) if: • Non-ROC EMS provider agency

17. What should I do with the AED? • The ROC AED or monitor/defibrillator should be applied and compressions begun as soon as possible. Modified final version 1, 09-19-2011

18. Either approach is acceptable Should I count chest compressions or use a timing device?

19. Should I compress while the defibrillator is charging? • Yes - if using Medtronic/PhysioControl device • No – if using Philips MRX device (it charges fully during analysis) • Immediately resume compressions after shock delivered • Charge/shock time does not count as part of CPR cycle. Modified final version 1, 09-19-2011

20. What if I am having difficulty with advanced airway insertion? • Continue assigned CPR protocol until advanced airway placed • Consider other local options for advanced airway Modified final version 1, 09-19-2011

21. Integrating CCC and ALPS when ALS is first on-scene • CCC and ALPS may be run concurrently or separately • ALPS drug is administered ASAP for persistent or recurrent VF/pulseless VT after ≥ 1 shock Still VF Give ALPS #2 Continue same CPR protocol until placement of advanced airway Still VF Give ALPS #1A & #1B EMS On Scene OR Continue CPR Set CPR Set CPR Set 30 CC’s as Defib readied Standard ? ? ? ? ~ ~ ~ ~ # 1* # 2* #3* ACLS IV / IO Epinephrine / Vasopressin ASAP Advanced airway Modified final version 1, 09-19-2011 End of Study *Each “CPR Set” consists of 200 continuous chest compressions or 5 cycles at 30:2, over approximately 2 minutes Protocol

22. CCC and ALPS • May start ALPS during or after CCC completed Modified final version 1, 09-19-2011

23. Important Points ! • CCC gets BVM at 10:1 • One breath between every 10th chest compression • Deliver each rescue breath over 1 sec to produce chest rise • No break in chest compressions • 30:2 gets standard BVM ventilation • 30 chest compressions—break/2 ventilations • Deliver each rescue breath over 1 sec to produce chest rise • CCC vs 30:2 protocol is complete after placement of advanced airway Modified final version 1, 09-19-2011

24. After the Call • The CPR process file is the only way to verify that you did CCC or 30:2 CPR • Call ROC hot-line Document & Download Modified final version 1, 09-19-2011

25. Final Questions ?