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