cardiac resuscitation - fresh views and changes!
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From CPR to CCR- why the
change ?
Dr. Imran AhmedDM. (Cardiology) Kolkata, India
Major Determinants of Survival From Cardiac Arrest
Early / Effective CPR
Early Defibrillation
Three-Phase Model of Resuscitation
Three-Phase Model of Resuscitation
0 2 4 6 8 10 12 14 16 18 20
Arrest Time (min)
CirculatoryPhase
ElectricalPhase
MetabolicPhase
0
100%Myocardial ATP
Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8
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
How Compressions move blood
5 sec
80
160
mm
Hg
Time (sec)
40
120
0
Standard CPR: 30:2
Interruption of chest compression/relaxation directly effects the level of CPP
From CPR to CCR- why the
change ?
Simultaneous aortic (red) and right atrial (blue) pressure tracings are shown. With the initiation of chest compressions, it takes some time for the coronary perfusion pressures (aortic diastolic minus the right atrial diastolic pressure) to increase. The chest compression rate is 100/min.
Standard CPR: 30:2
Ewy GA, Circulation 2005;111:2131-2142
Pausing Chest Compressions (CC)to Shock Impacts survival
(Yu - Circulation 106:368; 2002)
Increasing the pause
Reduces success rate
Of resuscitation – Edelson(2005) 87% - 9.7 sec
– 20% - 22.5 sec
•More deaths
•Longer time to Return of Spontaneous Circulation (ROSC)
Drawbacks of mouth to mouth ventilations
• Bystanders not willing to perform mouth to mouth
• Long interruptions of chest compression• Intrathoracic pressure is increased• Can lead to gastric regurgitations• Not necessary in those who are gasping
initially – CC suffices
Virkunnen I. J Int Med. 2010, 260:39-42
Summary of pathophysiology of Resuscitation
Chest compressions are the single most important intervention !!!!Optimal QUALITY is essentialInterruptions are deadly → continuous
Ventilation can be deadlyDon’t do when not neededDo it without error when needed
Interventions MUST be prioritized. LearnWhat to do itWhen to do itHow to do it as well as possibleDefibb is better than chest compressions only in the <4 mins
Survival in Tucson AZ with Cardiocerebral Resuscitation(2.8x)
Hosp
ital D
isch
arg
e S
urv
ival 40%
30%
20%
10%
0%CPR CCR
9%28/314
25%34/136
Terry Valenzuela MD AHA Resuscitation Science Symposium 2006
11/03-8/06
1997-1999
Survival in Kansas CityPre-Hospital Return of Spontaneous
Circulation (ROSC)Pre
-Hosp
ital R
OS
C
100%
80%
60%
40%
20%
0%CPR CCR
15%
52%
Bobrow and SHARE study group
Survival in WISCONSIN with Normal Brains
Three Year Results (2.7x)Cardiocerebral ResuscitationWitnessed collapse with shockable rhythm
Neu
rolo
gica
lly in
tact
sur
viva
l 50%
40%
30%
20%
10%
0%CPR CCR
15%
40%
p = 0.001
14/92
36/89
Why Learn Cardiocerebral Resuscitation (CCR)?
Because IT WORKS!! It saves lives = SURVIVAL
Until now standard BLS + ALS has failedSurvival has been dismalAnd essentially unchangedDespite 40 years of “improvements” & updates
CCR on the other handDramatically increases survivalIncluding neurologically normal survival
Why is Cardiocerebral Resuscitation (CCR) better than Cardiopulmonary
Resuscitation (CPR)? “CPR” evolved as a single treatment for two totally different disease
processes:Respiratory and Cardiac arrests
They differ dramatically in how much oxygen exists in their blood at the onset of arrest
Drowning or choking victims use up all available oxygen before arresting.
They DO need early ventilationCardiac arrest victims have normal oxygenation
Initially they do NOT need additional oxygenInstead they need existing O2 pumped to the two organs that
determine survival – the heart and brain
CCR is REALLY SIMPLE stuff !
Continuous Chest CompressionsQuality Chest CompressionsUninterrupted Chest CompressionsQuality is crucial – MUST be monitored by the other pumper
Rate (use metronome) of 100 / min Depth adequate Recoil absolutely crucial
You can ONLY stop Chest Compressions (CC) forSwitching pumpers (every minute) 2-3 seconds Analysis - Is shock indicated (every 200 CC)? 2-3 secondsShocking 5-7 sec
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)
CCR vs. ACLSFUNDAMENTAL DIFFERENCES
For Adult Non-Traumatic Cardiac Arrest
Order in which interventions are performed
Specified Continuous Cardiac Compressions
Faster more forceful compressionsCompressions Before and After
DefibrillationEarly IV Epinephrine
Delay intubation for first 3 roundsAirway: Face Mask 02
No Atropine for first 3 rounds
EPINEPHRINE
Attempt to administer early IV epinephrine
Intraosseous administration fastest
Tobias JD, Ross AK (2010). "Intraosseous infusion". ANALGESIA 110 (2): 391–401
FundamentalsThink 3 cycles: each = 200 CC + analysis ± shock
Compressions started immediately upon arrivalAll victims are initially presumed shockable
Therefore all get the same Rx during first 2 minutes (McMAID)
All get 200 Chest Compressions (CC) before analysisFirst rhythm (after 200 CC) is either shockable or notResume Chest Compressions (CC) Immediately after
analysis ± shock – DO NOT pay attention to post shock rhythms (off the chest for < 5 seconds)
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
CCC
Only•
EMSarrival
Administer 1 mg IV Epinephrine
Ana
lysi
s
• If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis
Protocol
Oral Pharyngeal (OP) airwayNon-rebreather face mask @15 L/min200 compressionsIV accessEpinephrine 1mg IVPOne shock, 3-5 seconds, no pulse checks.
Begin second round of 200 compressionsAmiodarone 300mg IVP (anti-arrhythmic)Shock x1 at max joulesNo pulse checks, not off chest more than 5 seconds.
Protocol
Begin third round of 200 compressionsEpinephrine 1mg IVPShock x1Rapid Sequence Intubation (RSI). Ventilate at 6 breaths/minute (BPM)
Insert ET tube during the fourth round of 200 chest compressions after the 3rd round shock
Protocol
First 2 minutes
Monitor
Airway
IV
Drugs
Mc MAID
Metronome
Chest Compressions
First 2 minutesM c MAID - Metronome / Chest
Compressions
Get the Metronome – know how to start it
Chest Compression (CC) Rate is criticalCC rates < 90 → inadequate outputCC rates > 120 → inadequate outputWithout a metronome pumpers compression
rates of 130-150 are common
First 2 minutesMc M AID - Monitor
Delegate someone to do these (usually the code commander) Turn the Monitor ON first (clock useful) Place the pads without interrupting compressions.
Change to DEFIB mode (not monitor) Shock energy will be preset to maximum Joules (360 J) Place pads without interrupting compressions
First 2 minutesMcM A ID - Airway (initial)
Delegate someone to do this
Insert Oral Pharyngeal Airway
O2 via Non-rebreather mask
Ensure airway patency
First 2 minutesMcMA I D - IV - vascular access
Use Interosseous (IO) whenever a delay is anticipated
First 2 minutes - McMAI D - Drugs
Delegate one person for this task Responsible for
Giving drug Recording when given Anticipating when next dose is due
Be ready to give ASAP after analysis ± shock Vasopressors: EPI first – then vasopressin
Exception may be patient expected to respond with ROSC after first shock – use vasopressin 1st instead
Be sure repeat EPI doses given every 2 cycles (~ 4 min) Amiodarone if first rhythm is shockable
Must remember to give for recurrent or persisting VF
First 2 minutes
Metronome Monitor Airway IV Drugs
McMAID
Practice this until one can,as a team,
routinely do it in 2 minutesWith 2 and more persons on scene
CC
Even seconds without
Chest Compressions
are deadly
First 2 minutesHow to analyze ± Shock
Practice this – – –ONLY the Code Commander looks at the rhythm.
Be sure to switch Pumpers after shock
Epi
Invasive Airway + Ventilations 1 rescuer MUST be available to devote full-time attention to this task Endotracheal (ET) insertion will always reduce the quality of Chest
Compressions (CC) Paramedics are directed to use a Combitube if they do not get ET on
the FIRST try Anticipate this and have a Combitube ready! Consider using Combitube in ALL initially shockable patients
A 2nd person must ensure proper ventilation Time each individual ventilation (1 second) 8-10 seconds between vents (6-8 ventilations / minute) Volume ~ 500 CC (about 1/2 of an Adult Bag Valve Mask) ** Volume given over 1 second **
Attach EtCO2
When to Stop Chest Compressions (CC)?
If the patient shows signs of brain function AND the rhythm is non-shockable
Clues to ROSC (Return of Spontaneous Circulation) Waking up Visualized carotid pulses Agonal gasps → regular respirations End tidal CO2 jumps to normal or supra-normal
Pulse check ONLY during pause for analysis Correlate with rhythm DO NOT stop Chest Compressions for a good looking rhythm
without other clues that ROSC has occurred.
9.29.2
28.128.1
3.63.6
10.910.9
ResultsSurvival from Out of Hospital Cardiac Arrest
Su
rviv
al to
Ho
spita
l Dis
cha
rge
(%)
Su
rviv
al to
Ho
spita
l Dis
cha
rge
(%)
30
25
20
15
10
5
0
30
25
20
15
10
5
0All cardiac arrestsAll cardiac arrests Witnessed with VFWitnessed with VF
(55/598)(55/598)
(61/1686)(61/1686)
(36/128)(36/128)
(38/348)(38/348)
CCRCCR
ALSALS
Witnessed VF Survival Passive Oxygen Insufflation vs.
BVM Ventilation
(17/35)48%
(12/60)20%
50%
40%
30%
20%
10%
0%
Sur
viva
l
BVM Ventilation
Passive Oxygen Insufflation
Possible Reasons for 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
Our Goal Should be what is seen in animals
(60-70+ survival)
24-H
our
Goo
d N
euro
Sur
viva
l
100
80
60
40
20
0
80%
13%
Standard CPR CCC CPR
Kern, Hilwig, Berg, Sanders, Ewy. Circulation 2002
Adult Basic Life Support
• Minimize the frequency and duration of interruptions in compressions (Class IIa).
• Once chest compressions have been started, a trained rescuer should deliver rescue breaths by mouth-to-mouth or bag-mask to provide oxygenation and ventilation.
Adult Basic Life Support• Rescuer fatigue may lead to inadequate
compression rates or depth.• When 2 or more rescuers are available it
is reasonable to switch chest compressors approximately every 2 minutes (or after about 5 cycles of compressions and ventilations at a ratio of 30:2) to prevent decreases in the quality of compressions (Class IIa).
• Every effort should be made to accomplish this switch in 5 seconds.
Adult Basic Life Support• As long as the patient does not have an
advanced airway in place, the rescuers should deliver cycles of 30 compressions and 2 breaths during CPR.
• The rescuer delivers ventilations during pauses in compressions and delivers each breath over 1 second (Class IIa).
• The healthcare provider should use supplementary oxygen (O2 concentration 40%, at a minimum flow rate of 10 to 12 L/min) when available.
Adult Basic Life Support• Excessive ventilation is
unnecessary and can cause gastric inflation and its resultant complications, such as regurgitation and aspiration (Class III).
• Rescuers should avoid excessive ventilation (too many breaths or too large a volume) during CPR (Class III).
Adult Basic Life SupportCricoid Pressure• Cricoid pressure might be used
in a few special circumstances (eg, to aid in viewing the vocal cords during tracheal intubation).
• Routine use of cricoid pressure in adult cardiac arrest is not recommended (Class III).
Example of cardiopulmonary resuscitation prearrival instructions for an adult who has suddenly collapsed.
Lerner E B et al. Circulation 2012;125:648-655
Copyright © American Heart Association
Therapeutic Hypothermia
No More Mouth to Mouth Breathing!
Conclusions
• CCR provides uninterrupted perfusion to heart and brain essential for neurologically intact survival
• CCR has led to dramatic improvements in survival vs CPR
• More aggressive post resuscitation care with hypothermia / emergent cath-PCI is required to save even more victims of cardiac arrest
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