Cardiocerebral Resuscitation (CCR) The New Approach to Cardiac Arrest

Ben Bobrow, MD Medical Director
www.azshare.gov

Lani Clark Research and QI Director
lani@email.arizona.edu

Arizona Department of Health Services Bureau of Emergency Medical Services & Trauma System

SHARE – Save Hearts in Arizona Registry and Education
Prehospital Emergency Care in Press

68 SHARE Participants
Apache Junction FD Arivaca FD Avondale FD Blue Ridge FD Buckeye Valley FD Chandler FD Central Yavapai FD Chino Valley FD Daisy Mountain FD Elephant Head Volunteer FD El Mirage FD Flagstaff FD Gila River Indian Community EMS Gilbert FD Glendale FD Golden Valley FD Goodyear FD Grapevine Mesa FD Green Valley FD Guadalupe FD Guardian Medical Transport Helmet Peak FD Hualapai Valley FD Kingman FD Lake Mohave Ranchos FD Lifeline Ambulance Lifestar Ambulance Maricopa FD Mayer FD Mesa FD Montezuma/Rim Rock FD Nogales FD Nogales Suburban FD Northwest FD Page FD Patagonia Lake State Park/ Sonoita Creek State Natural Area FD Patagonia Volunteer FD Payson FD Peach Springs EMS Peoria FD Phoenix FD Pine Lake FD Pinewood FD Pinion Pine FD PMT Puerco Valley FD River Medical Ambulance Rural Metro Scottsdale FD Sedona FD Sonoita – Elgin FD Southwest Ambulance Summit FD Sun City FD Sun City West FD Sun Lakes FD Surprise FD Tempe FD Tolleson FD Tonopah Valley FD Tubac FD Tucson FD United States Border Patrol - AZ Tusayan FD Verde Valley FD Western Air Rescue Yarnell Fire District Yuma FD 5/20/2008

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 .

Different Approach to SCA OHCA is a major public health problem SHARE is a public health program to address this problem. We should maximize our resources and collaborations to improve survival .

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

.

Major Determinants of Survival From Cardiac Arrest Early/Effective CPR Early Defibrillation .

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

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

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 .

Vadeboncoeur et al. the percentage of arrests occurring in private residences increases to 82%.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. Resuscitation 2007 .

Typical cardiac arrest scenario: – Victim collapses and is unresponsive – “911” is called – Wait for professional help to arrive 2/3 of all Cardiac Arrest victims in Arizona do NOT receive “Bystander” CPR WHY is this??? .

.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….

Few rescuers wants to do Mouth-to-Mouth breathing! .

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

ideal (2 breaths in 4 seconds) CPR .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.

90 80 70 60 50 40 30 20 10 0 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 .

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. .

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

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

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

Coronary Perfusion Pressure in Humans Study of 100 patients with 24 Hr. JAMA 1990. 263: 1106 . ROSC ROSC No ROSC Maximal CPP 26 + 8 8 + 10 Initial CPP 13 + 9 2+ 9 No ROSC when CPP < 15 mm Hg Paradis et al.

.e.Causes of Chest Compression Interruptions For EMS Providers Assessing patient (i. 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 .

Ventilation Rate during Out-ofHospital CPR  13 out-of-hospital cardiac arrest patients  Ventilation rate measured during CPR Avg. Circulation 2004. 109:1960-5 . ventilation rate=37 + 3 per minute (range 15-49) Aufderheide et al.

Circulatory Phase Should CPR ever be done BEFORE Defib? YES .

Response time < 4 min 40 35 30 25 20 15 10 5 0 Survival Response time > 4 min 40 p = 0.007 Survival Defib CPR 0 Defib CPR .87 35 30 25 20 15 10 5 p <0.

44 CPR first Standard Wik et al. CPR first (< 5 minute response time) 60% 50% 40% 30% 20% 10% 0% ROSC D/C Hosp 1yr Surv P=.61 P=. JAMA 2003: 289:1389-95 .82 P=.Defibrillation vs.

006 P=.Defibrillation vs. JAMA 2003: 289:1389-95 .04 P=.01 CPR first Standard Wik et al. CPR first (> 5 minute response time) 60% 50% 40% 30% 20% 10% 0% ROSC D/C Hosp 1yr Surv P=.

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

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 .CCR vs.

EPINEPHRINE Attempt to administer early IV epinephrine Intraosseous administration fastest .

EMS providers perform immediate rhythm analysis .Cardiocerebral Resuscitation (CCR) EMS arrival CCC Only• 200 chest compressions Single shock without pulse Check or rhythm analysis Single shock if Indicated without pulse check or rhythm analysis Single shock if Indicated without pulse check or rhythm analysis Analysis Analysis 200 chest compressions 200 chest compressions Analysis 200 chest compressions 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.

8 Minutes 20 15 10 5 0 19.2 5.Results: Mean Time Intervals 35 30 25 31.3 Dispatch to arrival interval On scene interval 18.0 CCR ALS .9 5.4 18.6 7.2 Transport interval Total time 6.2 30.

9 3.Results Survival from Out of Hospital Cardiac Arrest Survival to Hospital Discharge (%) 30 25 20 15 28.1 (36/128) CCR ALS 10 5 0 (61/1686) (55/598) (38/348) 9.2 10.6 All cardiac arrests Witnessed with VF .

Witnessed VF Survival Passive Oxygen Insufflation vs. BVM Ventilation 50% 40% Survival 30% 20% 10% 0% (12/60) 20% (17/35) 48% BVM Ventilation Passive Oxygen Insufflation .

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

CCR Compliance
1) 200 pre-shock chest compressions 2) Delayed endotracheal intubation for three cycles of 200 compressions, rhythm analysis, shock if indicated and IV/IO Epi when possible 3) Attempted intravenous epinephrine administration during the first or second series of chest compressions 4) 200 post shock chest compressions

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 Protocol Compliance 22% of patients did NOT receive CCR 78% of patients did receive CCR .

41% Witnessed VF survival .Cardiocerebral Resuscitation Protocol Compliance 22% of patients did NOT receive CCR -8% survivors with witnessed VF 78% of patients DID receive CCR .

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

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) .

.Future of Cardiocerebral Resuscitation: We have experienced a tremendous improvement in survival with CCR without any information on the QUALITY of CHEST COMPRESSIONS Imagine what we could do with OPTIMAL rate. depth. Waveform Data Improved Protocol Compliance Improved Documentation . and recoil.

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. 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 . by whom CCC – # compressions pre and post shock.

al.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..154:2433 . Arch Intern Med 1992.e. infection.) Schoenenberger et. etc..

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

Class IIb American Heart Association 2005 Guidelines 55 .6°F to 93. Class IIa Similar therapy may be beneficial for patients with non-VF arrest out of hospital or for inhospital arrest.2°F) for 12 to 24 hours when the initial rhythm was ventricular fibrillation.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.

Cardiac Arrest Centers Our Vision for Arizona .

EMS Post Resuscitation Care Support Ventilation 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 Consider Anti-Arrhythmic Drug-Lidocaine. Amiodarone. Magnesium Transport to a Cardiac Arrest Center when practical .

AZ EMS Partnership: Participate in SHARE – let’s work together – Suggestions always welcome! Teach your communities to do CCC-CPR in mass – PowerPoint available from SHARE .

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! .

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

.

azshare.gov .Acknowledgements We are grateful to all the EMS providers in the state of Arizona participating in the SHARE program The SHARE Program is dedicated to the firefighters and paramedics who risk their lives everyday to save others www.