Cardiocerebral Resuscitation

     Cardiocerebral resuscitation (CCR) is a new approach to patients with out-of-hospital cardiac arrest that has been shown to improve rates of neurologically intact survival by 250%–300% over the approach advocated by the 2000 American Heart Association guidelines. And EMS systems can realize these improvements without having to buy a single new gadget or device.

     CCR consists of three major components:

1. Continuous chest compressions (CCC) without mouth-to-mouth ventilation for all bystanders of witnessed cardiac arrests and for first responders.
2. A new advanced cardiac life support algorithm that delays endotracheal intubation, emphasizes minimal interruptions of chest compressions, deemphasizes positive-pressure ventilations, prioritizes defibrillation according to the three-phase time-sensitive model of ventricular fibrillation, and encourages early administration of epinephrine. Cardiocerebral resuscitation is also for basic EMTs—they, too, should deliver continuous chest compressions at a rate of 100 per minute. Invasive airway insertion is delayed, and positive-pressure ventilations are not utilized during the initial minutes of resuscitation. Epinephrine, when appropriate, is administered via IV or IO ASAP when paramedics arrive.
3. The newest component of cardiocerebral resuscitation is advocating the establishment of cardiac arrest centers that can provide optimal care that includes urgent cardiac catheterization, controlled mild therapeutic hypothermia and standardized supportive care for patients in coma after resuscitation from cardiac arrest.

     Why cardiocerebral resuscitation instead of standard CPR and ACLS? It saves more lives! In the absence of early defibrillation by AEDs, survival of patients with out-of-hospital cardiac arrest (OHCA) treated per American Heart Association guidelines has, since their introduction in 1974, been poor in most of the world. It has not significantly improved in spite of updated standards and/or guidelines in 1980, 1992 and 2000, despite millions of dollars and man-hours spent in development, training and implementation. While we are intellectually convinced that CCR is now the optimal approach to patients with out-of-hospital cardiac arrest, the greatest proponents are providers in systems that have adopted CCR. CCR was instituted in Tucson, AZ, in 2003; in Rock and Walworth Counties, WI, in 2004; in metropolitan Phoenix in 2005 and across Arizona thereafter; and in Kansas City, MO, in 2006 and Kansas City, KS, in 2007. Providers in these communities have viscerally experienced the improved results. In 2008, CCR was instituted in other areas of Wisconsin. Darren Bean, MD, an emergency physician in Madison, reported that, "We have had four survivors in the past 14 days, one of whom had 43 minutes of refractory VF prior to ROSC. To our collective disbelief (even the most enthusiastic supporters of CCR have difficulty believing that 43 minutes of low-flow state could result in anything other than neurologic devastation), he awoke with a completely normal neurologic outcome."

CCR FOR BYSTANDERS
     We were delighted that the AHA recently advocated "hands-only" or "compression-only" CPR for bystanders of witnessed arrests. We have been advocating this approach for years. However, we do not think the AHA recommendations go far enough, as they state that trained individuals should still utilize the 30:2 compression-to-ventilation ratio if they believe they can perform the ventilations with minimal interruptions of chest compressions.

     While ventilations are probably necessary in unwitnessed cardiac arrests, patients with witnessed arrests do not initially need assisted ventilation because their arterial oxygen content is sufficient for several minutes of chest compression-only CPR. In subjects who gasp, the arterial oxygen content remains adequate for up to 15 minutes with chest compressions only. Because the perfusion of the brain and heart are so marginal during resuscitation efforts, interrupting or delaying chest compressions for ventilation or other interventions, except for defibrillation, is deleterious.