Mulia and Siswanto 306 Med J Indones

Correspondence email to: [email protected]

Cardiocerebral resuscitation: advances in cardiac arrest resuscitation
Erwin Mulia, Bambang B. Siswanto
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan
Kita, Jakarta, Indonesia
Abstrak
Henti jantung masih merupakan penyebab kematian utama di dunia. Walau telah ada kemajuan dalam hal tatalaksana
kegawatdaruratan kardiovaskular, angka ketahanan hidup mereka dengan henti jantung di luar rumah sakit tetap rendah.
Pedoman resusitasi jantung paru dan kegawatdaruratan kardiovaskular meski telah diperbaharui namun pendekatan
terhadap keadaan henti jantung di luar rumah sakit masih jauh dari optimal. Hal ini memberi peluang bagi resusitasi
kardioserebral untuk menjadi alternatif resusitasi pada keadaan henti jantung di luar rumah sakit. Resusitasi kardioserebral
layak menggantikan resusitasi jantung paru pada keadaan henti jantung di luar rumah sakit karena telah terbukti
memperbaiki ketahanan hidup dan fungsi serebral pada pasien dengan henti jantung. (Med J Indones 2011; 20:306-9)
Abstract
Cardiac arrest remains a leading cause of death in the world. Although advances in emergency cardiac care has been
achieved, the survival rate of those non hospitalized hospital cardiac arrest remains low. Update in guidelines for CPR
and emergency cardiovascular, their approach to out of hospital cardiac arrest is far from optimal. This provides an
opportunity to advocate cardiocerebral resuscitation as an alternative to traditional cardiopulmonary resuscitation
for non hospitalized cardiac arrest. Because cardiocerebral resuscitation results in improved survival and cerebral
function in patients with witnessed cardiac arrest and a shockable rhythm whom have greatest chance of survival, it
should replace CPR especially for non hospitalized cardiac arrest. (Med J Indones 2011; 20:306-9)
Keywords: cardiocerebral resuscitation, cardiac arrest, cardiopulmonary resuscitation
Despite of the development of standards and
guidelines for emergency cardiac care that included
CPR (CardioPulmonary Resuscitation) and ACLS
(Advanced Cardiac Life Support), the survival rate
of victims of OHCA (Out of Hospital Cardiac Arrest)
remains disappointingly low. Bystander CPR and rapid
response times improve survival rates after OHCA.
1-5
However, in this age of universal precautions, only 1 in
4 or 5 patients with OHCA currently receive bystander
CPR. Survival to discharge in patients with witnessed
OHCA and VF (Ventricular Fibrillation) improved by
nearly 40% when they provide a single shock followed
by immediate chest compressions rather than previously
recommended stacked shocks.
5
The initiations of
bystander resuscitations, especially when begun within
1 minute of the arrest, markedly improve survival.
6
Rescue breathing
Rescue breathing is a misnomer because this
requirement decreases the survival chances of patients
with witnessed cardiac arrest receiving bystander
resuscitation. The requirement for mouth-to-mouth
ventilations has several major drawbacks for patients
with cardiac arrest.
7
First, it decreases the number of
individuals who receive prompt bystander resuscitation
efforts. Most bystanders are not willing to initiate
bystander rescue efforts because they are not willing
to perform mouth-to-mouth ventilation. Second,
rescue breathing results in long interruptions
of chest compressions during cardiac arrest and
long interruptions of chest compressions decrease
neurologically normal survival.
8
The 2005 CPR
guidelines also changed their recommendation on
compression to perfusion ratio (30:2), recognizing the
importance of delivering more chest compressions with
less interruptions.
7
In laboratory model of clinically
realistic OHCA, normal neurologic survival was better
with CCC (Continous Chest Compressions) than
with 30:2 compressions to ventilations.
9
The forward
blood fow is so marginal during chest compressions
for cardiac arrest, that any interruption of chest
compressions decreases vital blood fow to the brain.
Third, even if chest compressions are not interrupted,
positive-pressure ventilation during cardiac arrest
increases intrathoracic pressure then decreases venous
return to the thorax and subsequent perfusion of the
heart and the brain.
10
This phenomenon is made worse
when forceful ventilations are given while the chest
is being compressed.
11
Another concern is the amount
of air that enters the stomach rather than the lungs
during rescue breathing. Mouth-to-mouth ventilation
can cause regurgitation in nearly 50% of patients. The
pulmonary veins, left heart and entire arterial system
are flled with oxygenated blood at the onset of VF-
induced arrest. The important issue is to circulate
such oxygenated blood to the tissues, particularly the
brain and myocardium. The recommended ventilations
further delay the onset of critical chest compressions.
12

Finally, rescue breathing is not necessary in victims
of witnessed cardiac arrest because they initially
gasp and if chest compressions are started early and
Vol. 20, No. 4, November 2011 Cardiocerebral resuscitation
307
continued, many victims will continue to gasp and
there by provide physiologic ventilation.
13
Cardiac arrest phase
Early in cardiac arrest when adequate tissue oxygenation
delivery is critically important, CCC provides this
crucial oxygen delivery.
14
Weisfeldt and Becker
described 3-phase time-sensitive model of cardiac
arrest due to VF which was the rationale of CCR
(Cardio Cerebral Resuscitation) recommendation.
15
The
frst phase, the electrical phase, lasts about 4 to 5 min.
The most important intervention during this phase is
defbrillation. The second phase, the circulatory phase,
which lasts approximately from minute 4 or 5 to minute
15. The generation of adequate cerebral and coronary
perfusion pressures by chest compressions before
and after defbrillation during this phase is critical to
neurologically normal survival. Ironically, if an AED
(Automatic External Defbrillator) is applied during
this phase without pre-shock chest compressions, the
subject is much less likely to survive and almost always
results in asystole or pulseless electrical activity (PEA).
The previous recommendation for a stacked-shock
protocol resulted in prolonged interruption of chest
compressions for rhythm analysis before and after
shocks during the circulatory phase of cardiac arrest.
16,17
Successful resuscitation of a patient with a pulseless
rhythm usually requires pre-shock chest compressions
and prompt effective resumption of chest compressions
post-shock along with vasopressors. For these reasons,
CCR recommends 200 chest compressions to provide
myocardial perfusion prior to a single shock for VF
in the circulatory phase and immediate application
of another 200 chest compressions without prior
assessment of the rhythm or pulse.
18,19
Three pillars of
CCR include CCC, CCR and post resuscitation care
(hypothermia and early PCI).
Cardiocerebral resuscitation
Another reason that survival of OHCA has been so
poor is that paramedics, who almost always arrive
after the electrical phase of VF cardiac arrest, spend
only one-half of the time doing chest compressions.
16,20
Another major problem during resuscitation efforts is
endotracheal intubation. Endotracheal intubation has
adverse effects due to the relatively long interruptions
of chest compressions during placement and adverse
effects of positive-pressure ventilation and frequent
hyperventilation.
21
CCR accordingly discourages
endotracheal intubation during the electrical and
circulatory phases of cardiac arrest due to VF.
22
Another important aspects of CCR is that after the
defbrillation shock, 200 additional chest compressions
are provided before rhythm and pulse are analyzed. A
defbrillation shock rarely produced a perfusion rhythm
in prolonged VF. The VF almost always changes to either
asystole or PEA. The key to successfully treating these post-
defbrillation rhythms is urgent myocardial reperfusion.
Chest compressions are of paramount importance after the
defbrillation shock, especially in patients with PEA. Small
pulsatile increases in aortic pressure post-shock (pseudo-
pulseless electrical activity). Aortic pressures of 20/10
mmHg are common in such a period. If hemodynamic
support is provided by immediate chest compressions, these
pressures often increase to 40/20 mmHg and will continue to
increase. Without immediate post-shock chest compressions,
the aortic pressure will decline and soon be truly asystolic.
Therefore, CCR recommends for an additional 200 chest
compressions immediately after the shock without a pause
to assess the post-shock rhythm.
18,19,22
A dramatic increase in neurologically intact survival
were found with CCR. The mean survival to hospital
discharge with intact neurologic function was 15% in
the 3 years prior and 48% during the year when CCR
was provided.
22
In patients with witnessed cardiac arrest
and shockable rhythm, there was dramatic improvement
(15% to 40%) in neurologic intact survival at hospital
discharge compared with the pre-CCR era.
23
Figure 1. Neurologically normal survival of patients with
witnessed OHCA and a shockable rhythm
Therapeutic hypothermia and early PCI
Sunde et al. performed an aggressive approach with
post-resuscitation care patients. They emphasized
therapeutic hypothermia to all who remained comatose
post-resuscitation and performing early coronary
angiography and percutaneous coronary intervention
(PCI) in any patients with possible myocardial ischemia
as a contributing factor to their cardiac arrests. They
found a signifcant improvement in survival using
this approach. During this interventional period, 77%
of all resuscitated victims had coronary angiography.
The vast majority (96%) of those undergoing cardiac
catheterization had documented coronary disease and
ventilation and frequent hyperventilation.
21
CCR accordingly discourages endotracheal
intubation during the electrical and circulatory phases of cardiac arrest due to VF.
22
Another important aspects of CCR is that after the defibrillation shock, 200 additional
chest compressions are provided before rhythm and pulse are analyzed. A defibrillation shock
rarely produced a perfusion rhythm in prolonged VF. The VF almost always changes to either
asystole or PEA. The key to successfully treating these post-defibrillation rhythms is urgent
myocardial reperfusion. Chest compressions are of paramount importance after the
defibrillation shock, especially in patients with PEA. Small pulsatile increases in aortic
pressure post-shock (pseudo-pulseless electrical activity). Aortic pressures of 20/10 mmHg
are common in such a period. If hemodynamic support is provided by immediate chest
compressions, these pressures often increase to 40/20 mmHg and will continue to increase.
Without immediate post-shock chest compressions, the aortic pressure will decline and soon
be truly asystolic. Therefore, CCR recommends for an additional 200 chest compressions
immediately after the shock without a pause to assess the post-shock rhythm.
18,19,22
A dramatic increase in neurologically intact survival were found with CCR. The mean
survival to hospital discharge with intact neurologic function was 15% in the 3 years prior
and 48% during the year when CCR was provided.
22
In patients with witnessed cardiac arrest
and shockable rhythm, there was dramatic improvement (15% to 40%) in neurologic intact
survival at hospital discharge compared with the pre-CCR era.
23
Figure 1. Neurologically Normal Survival of Patients With Witnessed OHCA and a
Shockable Rhythm (p=0.002)
23
Therapeutic Hypothermia and Early PCI




90
80
70
60
50
40
30
20
10
0
CPR 3 Years CCR 3 Years
Neurogically Intact
Neurogically Non Intact
Mulia and Siswanto 308 Med J Indones
82% of those had total occlusions of an epicardial
coronary vessel. They revealed that reperfusion therapy
was by far the most infuential factor on survival.
24
Finally, the neurologic status of long-term survivors
during the experimental period of aggressive post-
resuscitation care was excellent, with more than 90%
having no neurologic defcits and 9% having mild
defcits. These data suggest strongly that signifcant
improvement in survival to discharge and even
1-year survival can be achieved with an aggressive
and standardized approach to post-resuscitation care.
Reperfusion therapy, either PCI or coronary artery bypass
graft, had the most profound effect on outcome. Two
large, randomized, prospective trials published in 2002
showed improved survival and neurologic function
of survivors when therapeutic hypothermia (32C to
34C) was used for comatose victims of OHCA.
25,26
Quintero-Moran et al. found that 54% patient with
OHCA survived to hospital discharge with aggressive
early cardiac catheterization and angioplasty strategy.
27

Gorjup et al. reported survival to hospital discharge
was achieved in 67% of 135 patients with STEMI
and associated cardiac arrest. Among the patients who
were comatose at the time of cardiac catheterization,
survival was achieved in 51% and the patients who were
conscious after their cardiac arrests had a survival rate
of 100%.
28
Garot et al. reported on 186 patients suffering
cardiac arrest as a complication of their myocardial
infarctions (STEMI). Prior to cardiac catheterization, all
of these patients were sedated and given neuromuscular
blockage. Fifty-fve percent survived to hospital
discharge and among the survivors, 86% had normal
neurologic function, 10% had mild disability and 4%
were severely neurologically disabled.
29
Knafelj et al. then reviewed the combination of these
2 important resuscitation therapies, hypothermia and
early PCI. Their series contained 72 patients, all of
whom were comatose post-resuscitation after cardiac
arrest with signs of STEMI. The overall survival rate to
hospital discharge was 61%, but there was a signifcant
difference between those who were cooled pre-PCI
and those who were not. Of those who received both
angioplasty and hypothermia, the hospital discharge
survival rate was 75%, with 73% of those survivors
having good neurologic function. Among those who
did not receive hypothermia, 44% were discharged
from the hospital and only 16% had normal neurologic
function. This is much better than what has been
achieved without moderate hypothermia, early cardiac
catheterization and PCI when indicated. For optimal
results with CCR, aggressive post-resuscitation care that
includes both of therapeutic hypothermia and emergent
cardiac catheterization and PCI when appropriate
must be included. Thus, this third component has been
recently added to protocol of CCR.
30
Figure 2. Survival to hospital discharge of patients with OHCA
treated by 2 different emergency medical services
protocols (OR 8.6)
14
Table 1. Comparison Between Cardiocerebral Resuscitation and AHA CPR
Cardiocerebral Resuscitation 2003
AHA 2005 Guidelines and 2008 Advisory
Statement
Chest Compression Continuous CC for bystanders Bystander hands-only CPR
Rescue Breathing Decrease rescue breathing Decrease CC interruptions
BLS No rescue breaths 30:2 CCs to ventilations
ACLS Passive oxygen insuffation or limited breaths/min 8-10 breaths/min
200 CCs prior to shock Optional 5 cycles of 30:2 prior to shock
200 CCs immediately after shock 5 cycles of 30:2 immediately after shock
Post Cardiac Arrest Care Therapeutic hypothermia for all unconscious post-resuscitation Therapeutic hypothermia for all unconscious
post-resuscitation from VFCA
Early, emergent catheterization and PCI for all resuscitated
victims regardless of electrocardiographic fndings
No offcial statement
ACLS = advanced cardiac life support; AHA = American Heart Association; BLS = basic life support; CC = chest compression; CPR = cardiopulmonary resuscitation; PCI =
percutaneous coronary intervention; VFCA = ventricular fbrillation cardiac arrest]
having good neurologic function. Among those who did not receive hypothermia, 44% were
discharged from the hospital and only 16% had normal neurologic function. This is much
better than what has been achieved without moderate hypothermia, early cardiac
catheterization and PCI when indicated. For optimal results with CCR, aggressive post-
resuscitation care that includes both of therapeutic hypothermia and emergent cardiac
catheterization and PCI when appropriate must be included. Thus, this third component has
been recently added to protocol of CCR.
30
Figure 2. Survival to Hospital Discharge of Patients With OHCA Treated by 2 Different
Emergency Medical Services Protocols (OR 8.6)
14
Conclusions
Table 1. Comparison Between Cardiocerebral Resuscitation and AHA CPR
Cardiocerebral Resuscitation
2003
AHA 2005 Guidelines and
2008 Advisory Statement
Chest Compression Continuous CC for bystanders Bystander hands-only CPR
Rescue Breathing Decrease rescue breathing Decrease CC interruptions
BLS No rescue breaths 30:2 CCs to ventilations
ACLS Passive oxygen insufflation or
limited breaths/min
8-10 breaths/min
200 CCs prior to shock
Optional 5 cycles of 30:2
prior to shock
200 CCs immediately after shock
5 cycles of 30:2 immediately
after shock
having good neurologic function. Among those who did not receive hypothermia, 44% were
discharged from the hospital and only 16% had normal neurologic function. This is much
better than what has been achieved without moderate hypothermia, early cardiac
catheterization and PCI when indicated. For optimal results with CCR, aggressive post-
resuscitation care that includes both of therapeutic hypothermia and emergent cardiac
catheterization and PCI when appropriate must be included. Thus, this third component has
been recently added to protocol of CCR.
30
Figure 2. Survival to Hospital Discharge of Patients With OHCA Treated by 2 Different
Emergency Medical Services Protocols (OR 8.6)
14
Conclusions
Table 1. Comparison Between Cardiocerebral Resuscitation and AHA CPR
Cardiocerebral Resuscitation
2003
AHA 2005 Guidelines and
2008 Advisory Statement
Chest Compression Continuous CC for bystanders Bystander hands-only CPR
Rescue Breathing Decrease rescue breathing Decrease CC interruptions
BLS No rescue breaths 30:2 CCs to ventilations
ACLS Passive oxygen insufflation or
limited breaths/min
8-10 breaths/min
200 CCs prior to shock
Optional 5 cycles of 30:2
prior to shock
200 CCs immediately after shock
5 cycles of 30:2 immediately
after shock
CCR
CPR
Not Survived
Survived
Vol. 20, No. 4, November 2011 Cardiocerebral resuscitation
309
In conclusion, uninterrupted perfusion to the heart and
brain by CCC prior to defbrillation during cardiac
arrest is essential to neurologically normal survival.
CCC CPR by bystanders as a solution to this critical
issue because eliminating mouth-to-mouth rescue
breathing will go a long way toward increasing the
incidence of bystander resuscitation efforts. These
changes resulted in dramatic improvement in survival
of patients most likely to survive: those with witnessed
cardiac arrest and shockable rhythm. More aggressive
post-resuscitation care, including hypothermia and
emergent cardiac catheterization and PCI, are required
to save more victims of sudden cardiac arrest.
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