Adapted from slides by: Ben Bobrow, MD & Lani Clark of: Adapted from slides by: Ben Bobrow, MD & Lani Clark of: Arizona Department of Health Services Bureau of Emergency Medical Arizona Department of Health Services Bureau of Emergency Medical

Services & Trauma SystemServices & Trauma System

Cardiocerebral Resuscitation (CCR)AKA

Compression only CPRAKA

Minimally Interrupted CPR (MICPR)

Todd Lang, MD VVEMS Medical Director

Sudden Cardiac Arrest (SCA)Approximately 400,000 Approximately 400,000 SCA/YR in USSCA/YR in US

Avg 18 SCA/day in AZAvg 18 SCA/day in AZ

#1 cause of adult death in #1 cause of adult death in the USthe US

Critical/Quantifiable EMS Critical/Quantifiable EMS functionfunction

Test of entire EMS Test of entire EMS SystemSystem

OHCAOHCA SurvivalSurvival in Arizonain Arizona

Arizona

With so few survivors, we felt

compelled to make modifications to

protocol based upon current evidence

and track the results closely

50

40

30

20

10 0

Bobrow B et al. Circulation. 2006; 114:II 350.

%

3

Major Determinants of Survival From Cardiac Arrest

• Early/Effective CPREarly/Effective CPR• Early DefibrillationEarly Defibrillation

• ““Early ACLS” is not supported by Early ACLS” is not supported by quality data.quality data.

Three-Phase Model of Resuscitation

0 2 4 6 8 10 12 14 16 18 20Arrest Time (min)

CirculatoryPhase

ElectricalPhase

MetabolicPhase

0

100%Myocardial ATP

Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8

Chicago City Chicago Airport

Surv

i val

VF

Car

diac

Arr

est

2 %*

80 %(8/10)

* Lance Becker, M.D.

30 AEDs in Chicago O’Hare Airport

15 arrests 10 VF

It is not likely that we can It is not likely that we can make the Verde Valley in to make the Verde Valley in to

the O’hare Airportthe O’hare Airport•Less dense populationLess dense population•Slower time to defibrillationSlower time to defibrillation•Other factors?Other factors?

Outcomes of Rapid Defibrillation by Security Officers after Cardiac Arrest in Casinos

Survival rate 74 % in patients who Survival rate 74 % in patients who received first shock within 3 minutesreceived first shock within 3 minutesSurvival rate 49 % in patients who Survival rate 49 % in patients who received first shock after 3 minutesreceived first shock after 3 minutesIntervals of no more than 3 minutes from Intervals of no more than 3 minutes from collapse to defibrillation are necessary to collapse to defibrillation are necessary to achieve the highest survival ratesachieve the highest survival rates

Valenzuela et al NEJM 2000; 343: 1206

What about home AEDs?What about home AEDs?

They studied it….They studied it….

Home Use of Automated External Home Use of Automated External Defibrillators for Sudden Cardiac ArrestDefibrillators for Sudden Cardiac Arrest

Bardy, et al NEJM 4/24/2008Bardy, et al NEJM 4/24/2008

Conclusions:Conclusions: For survivors of anterior- For survivors of anterior-wall myocardial infarctionwall myocardial infarction who were not who were not

candidates for implantation of a candidates for implantation of a cardioverter–defibrillator,cardioverter–defibrillator, access to a access to a

home AED did not significantly improve home AED did not significantly improve overall survival,overall survival, as compared with as compared with

reliance on conventional resuscitation reliance on conventional resuscitation methods.methods.

Bystander CPRBystander CPR

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

Vadeboncoeur et al. Resuscitation 2007

Reasons forLow Rates of Bystander CPR

#5 Lack of training (Time & Cost)#5 Lack of training (Time & Cost)#4 CPR as taught is a complex psychomotor task#4 CPR as taught is a complex psychomotor task

-fear of not getting it right-fear of not getting it right#3 Public fear of harming victim#3 Public fear of harming victim#2 Fear of litigation#2 Fear of litigation#1 Reason no one wants to do CPR….#1 Reason no one wants to do CPR….

Can We Simplify BLS for Bystanders?

Eliminate Mouth-to-mouth Rescue Breathing!!

Chest Compression-only BLS for Lay Persons

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 6 different published studies all show that in experiment models of out-of-hospital experiment models of out-of-hospital

cardiac arrest in swine, survival is the same cardiac arrest in swine, survival is the same with continuous chest compression CPR and with continuous chest compression CPR and standard, ideal (2 breaths in 4 seconds) CPRstandard, ideal (2 breaths in 4 seconds) CPR

0

10

20

30

40

50

60

70

80

90

ROSC 24-48 Hour

StandardCC-OnlyNo BLS

EMS almost always arrive during the EMS almost always arrive during the Circulatory PhaseCirculatory Phase

Electrical Phase (Early Defibrillation Critical)Electrical Phase (Early Defibrillation Critical)Minute 0 to 5Minute 0 to 5

Circulatory Phase (Perfusion Critical)Circulatory Phase (Perfusion Critical)Untreated = Minute 5 to 15Untreated = Minute 5 to 15

EMS arrives during circulatory phase (min 4-10)

0 2 4 6 8 10 12 14 16 18 20Arrest Time (min)

CirculatoryPhase

ElectricalPhase

MetabolicPhase

0

100%Myocardial ATP

Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8

Circulatory Phase

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

Coronary Perfusion pressure (Ao diastolic- RA diastolic)

Standard CPR 15:2

5 sec

80

160

mm

Hg

Time (sec)

40

120

0

Standard CPR: 30:2Standard CPR: 30:2

0

5 sec

80

160

mm

Hg

Time (sec)

40

120

Continuous Chest CompressionsContinuous Chest Compressions

Causes of Chest Compression Interruptions

For EMS ProvidersAssessing patient (i.e., repeatedly)Assessing patient (i.e., repeatedly)Preparing and/or Over VentilationPreparing and/or Over VentilationIV placementIV placementIntubationIntubationChanging RescuersChanging RescuersDefibrillation, particularly use of AEDsDefibrillation, particularly use of AEDs

What about Oxygen?What about Oxygen?

VFCA: VFCA: – Lungs and arterial circulation full of oxygenLungs and arterial circulation full of oxygen– Key is circulating the oxygen already thereKey is circulating the oxygen already there– Experimental work has shown Arterial Sats Experimental work has shown Arterial Sats

remain acceptable for up to 10 min of CCCremain acceptable for up to 10 min of CCC

Respiratory Arrest-Different !Respiratory Arrest-Different !– Ventilation crucial to replace OxygenVentilation crucial to replace Oxygen

Respiratory Arrest-Different !Respiratory Arrest-Different !Ventilation crucial to replace OxygenVentilation crucial to replace Oxygen

We must identify and treat respiratory arrests We must identify and treat respiratory arrests differentlydifferentlyChokingChokingTraumaTraumaIntoxication/ODIntoxication/ODCopd/pneumonia/some CHFCopd/pneumonia/some CHFWas dyspnea present a while prior to arrest?Was dyspnea present a while prior to arrest?Turn blue?Turn blue?

0

5

10

15

20

25

30

35

40

Survival

0

5

10

15

20

25

30

35

40

Survival

Defib CPR Defib CPR

Response time < 4 min Response time > 4 min

p = 0.87 p <0.007

Wik et al. JAMA 2003: 289:1389-95

0%

10%

20%

30%

40%

50%

60%

ROSC D/C Hosp 1yr Surv

CPR firstStandard

P=.82

P=.61 P=.44

Defibrillation vs. CPR first

(< 5 minute response time)

Wik et al. JAMA 2003: 289:1389-95

0%

10%

20%

30%

40%

50%

60%

ROSC D/C Hosp 1yr Surv

CPR firstStandard

P=.006 P=.01

P=.04

Defibrillation vs. CPR first

(> 5 minute response time)

2005 AHA Guidelines

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

CCR vs. ACLSCCR vs. ACLSFUNDAMENTAL DIFFERENCESFUNDAMENTAL DIFFERENCES

For Adult Non-Traumatic Cardiac Arrest For Adult Non-Traumatic Cardiac Arrest

Order in which interventions are performedOrder in which interventions are performedSpecified Continuous Cardiac CompressionsSpecified Continuous Cardiac Compressions

Faster more forceful compressions??Faster more forceful compressions??Compressions Before and After DefibrillationCompressions Before and After Defibrillation

Early IV EpinephrineEarly IV EpinephrineDelay intubation for first 3 roundsDelay intubation for first 3 rounds

Airway: Face Mask 02Airway: Face Mask 02No Atropine for first 3 roundsNo Atropine for first 3 rounds

EPINEPHRINEEPINEPHRINE

Attempt to administer early IV epinephrineAttempt to administer early IV epinephrine

Intraosseous administration fastestIntraosseous administration fastestIn the Verde Valley, this will be a primary In the Verde Valley, this will be a primary use for IO lines and should be considered use for IO lines and should be considered a reasonable option after a brief attempt at a reasonable option after a brief attempt at IV access lasting no more than 90 sec. IV access lasting no more than 90 sec.

Is CCR better than 2005 Is CCR better than 2005 ACLS?ACLS?

No evidence directly answers No evidence directly answers that question. The big study that question. The big study was prior to 2005 changes.was prior to 2005 changes.

The 5 major changes in the 2005 guidelines:The 5 major changes in the 2005 guidelines:

1.1. improve delivery of effective chest compressionsimprove delivery of effective chest compressions2.2. single compression-to-ventilation ratio (30:2) single compression-to-ventilation ratio (30:2)

(except newborns)(except newborns)3.3. each rescue breath should be given over 1 second each rescue breath should be given over 1 second

to produce visible chest riseto produce visible chest rise4.4. single shock followed by immediate CPR without single shock followed by immediate CPR without

pulse or rhythm check for VF/ PVT cardiac arrestpulse or rhythm check for VF/ PVT cardiac arrest5.5. AED use in children (1-8 years)AED use in children (1-8 years)

SUMMARY SUMMARY ofof AHA ECC 2005 GUIDELINESAHA ECC 2005 GUIDELINES

““Push hard and push fast with adequate Push hard and push fast with adequate recoil and minimal interruptions”recoil and minimal interruptions”

SUMMARY SUMMARY ofof AHA ECC 2005 GUIDELINESAHA ECC 2005 GUIDELINES

Effective ACLS begins with high-quality Effective ACLS begins with high-quality BLS...particularly high-quality CPR!BLS...particularly high-quality CPR!

The potential effects of any drugs or ACLS The potential effects of any drugs or ACLS therapy on outcome from VF SCA arrest are therapy on outcome from VF SCA arrest are dwarfed by the potential effects of high-dwarfed by the potential effects of high-quality CPR.quality CPR.

What is the Risk of CCR?What is the Risk of CCR?

Training expenseTraining expenseNew ACLS likely will be a little differentNew ACLS likely will be a little differentDeviation from widespread standardDeviation from widespread standard

Possible benefits of CCRPossible benefits of CCR

Unlikely to make things worseUnlikely to make things worseBetter survival from CCRBetter survival from CCRBetter CPR leads to better survivalBetter CPR leads to better survivalPossible early adoption of key 2010 ACLS Possible early adoption of key 2010 ACLS changeschanges

Cardiocerebral Resuscitation (CCR)Cardiocerebral Resuscitation (CCR)

200 chestcompressions

200 chestcompressions

Single shockwithout pulse Check or rhythm analysis

BVM or PassiveInsufflation 15L 02

Begin IV

Ana

lysi

s

200 chestcompressions

Single shock if Indicated without pulse check orrhythm analysis

Ana

lysi

s

Single shock if Indicated without pulse check orrhythm analysis

Resume Standard ACLSConsider Endotracheal

Intubation

200 chestcompressions

CCCOnly•

EMSarrival

Administer 1 mg IV Epinephrine

Ana

lysi

s

• If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis

Results: Mean Time IntervalsResults: Mean Time Intervals

18.2

5.2

19.3

6.9

31.4

5.6

18.2

7.0

30.8

0

5

10

15

20

25

30

35

Min

utes

CCR ALS

Dispatch toarrival intervalOn scene interval

Transport interval

Total time

9.2

28.1

3.610.9

ResultsResultsSurvival from Out of Hospital Cardiac ArrestSurvival from Out of Hospital Cardiac Arrest

Sur

viva

l to

Hos

pita

l Dis

char

ge (%

) 30

25

20

15

10

5

0All cardiac arrests Witnessed with VF

(55/598)

(61/1686)

(36/128)

(38/348)

CCRALS

Discussion: Discussion: Possible Beneficial Effects of CCRPossible Beneficial Effects of CCR

Minimize interruptions of marginal forward Minimize interruptions of marginal forward blood flow during resuscitation effortsblood flow during resuscitation efforts

Minimize hyperventilation during Minimize hyperventilation during resuscitationresuscitation

Delay of advanced airway interventions Delay of advanced airway interventions maymay enable providers to focus on compressions enable providers to focus on compressions and earlier epinephrine administrationand earlier epinephrine administration

Actual Effectiveness of Cardiocerebral Resuscitation Depends upon Compliance!!

Outcomes of patients who did Outcomes of patients who did and who did not receive all and who did not receive all

four critical CCR steps four critical CCR steps

Cardiocerebral ResuscitationCardiocerebral Resuscitation

200 chestcompressions

200 chestcompressions

Single shockwithout pulse Check or rhythm analysis

BVM or PassiveInsuflation 100% FIO2

Begin IV

Ana

lysi

s

200 chestcompressions

Single shock if Indicated without pulse check orrhythm analysis

Ana

lysi

s

Single shock if Indicated without pulse check orrhythm analysis

Resume Standard ACLSConsider Endotracheal

Intubation

200 chestcompressions

CCOnly•

EMSarrival

Administer 1 mg IV Epinephrine

Ana

lysi

s

• If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis

SHARE and CCR GoalSHARE and CCR Goal

Optimal timing of defibrillationOptimal timing of defibrillationReducing all “Hands-Off” IntervalsReducing all “Hands-Off” IntervalsAvoid hyper-ventilationAvoid hyper-ventilationAdminister early IV/IO epinephrineAdminister early IV/IO epinephrineIncrease and maintain coronary perfusion Increase and maintain coronary perfusion pressurepressureIncrease % of bystander CPRIncrease % of bystander CPR

Team membersTeam members

CPR guyCPR guyAED guyAED guyEpinephrine/airway guyEpinephrine/airway guyAirway guy? Or supervisor guy?Airway guy? Or supervisor guy?

Most Common CCR ErrorsMost Common CCR Errors

Stacked Shocks Stacked Shocks Early Endotracheal Intubation before 3 Early Endotracheal Intubation before 3 cycles completedcycles completedHyperventilationHyperventilationLate Administration of EpinephrineLate Administration of EpinephrineOmitting or delaying Post-Shock Omitting or delaying Post-Shock CompressionsCompressionsAdministration of Other Meds (atropine)Administration of Other Meds (atropine)

Where do we go from here?Where do we go from here?

Compression-only CPR for Compression-only CPR for laypeople – mass traininglaypeople – mass trainingEMS – more emphasis on EMS – more emphasis on uninterrupted chest uninterrupted chest compressionscompressionsIn-hospital – Cardiac In-hospital – Cardiac Arrest Center conceptArrest Center conceptChildren – prevent arrestChildren – prevent arrest

DOCUMENTATION

Complete and accurate documentation Complete and accurate documentation is critical to know the success of your is critical to know the success of your

efforts!efforts!

The following data is required IN The following data is required IN ADDITION to your standard, current ADDITION to your standard, current

documentation ------documentation ------

ADDITIONAL DATA Write “CCR” if you intended to do protocolWrite “CCR” if you intended to do protocolBystander CPR – type (CCC/CPR) and quality, by whomBystander CPR – type (CCC/CPR) and quality, by whomCCC – # compressions pre and post shock, how many CCC – # compressions pre and post shock, how many cyclescyclesWhen was IV Epi #1 given and howWhen was IV Epi #1 given and howVentilation – method and rateVentilation – method and rateAt what point in resuscitation was intubation attempted / At what point in resuscitation was intubation attempted / accomplishedaccomplishedPatient’s condition when you went back in servicePatient’s condition when you went back in serviceEthnicityEthnicityElectronic data collection is the goal!Electronic data collection is the goal!Patient Medical Record Number if possiblePatient Medical Record Number if possible

Deaths Post Resuscitation

Many post-ROSC patients die Many post-ROSC patients die

– About 1/3 are from CNS injuryAbout 1/3 are from CNS injury

– About 1/3 from Myocardial injuryAbout 1/3 from Myocardial injury

– And about 1/3 from variety of causes (i.e., infection, And about 1/3 from variety of causes (i.e., infection, etc.) etc.)

Schoenenberger et. al., Arch Intern Med 1992;154:2433Schoenenberger et. al., Arch Intern Med 1992;154:2433

Therapeutic Hypothermia

http://www.med.upenn.edu/resuscitation/Hypothermia.htm

VVEMS will begin cooling shortly. VVMC will begin cooling shortly.

52

RecommendationsRecommendationsUnconscious adult patients with return of Unconscious adult patients with return of spontaneous circulation (ROSC) after out-of spontaneous circulation (ROSC) after out-of hospital cardiac arrest should be cooled to hospital cardiac arrest should be cooled to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours when the initial rhythm was ventricular hours when the initial rhythm was ventricular fibrillation. fibrillation. Class IIaClass IIa

Similar therapy may be beneficial for patients Similar therapy may be beneficial for patients with non-VF arrest out of hospital or for in-with non-VF arrest out of hospital or for in-hospital arrest. hospital arrest. Class IIbClass IIb

American Heart Association 2005 Guidelines

EMS Post Resuscitation CareEMS Post Resuscitation Care

Ventilation Rate of 8-10/minuteVentilation Rate of 8-10/minute12-lead ECG with Prenotification if STEMI12-lead ECG with Prenotification if STEMICOLD IV Normal Saline Fluid Bolus (500cc)COLD IV Normal Saline Fluid Bolus (500cc)Do NOT actively WARM PatientDo NOT actively WARM PatientTransport to a Cardiac Arrest Center when practicalTransport to a Cardiac Arrest Center when practical

What is at Stake?What is at Stake?

1000 OHCA patients in VF1000 OHCA patients in VFBaseline survival rate of 7% = 70 lives Baseline survival rate of 7% = 70 lives Goal survival rate of at least 34% = 340 livesGoal survival rate of at least 34% = 340 lives

We can potentially save over We can potentially save over

270 Additional Lives Per Year!270 Additional Lives Per Year!

AZ Share Data is amazing.AZ Share Data is amazing.

We are contributingWe are contributingThis database will be a huge source of This database will be a huge source of research which guides resuscitation research which guides resuscitation sciencescienceWe can expect future revisions of ACLS to We can expect future revisions of ACLS to incorporate data derived from your/our incorporate data derived from your/our work as AZ state Share enrollees.work as AZ state Share enrollees.

Common Questions

Is this standard of care?Is this standard of care?What about children?What about children?What about trauma, OD, drowning?What about trauma, OD, drowning?Is this a research study?Is this a research study?What does the AHA say about this?What does the AHA say about this?

www.azshare.gov for info/updates for info/updates