Cardiocerebral Resuscitation (CCR) The New Approach to Cardiac Arrest

Ben Bobrow, MD Medical Director

www.azshare.gov

Lani Clark Research and QI Director

[email protected]

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, 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

100%

Three-Phase Model of Resuscitation Myocardial ATP

Electrical Phase

Circulatory Phase

Metabolic Phase

10

12

14

16

18

20

Arrest Time (min)

Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8

30 AEDs in Chicago OHare Airport

80 % (8/10)

2 %*
Chicago City
* Lance Becker, M.D.

Chicago Airport
15 arrests 10 VF

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

Bystander CPR
67% of all OHCA occur in the victims 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

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

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

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.

Standard CPR 15:2

Coronary Perfusion pressure (Ao diastolic- RA diastolic)

Standard CPR: 30:2

160
5 sec

120 mmHg

80

40

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. 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. JAMA 1990; 263: 1106

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

Ventilation Rate during Out-ofHospital CPR

13 out-of-hospital cardiac arrest patients

Ventilation rate measured during CPR

Avg. ventilation rate=37 + 3 per minute (range 15-49)

Aufderheide et al. Circulation 2004; 109:1960-5

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 = 0.87

35 30 25 20 15 10 5

p <0.007

Survival

Defib

CPR

Defib

CPR

Defibrillation vs. CPR first

(< 5 minute response time)
60% 50% 40% 30% 20% 10% 0% ROSC D/C Hosp 1yr Surv

P=.82

P=.61

P=.44

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% ROSC D/C Hosp 1yr Surv

P=.04

P=.006

P=.01

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

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, EMS providers perform immediate rhythm analysis

Results: Mean Time Intervals

35 30 25
31.4

18.2 30.8

Minutes

20 15 10 5 0

19.3

Dispatch to arrival interval On scene interval 18.2 Transport interval Total time

6.9 5.2

5.6

7.0

CCR

ALS

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

10.9

3.6 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

Cardiocerebral Resuscitation Protocol Compliance

22% of patients did NOT receive CCR

-8% survivors with witnessed VF

78% of patients DID receive CCR

- 41% Witnessed VF survival

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, and recoil.. Waveform Data Improved Protocol Compliance Improved Documentation

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 Patients 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

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 32C to 34C (89.6F to 93.2F) 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 inhospital arrest. Class IIb
American Heart Association 2005 Guidelines
55

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 lets 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!

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?

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.azshare.gov