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Adapted from slides by: Ben Bobrow, MD & Lani Clark of:

Cardiocerebral Resuscitation (CCR) AKA Compression only CPR AKA Minimally Interrupted CPR (MICPR) Todd Lang, MD VVEMS Medical Director. Adapted from slides by: Ben Bobrow, MD & Lani Clark of: Arizona Department of Health Services Bureau of Emergency Medical Services & Trauma System.

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Adapted from slides by: Ben Bobrow, MD & Lani Clark of:

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  1. Cardiocerebral Resuscitation (CCR) AKA Compression only CPR AKA Minimally Interrupted CPR (MICPR) Todd Lang, MD VVEMS Medical Director Adapted from slides by: Ben Bobrow, MD & Lani Clark of: Arizona Department of Health Services Bureau of Emergency Medical Services & Trauma System

  2. Approximately 400,000 SCA/YR in US Avg 18 SCA/day in AZ #1 cause of adult death in the US Critical/Quantifiable EMS function Test of entire EMS System Sudden Cardiac Arrest (SCA)

  3. OHCASurvivalin Arizona 50 40 30 20 10 0 With so few survivors, we felt compelled to make modifications to protocol based upon current evidence and track the results closely % 3 Arizona Bobrow B et al. Circulation. 2006; 114:II 350.

  4. Major Determinants of Survival From Cardiac Arrest • Early/Effective CPR • Early Defibrillation • “Early ACLS” is not supported by quality data.

  5. Circulatory Electrical Metabolic Phase Phase Phase Three-Phase Model of Resuscitation 100% Myocardial ATP 0 0 2 4 6 8 10 12 14 16 18 20 Arrest Time (min) Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8

  6. 30 AEDs in Chicago O’Hare Airport 80 % (8/10) Survival VF Cardiac Arrest 2 %* Chicago City Chicago Airport * Lance Becker, M.D. 15 arrests 10 VF

  7. It is not likely that we can make the Verde Valley in to the O’hare Airport Less dense population Slower time to defibrillation Other factors?

  8. Outcomes of Rapid Defibrillation by Security Officers after Cardiac Arrest in Casinos • Survival rate 74 % in patients who received first shock within 3 minutes • Survival rate 49 % in patients who received first shock after 3 minutes • Intervals of no more than 3 minutes from collapse to defibrillation are necessary to achieve the highest survival rates Valenzuela et al NEJM 2000; 343: 1206

  9. What about home AEDs? They studied it….

  10. Home Use of Automated External Defibrillators for Sudden Cardiac ArrestBardy, et al NEJM 4/24/2008 Conclusions: For survivors of anterior-wall myocardial infarctionwho were not candidates for implantation of a cardioverter–defibrillator,access to a home AED did not significantly improve overall survival,as compared with reliance on conventional resuscitation methods.

  11. Bystander CPR • 67% of all OHCA occur in the victim’s private residence and that only 15% occur in actual public areas. • When “extended care and medical facilities” are excluded, the percentage of arrests occurring in private residences increases to 82%. Vadeboncoeur et al. Resuscitation 2007

  12. Reasons forLow Rates of Bystander CPR #5 Lack of training (Time & Cost) #4 CPR as taught is a complex psychomotor task -fear of not getting it right #3 Public fear of harming victim #2 Fear of litigation #1 Reason no one wants to do CPR….

  13. Can We Simplify BLS for Bystanders? Eliminate Mouth-to-mouth Rescue Breathing!!Chest Compression-only BLS for Lay Persons

  14. This has been studied extensively by the CPR research group at the Sarver Heart Center in University of Arizona 6 different published studies all show that in experiment models of out-of-hospital cardiac arrest in swine, survival is the same with continuous chest compression CPR and standard, ideal (2 breaths in 4 seconds) CPR

  15. EMS almost always arrive during the Circulatory Phase Electrical Phase (Early Defibrillation Critical) Minute 0 to 5 Circulatory Phase (Perfusion Critical) Untreated = Minute 5 to 15

  16. Circulatory Electrical Metabolic Phase Phase Phase EMS arrives during circulatory phase (min 4-10) 100% Myocardial ATP 0 0 2 4 6 8 10 12 14 16 18 20 Arrest Time (min) Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8

  17. CirculatoryPhase The period of VF after the first 4-5 minutes is referred to as the CIRCULATORY phase and it appears that the critical intervention at this point is perfusing the myocardium.

  18. Standard CPR 15:2 Coronary Perfusion pressure (Ao diastolic- RA diastolic)

  19. 160 5 sec 120 mmHg 80 40 Time (sec) Standard CPR: 30:2 0

  20. 160 5 sec 120 mmHg 80 40 Time (sec) Continuous Chest Compressions 0

  21. Causes of Chest Compression InterruptionsFor EMS Providers • Assessing patient (i.e., repeatedly) • Preparing and/or Over Ventilation • IV placement • Intubation • Changing Rescuers • Defibrillation, particularly use of AEDs

  22. What about Oxygen? • VFCA: • Lungs and arterial circulation full of oxygen • Key is circulating the oxygen already there • Experimental work has shown Arterial Sats remain acceptable for up to 10 min of CCC • Respiratory Arrest-Different ! • Ventilation crucial to replace Oxygen

  23. Respiratory Arrest-Different !Ventilation crucial to replace Oxygen • We must identify and treat respiratory arrests differently • Choking • Trauma • Intoxication/OD • Copd/pneumonia/some CHF • Was dyspnea present a while prior to arrest? • Turn blue?

  24. Response time < 4 min Response time > 4 min p = 0.87 p <0.007 Defib CPR Defib CPR

  25. Defibrillation vs. CPR first (< 5 minute response time) P=.82 P=.61 P=.44 Wik et al. JAMA 2003: 289:1389-95

  26. Defibrillation vs. CPR first (> 5 minute response time) P=.04 P=.006 P=.01 Wik et al. JAMA 2003: 289:1389-95

  27. 2005 AHA Guidelines “For adult OHCA that is not witnessed, rescuers may give a period of CPR before checking the rhythm and attempting defibrillation” (Class IIb)

  28. CCR vs. ACLSFUNDAMENTAL DIFFERENCES For Adult Non-Traumatic Cardiac Arrest Order in which interventions are performed Specified Continuous Cardiac Compressions Faster more forceful compressions?? Compressions Before and After Defibrillation Early IV Epinephrine Delay intubation for first 3 rounds Airway: Face Mask 02 No Atropine for first 3 rounds

  29. EPINEPHRINE • Attempt to administer early IV epinephrine • Intraosseous administration fastest • In the Verde Valley, this will be a primary use for IO lines and should be considered a reasonable option after a brief attempt at IV access lasting no more than 90 sec.

  30. Is CCR better than 2005 ACLS? No evidence directly answers that question. The big study was prior to 2005 changes.

  31. The 5 major changes in the 2005 guidelines: • improve delivery of effective chest compressions • single compression-to-ventilation ratio (30:2) (except newborns) • each rescue breath should be given over 1 second to produce visible chest rise • single shock followed by immediate CPR without pulse or rhythm check for VF/ PVT cardiac arrest • AED use in children (1-8 years)

  32. SUMMARY ofAHA ECC 2005 GUIDELINES “Push hard and push fast with adequate recoil and minimal interruptions”

  33. SUMMARY ofAHA ECC 2005 GUIDELINES • Effective ACLS begins with high-quality BLS...particularly high-quality CPR! • The potential effects of any drugs or ACLS therapy on outcome from VF SCA arrest are dwarfed by the potential effects of high-quality CPR.

  34. What is the Risk of CCR? • Training expense • New ACLS likely will be a little different • Deviation from widespread standard

  35. Possible benefits of CCR • Unlikely to make things worse • Better survival from CCR • Better CPR leads to better survival • Possible early adoption of key 2010 ACLS changes

  36. Cardiocerebral Resuscitation (CCR) Single shock if Indicated without pulse check or rhythm analysis Single shock if Indicated without pulse check or rhythm analysis Single shock without pulse Check or rhythm analysis EMS arrival CCC Only• 200 chest compressions 200 chest compressions 200 chest compressions 200 chest compressions Analysis Analysis Analysis BVM or Passive Insufflation 15L 02 Begin IV Administer 1 mg IV Epinephrine Resume Standard ACLS Consider Endotracheal Intubation • If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis

  37. Results: Mean Time Intervals 18.2

  38. ResultsSurvival from Out of Hospital Cardiac Arrest (36/128) CCR 30 25 20 15 10 5 0 ALS 28.1 Survival to Hospital Discharge (%) (38/348) (55/598) 10.9 9.2 (61/1686) 3.6 All cardiac arrests Witnessed with VF

  39. Discussion: Possible Beneficial Effects of CCR • Minimize interruptions of marginal forward blood flow during resuscitation efforts • Minimize hyperventilation during resuscitation • Delay of advanced airway interventions may enable providers to focus on compressions and earlier epinephrine administration

  40. Actual Effectiveness of Cardiocerebral Resuscitation Depends upon Compliance!! Outcomes of patients who did and who did not receive all four critical CCR steps

  41. Cardiocerebral Resuscitation Single shock if Indicated without pulse check or rhythm analysis Single shock if Indicated without pulse check or rhythm analysis Single shock without pulse Check or rhythm analysis EMS arrival CC Only• 200 chest compressions 200 chest compressions 200 chest compressions 200 chest compressions Analysis Analysis Analysis BVM or Passive Insuflation 100% FIO2 Begin IV Administer 1 mg IV Epinephrine Resume Standard ACLS Consider Endotracheal Intubation • If adequate bystander chest compressions are provided, EMS providers • perform immediate rhythm analysis

  42. SHARE and CCR Goal • Optimal timing of defibrillation • Reducing all “Hands-Off” Intervals • Avoid hyper-ventilation • Administer early IV/IO epinephrine • Increase and maintain coronary perfusion pressure • Increase % of bystander CPR

  43. Team members • CPR guy • AED guy • Epinephrine/airway guy • Airway guy? Or supervisor guy?

  44. Most Common CCR Errors • Stacked Shocks • Early Endotracheal Intubation before 3 cycles completed • Hyperventilation • Late Administration of Epinephrine • Omitting or delaying Post-Shock Compressions • Administration of Other Meds (atropine)

  45. Where do we go from here? • Compression-only CPR for laypeople – mass training • EMS – more emphasis on uninterrupted chest compressions • In-hospital – Cardiac Arrest Center concept • Children – prevent arrest

  46. DOCUMENTATION Complete and accurate documentation is critical to know the success of your efforts! The following data is required IN ADDITION to your standard, current documentation ------

  47. ADDITIONAL DATA • Write “CCR” if you intended to do protocol • Bystander CPR – type (CCC/CPR) and quality, by whom • CCC – # compressions pre and post shock, how many cycles • When was IV Epi #1 given and how • Ventilation – method and rate • At what point in resuscitation was intubation attempted / accomplished • Patient’s condition when you went back in service • Ethnicity • Electronic data collection is the goal! • Patient Medical Record Number if possible

  48. Deaths Post Resuscitation • Many post-ROSC patients die • About 1/3 are from CNS injury • About 1/3 from Myocardial injury • And about 1/3 from variety of causes (i.e., infection, etc.) Schoenenberger et. al., Arch Intern Med 1992;154:2433

  49. VVEMS will begin cooling shortly. VVMC will begin cooling shortly. Therapeutic Hypothermia http://www.med.upenn.edu/resuscitation/Hypothermia.htm

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