The New CCR by HC11112414493

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									      The New CCR

 Cardiocerebral Resuscitation
Revised for Shorewood Hills EMS
       February 7, 2008
                “ Uncle” Ewy




Cardiocerebral Resuscitation
Pathophysiology of V-Fib Arrest
How Compressions move blood
Pausing Chest Compressions to breathe
 reduces Coronary Perfusion Pressure
                             VF Survival Compared
                             Rea et al. Resuscitation 63:17 (2004)

                          Person Years               All-rhythm                                VF                        Incidence
Community         State    divided by        #             #          %             #           #            %
                             100,000      Arrests     Survivors     Survival     Arrests     Survivors     Survival    All         VF
Chicago           IL              54.00       6451            114         1.8         1394            46         3.3         119        26
New Haven         CT               1.91        245              -            -          75             3         4.0         128        39
Alachua Co        FL               2.11        145              6         4.1           53             3         5.7          69        25
New York          NY              36.67       2329             52         2.2          650            42         6.5          64        18
Rural Cos         MN               3.60        168              7         4.2           92             7         7.6          47        26
Salt Lake City    UT               4.80        322             26         8.1          166            13         7.8          67        35
Adams & York CO   PA               8.20        599             36         6.0          271            27        10.0          73        33
6 Counties        IN              10.46        388             21         5.4          180            19        10.6          37        17
Durham            NC               2.81        126             11         8.7           61             7        11.5          45        22
Tucson            AZ              25.03        665             46         6.9          348            41        11.8          27        14
Memphis           TN              19.84       1068             85         8.0          518            63        12.2          54        26
Allegheny Co      PA               4.35        282              -            -         132            18        13.6           -        30
Dade Co           FL              43.32        738             51         6.9          284            39        13.7          17         7
Kansas City       MO              13.50        832             67         8.1          429            59        13.8          62        32
Los Angeles       CA               6.50        300             30        10.0          135            19        14.1          46        21
Fresno            CA               2.96        253             16         6.3           83            12        14.5          85        28
San Francisco     CA               6.68        544             32         5.9          137            20        14.6          81        21
Houston           TX              38.00       2404            193         8.0          974          150         15.4          63        26
Pittsburg         PA               3.14        187             18         9.6           97            15        15.5          60        31
R-W Control       WI               7.65        267             20         7.5          114            19        16.7          35        15
30 Rural Cos      IO               3.12        110             12        10.9           64            12        18.8          35        21
Rural Island      AK               1.28         56              7        12.5           31             6        19.4          44        24
Minneapolis       MN               9.21        271             21         7.7          109            22        20.2          29        12
Milwaukee Co      WI              93.90       4216            533        12.6         1919          421         21.9          45        20
Colonie           NY               0.77         73              6         8.2           27             6        22.2          95        35
King Co           WA             108.23       5222            837        16.0         2427          729         30.0          48        22
Seattle           WA              11.27        744            112        15.1          303            97        32.0          66        27
San Juan Island   WA               0.88         78             17        21.8           47            17        36.2          89        53
Rochester         MN               5.41        246             53        21.5          131            53        40.5          45        24
R-W Project       WI               2.55         91             19        20.9           43            19        44.2          36        17
                                        Survival in Tucson AZ
                               with Cardiocerebral Resuscitation(2.8x)

                              40%
Hospital Discharge Survival




                              30%                                  11/03-8/06


                              20%
                                             1997-1999              25%
                              10%                                    34/136
                                               9%
                                               28/314
                               0%
                                              CPR                    CCR
                              Terry Valenzuela MD AHA Resuscitation Science Symposium 2006
                                      Survival in Southern Arizona
                                 Adult OOH Witnessed VF in Arizona (2.6x)
                                 40%
Survival to Hospital Discharge
  after OOH Witnessed VF



                                 30%


                                 20%
                                                          28.1%
                                 10%
                                          10.9%
                                 0%
                                           CPR              CCR
                                             Bobrow and SHARE study group
                              Survival in Kansas City
 Pre-Hospital Return of Spontaneous Circulation (ROSC)
     100%

                    80%
Pre-Hospital ROSC




                    60%

                    40%

                    20%
                                                         52%
                                  15%
                    0%
                                  CPR                    CCR
                         Bobrow and SHARE study group   In preparation
               Survival in Rock-Walworth WI
                  Three Year Results (2.7x)
                      Normal Brains
                                  Cardiocerebral Resuscitation
                                   Witnessed collapse with shockable rhythm
                                 50%
                                                                36/89
Neurologically intact survival




                                 40%
                                          p = 0.001
                                 30%

                                 20%         14/92
                                                               40%

                                 10%
                                            15%
                                 0%
                                            CPR                CCR
Why Learn Cardiocerebral Resuscitation (CCR)?
 Because IT WORKS!!
 It saves lives = SURVIVAL
       Until now standard BLS + ALS has failed
          Survival has been dismal
          And essentially unchanged
          Despite 40 years of “improvements” & updates

       CCR on the other hand
          Dramatically increases survival
          Including neurologically normal survival
          Wherever it has been utilized
   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)
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 ventilation

 Cardiac   arrest victims have normal oxygenation
     Initially they do NOT need additional oxygen
     Instead they need existing O2 pumped to the two organs that
      determine survival – the heart and brain
Essentials of Cardiocerebral Resuscitation (CCR)
 Chest   compressions are the single most important intervention !!!!
     Optimal QUALITY is   essential
     Interruptions are deadly → continuous


 Ventilation    can be deadly
     Don’t do  when not needed
     Do it without error when needed


 Interventions    MUST be prioritized. Learn
     What to do it
     When to do it
     How to do it as well as possible
             Why only ~ 50% compliance
with the Cardiocerebral Resuscitation (CCR) protocol?
    Some are Lazy
        Inattentive during training → revert to old CPR
    Others are Stubborn
        Past experience with new gismos those “experts” dream up not
         great
        Justifiable skepticism
    Anxiety is common
        BLS + ALS training can be confusing
    The major problem is our fault (the trainers)
        Inadequate training and infrequent re-training
Cardiocerebral Resuscitation (CCR) Fundamentals

 Think Cardio-Cerebral    … Brain Brain Brain

 There are   ONLY two rhythms
    Shockable    or Non-Shockable


 Their   Rx is
   Chest         compressions
             ACLS                   VS.                 CCR
    Advanced Cardiac Life Support              Cardiocerebral Resuscitation



 Adv.   CARDIAC Life Support              Cardio-   CEREBRAL Resusc.
 Lotsof Rhythms and                       Only TwoRhythms
 Algorithms for Each                       Shockable or Not

 Advanced        …                        Basic   - compressions
 Lots   of Drugs                          Only3: Vasopressin, Epi
                                           and Amiodarone
 Megacode         anxiety                 Organized Teamwork

 ABC                                      McccMAID
           This Really is REALLY SIMPLE stuff
 Continuous Chest Compressions
 Quality Chest Compressions
 Uninterrupted Chest Compressions


 Stopping Chest Compressions KILLS brains. None of you
 has the right to kill your patient ☺

 You   can ONLY stop Chest Compressions (CC) for
    Switching  pumpers (every minute) 2-3 seconds
    Is shock indicated (every 200 CC) 2-3 seconds
    Shocking 5-7 sec
                  Organization of Rescuers

   One person in charge – Code Commander
       In charge means IN CHARGE
       The boss – coaching other team members will be held
        responsible for any screw-ups
   ALL others are worker bees with assigned tasks
       And expected to know their job do that job, and only that job, and
        to do it without errors
   Crucial tasks are two person jobs
       Continuous Chest Compressions and Ventilations
                         Fundamentals
 Think   3 cycles: each = 200 CC + analysis ± shock
 Compressions     started immediately upon arrival
 Allvictims are initially presumed shockable
    Therefore all get the same Rx during first 2 minutes
     (McMAID)
    All get 200 Chest Compressions (CC) before analysis

 First rhythm   (after 200 CC) is either shockable or not
 Resume   Chest Compressions (CC) Immediately after
  analysis ± shock – DO NOT pay attention to post shock
  rhythms (off the chest for < 5 seconds)
                Chest Compressions
   Continuous. Interrupt ONLY for
       Switching pumpers
       Analysis and Shock
 At least a two person job (whenever possible)
 Switch pumpers every minute
 Quality is crucial – MUST be monitored by the other pumper
       Rate (use metronome) of 100 / min
       Depth adequate
       Recoil absolutely crucial
Why Chest Compressions (CC) before defibrillation
                   Wik - Human Data
CHEST COMPRESSIONS (CC)
    IS WHERE IT’S AT!!
Nothing….nothing can  interfere with
 compressions. They stop once every 200
 compressions to evaluate the rhythm and
 shock. Stop no more than 5 seconds.
             Pharmacology
No improvements evident based on   science with
 drugs to improve outcome
Epinephrine every 5 minutes
Vasopressin OK but use early and with
 epinephrine.
Use of anti-arrhythmic is important
               Defibrillation
 Primary treatment for V-fib at 3 minutes and under
 Should be delayed until good CC are done for 2
  minutes if down time is over 3 minutes
 Should always be one shock at max energy
 AEDs are good in the first 3 minutes, but bad after
  that
 One shock only with no pulse checks afterward
             Vascular Access
Avoid Endotracheal (ET) drugs
Peripheral IV’s OK
Interosseous recommended when   peripheral IV’s
 are not obtainable . . .
Use EZ-IO
        What about AEDs?

Great in first 2-3 minutes. We should still
promote them in the community.
Deadly after this as delay to shock is over 30
seconds. Manual defib required after four
minutes down time.
        Pulse Checks

Deadly!!
Only check pulses when rhythm appears to
have converted thru CCR on ECG or the
patient shows signs of life
 What about intubation?
In first 4 minutes, not a priority (V-fib)
Understand that positive pressure breaths
decrease cardiac output.
There is some air exchange from chest
compressions (CC) plus gasping.
Once intubated
  1 second breaths.
  6-8 per minute.
  About once every 10 seconds.
  NO MORE.
   Mechanical CPR Devices
No  definite benefit.
Delays to put on.
We will probably not be transporting patients
 in cardiac arrest
          Protocol
Dispatch instructs bystanders in Continuous
Chest Compression (CCC-CPR)
If good CPR is being done by bystanders upon
EMS arrival, then shock once immediately
If no CPR or poor CPR, then start chest
compressions immediate
            Protocol
Oral Pharyngeal (OP) airway
Non-rebreather face mask @15 L/min
200 compressions
IV access
Epinephrine 1mg IVP
One shock, 3-5 seconds, no pulse checks.
           Protocol
Begin second round of 200 compressions
Amiodarone 300mg IVP (anti-arrhythmic)
Shock x1 at max joules
No pulse checks, not off chest more than 5
seconds.
             Protocol
Begin third round of 200 compressions
Epinephrine 1mg IVP
Shock x1
Rapid Sequence Intubation (RSI). Ventilate at
6 breaths/minute (BPM)
  Insert Combitube during the fourth round of 200
  chest compressions after the 3rd round shock
  Can not provide good Chest
Compressions (CC) on the move.

 We will work the code where we find
  the patient until pulse is back, or they
  have a non-shockable rhythm.
          First 2 minutes



                  Mc MAID

Metronome
   Chest Compressions
       Monitor
           Airway
                 IV

                      Drugs
                 First 2 minutes
  M c MAID - Metronome / Chest Compressions
 You Must Know:
     Where it is (Velcro / attached to the Defibrillator)
     How to turn it on

   Chest Compression (CC) Rate is critical
     CC rates < 90     → inadequate output
     CC rates > 120    → inadequate output
     Without a metronome pumpers compression
      rates of 130-150 are common
   Some hear, some see the rate
                      First 2 minutes
                     Mc 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)
       Press ADVISORY button twice
       Otherwise no rhythm is visible
       You cannot charge in the monitor mode
   Shock energy will be preset to maximum Joules (360 J)
   Place pads without interrupting compressions
                    First 2 minutes
                McM A ID - Airway (initial)

 Delegate    someone to do this

 Insert   Oral Pharyngeal Airway

 O2   via Non-rebreather mask

 Ensure    airway patency
                    First 2 minutes
             McMA 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




                    McMAID

Metronome    CC     Monitor   Airway       IV   Drugs



            Practice this until you can,
                    as a team,
            routinely do it in 2 minutes
        With 2 and more persons on scene
Even seconds without

 Chest Compressions

     are deadly
              First 2 minutes
           How to analyze ± Shock




                                        Epi



              Practice this – – –
ONLY the Code Commander looks at the rhythm.
    Be sure to switch Pumpers after shock
                 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.
                    When to move the patient?
   Remember
        that moving the patient invariably results in poor quality Chest Compressions
        These people live or die by what you do (or don’t do) at the scene
   Move after 3 full cycles AND a non-shockable rhythm is observed
        3 cycles = after 3 sets of 200CC + analysis ± shock
   Initially shockable patients
        should continue to be worked in the field
        until a non-shockable rhythm is encountered
        Repeating EPI and Amiodarone appropriately by Paramedics
                   Follow this approach and
             these common errors will be avoided
   Rhythm initially not seen on monitor and charging delayed
   Poor quality Chest Compressions (rate, depth, recoil)
   Delays in restarting Chest Compressions after analysis ± shock
   Invasive airway inserted too early
   Hyperventilation
   Delays in repeat doses of EPI
   Failure to Rx with Amiodarone when needed
                       Training Plan
   Practice EACH task in McMAID separately
   Train focusing ONLY on the assigned task
   Plan / organize the crew before reaching the scene
   Delegate tasks to specific individuals
   Tasks performed
       without error
       Keeping nose out of other rescuers business
   Code Commander is in charge
   Retrain until it’s 2nd nature
                               Our Goal Should be what is seen in animals
                                               (60-70+ survival)
 24-Hour Good Neuro Survival

                               100

                               80

                               60

                               40                           80%

                               20
                                        13%
                                0
                                     Standard CPR        CCC CPR

Kern, Hilwig, Berg, Sanders, Ewy. Circulation 2002
Without all of you Cardiocerebral
Resuscitation would never have
      been so successful


            Thank you now
                 and
                in the
               Future


  Dr. Ewy                   Dr. Kellum
Gordon A. Ewy, MD
Professor and Chief, Section of Cardiology
Director of The University of Arizona Sarver Heart Center
University of Arizona College of Medicine
Gordon A. Ewy, M.D. Distinguished Endowed Chair in Cardiovascular Medicine
Medical Director of Cardiology, The University Medical Center



Tom P. Aufderheide, MD, FACEP
Professor of Emergency Medicine with Tenure
Associate Chair of Research Affairs
Medical College of Wisconsin, Department of Emergency Medicine
Milwaukee, Wisconsin



Thanks for Slides from Dr. Richard Barney
and Dr. Michael Kellum

								
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