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The New CCR Cardiocerebral Resuscitation Revised for Shorewood Hills EMS February 7, 2008 The New CCR Cardiocerebral Resuscitation Revised for Shorewood Hills EMS ... – PowerPoint PPT presentation

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Title: The New CCR Cardiocerebral Resuscitation Revised for


1
The New CCR
  • Cardiocerebral Resuscitation
  • Revised for Shorewood Hills EMS
  • February 7, 2008

2
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3
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4
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5
Pathophysiology of V-Fib Arrest
6
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8
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9
How Compressions move blood
10
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11
Pausing Chest Compressions to breathe reduces
Coronary Perfusion Pressure
12
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13
VF Survival ComparedRea et al. Resuscitation
6317 (2004)
14
Survival in Tucson AZ with Cardiocerebral
Resuscitation(2.8x)
40 30 20 10 0
11/03-8/06
25 34/136
Hospital Discharge Survival
1997-1999
9 28/314
CPR
CCR
Terry Valenzuela MD AHA Resuscitation Science
Symposium 2006
15
Survival in Southern ArizonaAdult OOH Witnessed
VF in Arizona (2.6x)
40 30 20 10 0
28.1
Survival to Hospital Discharge after OOH
Witnessed VF
10.9
CPR
CCR
Bobrow and SHARE study group
16
Survival in Kansas CityPre-Hospital Return of
Spontaneous Circulation (ROSC)
100 80 60 40 20 0
Pre-Hospital ROSC
52
15
CPR
CCR
Bobrow and SHARE study group In preparation
17
Survival in Rock-Walworth WIThree Year Results
(2.7x)Normal Brains
18
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

19
Pausing Chest Compressions (CC) to Shock Impacts
survival(Yu - Circulation 106368 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)

20
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

21
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
  • Dont 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

22
Why only 50 compliancewith 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

23
Cardiocerebral Resuscitation (CCR) Fundamentals
  • Think Cardio-Cerebral Brain Brain Brain
  • There are ONLY two rhythms
  • Shockable or Non-Shockable
  • Their Rx is
  • Chest compressions

24
CCRCardiocerebral Resuscitation
VS.
ACLSAdvanced Cardiac Life Support
  • Adv. CARDIAC Life Support
  • Cardio-CEREBRAL Resusc.
  • Only Two Rhythms Shockable or Not
  • Lots of Rhythms and Algorithms for Each
  • Advanced
  • Basic - compressions
  • Lots of Drugs
  • Only 3 Vasopressin, Epi and Amiodarone
  • Megacode anxiety
  • Organized Teamwork
  • ABC
  • McccMAID

25
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

26
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

27
Fundamentals
  • Think 3 cycles each 200 CC analysis shock
  • Compressions started immediately upon arrival
  • All victims 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 lt 5 seconds)

28
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

29
Why Chest Compressions (CC) before
defibrillationWik - Human Data
30
CHEST COMPRESSIONS (CC)IS WHERE ITS 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.

31
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

32
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

33
Vascular Access
  • Avoid Endotracheal (ET) drugs
  • Peripheral IVs OK
  • Interosseous recommended when peripheral IVs are
    not obtainable . . .
  • Use EZ-IO

34
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.

35
Pulse Checks
  • Deadly!!
  • Only check pulses when rhythm appears to have
    converted thru CCR on ECG or the patient shows
    signs of life

36
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.

37
Mechanical CPR Devices
  • No definite benefit.
  • Delays to put on.
  • We will probably not be transporting patients in
    cardiac arrest

38
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

39
Protocol
  • Oral Pharyngeal (OP) airway
  • Non-rebreather face mask _at_15 L/min
  • 200 compressions
  • IV access
  • Epinephrine 1mg IVP
  • One shock, 3-5 seconds, no pulse checks.

40
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.

41
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

42
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.

43
First 2 minutes
Mc MAID
Metronome
Chest Compressions
Monitor
Airway
IV
Drugs
44
First 2 minutesM 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 lt 90 ? inadequate output
  • CC rates gt 120 ? inadequate output
  • Without a metronome pumpers compression rates of
    130-150 are common
  • Some hear, some see the rate

45
First 2 minutesMc 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

46
First 2 minutesMcM A ID - Airway (initial)
  • Delegate someone to do this
  • Insert Oral Pharyngeal Airway
  • O2 via Non-rebreather mask
  • Ensure airway patency

47
First 2 minutesMcMA I D - IV - vascular access
  • Use Interosseous (IO) whenever a delay is
    anticipated

48
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

49
First 2 minutes
McMAID
Metronome
Monitor
Airway
IV
Drugs
CC
Practice this until you can, as a team, routinely
do it in 2 minutes With 2 and more persons on
scene
50
Even seconds withoutChest Compressions are
deadly
51
First 2 minutesHow to analyze Shock
Epi
Practice this ONLY the Code Commander looks
at the rhythm. Be sure to switch Pumpers after
shock
52
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

53
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.

54
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 dont
    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

55
Follow this approach andthese 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

56
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 its 2nd nature

57
Our Goal Should be what is seen in
animals(60-70 survival)
100 80 60 40 20 0
80
24-Hour Good Neuro Survival
13
Standard CPR
CCC CPR
Kern, Hilwig, Berg, Sanders, Ewy. Circulation 2002
58
Without all of you Cardiocerebral Resuscitation
would never havebeen so successful
Thank you now and in the Future
Dr. Kellum
Dr. Ewy
59
Gordon A. Ewy, MDProfessor and Chief, Section of
CardiologyDirector of The University of Arizona
Sarver Heart CenterUniversity of Arizona College
of MedicineGordon A. Ewy, M.D. Distinguished
Endowed Chair in Cardiovascular MedicineMedical
Director of Cardiology, The University Medical
Center 
Tom P. Aufderheide, MD, FACEPProfessor of
Emergency Medicine with TenureAssociate Chair of
Research AffairsMedical College of Wisconsin,
Department of Emergency MedicineMilwaukee,
Wisconsin
Thanks for Slides from Dr. Richard Barneyand Dr.
Michael Kellum
60
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