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

Sudden Cardiac Arrest (SCA)

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

50 40 % 30 20 10 0

OHCA Survival in Arizona

3 Arizona

With so few survivors, we felt compelled to make modifications to protocol based upon current evidence and track the results closely

Bobrow B et al. Circulation

. 2006; 114:II 350.

Major Determinants of Survival From Cardiac Arrest

•

Early/Effective CPR

• •

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

100%

Three-Phase Model of Resuscitation

Myocardial ATP

0

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

Weisfeldt ML, Becker LB.

JAMA

2002: 288:3035-8

30 AEDs in Chicago O’Hare Airport

80 % (8/10) 2 %*

Chicago City Chicago Airport * Lance Becker, M.D.

15 arrests 10 VF

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?

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

What about home AEDs?

They studied it….

Home Use of Automated External Defibrillators for Sudden Cardiac Arrest

Bardy, et al NEJM 4/24/2008

Conclusions:

For survivors of anterior wall myocardial infarction who 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.

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

Reasons for Low 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….

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 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

40 30 20 10 0 90 80 70 60 50 ROSC 24-48 Hour Standard CC-Only No BLS

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

100%

EMS arrives during circulatory phase (min 4-10)

Myocardial ATP

0

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

Weisfeldt ML, Becker LB.

JAMA

2002: 288:3035-8

Circulatory Phase

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.

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

160 120 80 40 0 Standard CPR: 30:2

5 sec

Time (sec)

80 40 0 160 Continuous Chest Compressions

5 sec

120 Time (sec)

Causes of Chest Compression Interruptions For EMS Providers

Assessing patient (i.e., repeatedly) Preparing and/or Over Ventilation IV placement Intubation Changing Rescuers Defibrillation, particularly use of AEDs

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

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?

Response time < 4 min

40 35 30 25 20 15 10 5 0

p = 0.87

Defib CPR Response time > 4 min

Survival 40 35 30 25 20 15 10 5 0

p <0.007

Defib CPR

Survival

Defibrillation vs. CPR first

(< 5 minute response time)

60% 50% 40% 30% 20% 10% 0% P=.82

P=.61

P=.44

ROSC D/C Hosp 1yr Surv CPR first Standard

Wik et al.

JAMA

2003: 289:1389-95

Defibrillation vs. CPR first

(> 5 minute response time)

60% 50% 40% 30% 20% 10% 0% P=.04

P=.006

P=.01

ROSC D/C Hosp 1yr Surv CPR first Standard

Wik et al.

JAMA

2003: 289:1389-95

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. ACLS FUNDAMENTAL 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

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.

Is CCR better than 2005 ACLS?

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

The 5 major changes in the 2005 guidelines: 1.

2.

3.

4.

5.

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)

SUMMARY of AHA ECC 2005 GUIDELINES

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

SUMMARY of AHA 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.

What is the Risk of CCR?

Training expense New ACLS likely will be a little different Deviation from widespread standard

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

Cardiocerebral Resuscitation (CCR) CCC Only arrival • EMS 200 chest compressions Single shock without pulse Check or rhythm analysis 200 chest compressions Single shock if Indicated without pulse check or rhythm analysis 200 chest compressions Single shock if Indicated without pulse check or rhythm analysis 200 chest compressions BVM or Passive Insufflation 15L 0 2 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

Results: Mean Time Intervals

35 30 25 20 15 10 5 0 5.2

19.3

6.9

31.4

CCR 18.2

30.8

18.2

5.6

7.0

ALS Dispatch to arrival interval On scene interval Transport interval Total time

Results

Survival from Out of Hospital Cardiac Arrest

(36/128) 30 25 20 15 10 5 0 CCR ALS (55/598) (61/1686)

9.2

3.6

All cardiac arrests (38/348)

28.1

10.9

Witnessed with VF

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

Actual Effectiveness of Cardiocerebral Resuscitation Depends upon

Compliance!!

Outcomes of patients who did and who did not receive all four critical CCR steps

Cardiocerebral Resuscitation

CC Only arrival • EMS 200 chest compressions Single shock without pulse Check or rhythm analysis 200 chest compressions Single shock if Indicated without pulse check or rhythm analysis 200 chest compressions Single shock if Indicated without pulse check or rhythm analysis 200 chest compressions 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

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

Team members

CPR guy AED guy Epinephrine/airway guy Airway guy? Or supervisor guy?

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)

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

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 ------

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

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

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

Therapeutic Hypothermia

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

Recommendations

Unconscious adult patients with return of spontaneous circulation (ROSC) after out-of hospital cardiac arrest should be cooled to 32 °C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours when the initial rhythm was ventricular fibrillation. Class IIa Similar therapy may be beneficial for patients with non-VF arrest out of hospital or for in hospital arrest. Class IIb

American Heart Association 2005 Guidelines

52

EMS Post Resuscitation Care

Ventilation Rate of 8-10/minute 12-lead ECG with Prenotification if STEMI COLD IV Normal Saline Fluid Bolus (500cc) Do NOT actively WARM Patient Transport to a Cardiac Arrest Center when practical

What is at Stake?

1000 OHCA patients in VF Baseline survival rate of 7% = 70 lives Goal survival rate of at least 34% = 340 lives We can potentially save over

270 Additional Lives Per Year!

AZ Share Data is amazing.

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

Common Questions

Is this standard of care?

What about children?

What about trauma, OD, drowning?

Is this a research study?

What does the AHA say about this?

www.azshare.gov

for info/updates