Cardiocerebral

Resuscitation
Daniel Green, A.A.S. NREMT-P
Out of Hospital Cardiac
Arrest (OHCA)

What is the current Survival Rate?

What deficits exist in OUR system?

What deficits exist in AHA and/or ACLS?

Can we do better for our Patients?

CCR Research
The American Journal of Medicine
(2006) 19, 335-340

Journal of American College of Cardiology

(2009) Vol. 53, No.2

Circulation: Journal of the American Heart Association

(2009) 119, 2597-2605

Journal of Emergency Medical Services

(2010) June & (2010) September Supplement
The American Journal of Medicine
Two Rural Counties

Rock County Wisconsin -

720 sq. mi and Pop 156,512

Walworth County Wisconsin -

555 sq. mi and Pop 98,334

Three year period of Standard CPR guidelines

One year of system-wide CCR

First Response and EMD instructions modified for CCR.

No Therapeutic Hypothermia, CCR only.

Dramatic increase in Survival Rates for Witnessed OHCA.

The American Journal of Medicine

PERCENTAGE OF NEUROLOGICAL INTACT SURVIVAL

Journal American College
of Cardiology
More inclusive and Comprehensive study

Includes data from Wisconsin Studies as well as Arizona

Studies

Provides Data for Therapeutic Hypothermia and Early

Aggressive Cardiac Catheterization

The combinations have resulted in >300% in survival in

Witnessed OHCA and V-fib/V-tach
 Journal American College
of Cardiology

RCENTAGE OF NEUROLOGICAL INTACT SURVIVAL - 3 YEARS OF EAC

Circulation: Journal of the
American Heart Association

KCMO Fire and MAST

Still provides ventilations at 50:2 ratio.

Uses same three phases of V-fib as basis for protocol.

Compression-centric protocol with focus on CCC and

simple airway management.
Circulation: Journal of the
American Heart Association

PERCENTAGE OF NEUROLOGICAL INTACT SURVIVAL

Journal of Emergency
Medical Services
Overviews of studies including the ones we’ve already
seen.

Includes Support for Therapeutic Hypothermia.

Our professional Journal concludes “CCR works-plain

and simple.”
Problems with Studies

Retrospective for regular CPR

Possible Hawthorne effect for CCR results

Baselines vary from region to region

Survival Rates still dismal

What is Cardiocerebral
Resuscitation (CCR)?
Revised approach to CPR

Focus on 3-phases model of Cardiac Resuscitation

Decreasing interruptions in chest compressions

Eliminating excessive Positive Pressure Ventilations

Aggressive Post-Resuscitation Care

Therapeutic Hypothermia

Early Cardiac Catheterization

Revised Approach to CPR
Team-based approach during Resuscitation
Code Commander (Monitor Technician)
Compression Technician(s)
IV/IO & Medication Technician
Ventilation Technician
Compressors should alternate EVERY two minutes
Code Commander (ideally) is Transporting Technician

ETI/BIAD only after Third cycle of CCC

3-Phase Model of Cardiac
Arrest/Resuscitation
Phase 1 is the Electrical Phase

0-5 minutes post-arrest

Most important intervention is Defibrillation

Phase 2 is the Circulatory Phase

5-15 minutes post-arrest

Achieving adequate Cerebral & Cardiac Perfusion is of utmost importance

Defibrillation without adequate chest compressions in this phase will almost always result in
PEA/Asystole
3-Phase Model of Cardiac
Arrest/Resuscitation

Phase 3 is the metabolic phase

Occurs after ROSC

Therapeutic Hypothermia to control inflammatory

response and subsequent re-perfusion injury

Early PCI after ROSC

Decreasing Interruptions
Continuous Chest Compressions(CCC) of utmost importance

OPA with NRB allows focus on CCC

Hypoxic arrest or non-shockable rhythm get ventilated with BVM at

6/min

Studies show both EMS and Hospital staff only do compressions >50%
of the time

Advanced Airway Placement(ETI/BIAD) deferred until after 600

compressions and CCC not interrupted for placement
Excessive Ventilations
EMTs, Paramedics, MDs, CRNAs, & RNs all over-ventilate

One study shows an average of 37 ventilations per minutes by

skilled EMS & Hospital Providers

Ventilations increase Intrathoracic Pressure which decreases

coronary perfusion as well as pre-load which down the line will
lead to poor cerebral perfusion.

Passive Ventilation and Low-rate ventilations reduce these

problems.
Aggressive Post-Resuscitation
Therapeutic Hypothermia has proven results

RAA ARCTIC Program

49% Survival in OHCA overall

76% Survival witnessed with V-Fib initially

Cooling done during Resuscitation (No RSI)

Wake County TH Protocol

28% Neurologically Intact with 30:2, ITD, & TH

Cooling done during arrest or after ROSC (no RSI)

Early Cardiac Catheterization

Should be performed if visible STEMI after ROSC in

presumed Cardiac related arrest.

In one study, when both TH and Early PCI were used

after successful ROSC, 73% survived neurologically
intact versus 16% who received PCI alone early.

Norway had an increase of 30% in 1-year survival using

early Angiography
CCR Protocols
Do we need to change how we handle OHCA?

Are we providing our patients with the best chance to go

back to the life they lived before?

What would this look like for us?

What adjustments would need to be made?

Should we do a controlled study? (i.e. One month of

what we do now vs. CCR)
Conclusion
No single procedure or drug makes a difference

Systematic team approach provides standardization that allows us

to see what is and isn’t working for our patients

Status Quo unacceptable

We want to be Medical Professionals, therefore we need to be using

Evidenced-Based Medicine to provide the very best for the people
we serve

Our Goal is to get those that suffer OHCA back to their lives and
back to their families
Cardiocerebral
Resuscitation
Daniel Green, A.A.S. NREMT-P