COMMENTARY

Cardiocerebral Resuscitation for Patients in Sudden Cardiac Arrest

Amal Mattu, MD, FAAEM, FACEP

Disclosures

August 20, 2009

Introduction

IIf you ask many older physicians in emergency medicine what "CCR" stands for, they might talk to you about a rock band that was popular in the 1960s and 1970s that still gets some play on the "oldies" radio stations. However, well-read emergency physicians who have a particular interest in prehospital care or cardiac arrest know that “CCR” now also represents the most important advance in the care of patients in cardiac arrest since cardiopulmonary resuscitation (CPR) was first described: cardiocerebral resuscitation. Some physicians refer to CCR as the new form of CPR, whereas others refer to it simply as the replacement for traditional CPR. Either way, cardiocerebral resuscitation is something that everyone practicing emergency medical care -- emergency medical technicians, emergency department nurses, emergency physicians, cardiologists, and intensive care physicians -- needs to know.

Sudden cardiac death (SCD) is one of the leading causes of mortality in the United States and other developed nations. Unfortunately, survival rates from SCD are abysmal despite the promulgation of layperson and first-responder CPR courses, as well as Advanced Cardiac Life Support courses over the past few decades. Critics of traditional CPR have stated that the emphasis on early ventilation (either mouth-to-mouth ventilation , bagging, or endotracheal intubation) is misguided for several reasons. First, it is well known that these airway interventions take time away from performing adequate chest compressions at 100/minute. Second, these airway interventions all produce an increase in intrathoracic pressure, decreasing venous return and thus cardiac output -- not a good thing in a patient in cardiac arrest. Third, the majority of patients with sudden cardiac arrest do not have hypoxia at the time of onset of the arrest, so the blood in the central circulation is not oxygen-deficient. Ventilations, therefore, are not immediately needed to improve oxygenation. Although these statements are certainly not true for patients having pulmonary arrest, the clear majority of patients with SCD have ventricular fibrillation (cardiac) arrest rather than pulmonary arrest.

Recent literature has also separated ventricular fibrillation arrest into time-sensitive phases.[1] During the first phase (the first 4-5 minutes), the heart is amenable to prompt defibrillation. This is termed the "electrical phase" of cardiac arrest. During the second phase, the "circulatory phase," the fibrillating myocardium has used up much of its energy stores, and chest compressions are necessary to perfuse or "prime" the heart before defibrillation will likely be successful. This second phase is usually the time in which prehospital care providers arrive.

Based on this information, researchers at the University of Arizona [2] broke from the traditional guidelines for CPR and created a new protocol for the management of out-of-hospital cardiac arrest that they termed "cardiocerebral resuscitation." CCR consists of 3 major parts: (1) continuous chest compressions with no early ventilations preshock and postshock; (2) delayed intubation; and (3) early use of epinephrine (EPI). A recent study[3] that compared CCR with standard CPR in patients with shockable rhythms demonstrated that both survival (47.2% vs 19.6%) and percentage of survivors with good neurologic outcome (83.3% vs 77.8%) were significantly improved in those who underwent CCR.

Recent Advances in Cardiopulmonary Resuscitation: Cardiocerebral Resuscitation

Ewy GA, Kern KB
J Am Coll Cardiol. 2009;53:149-157

Summary

Ewy and Kern, both leaders in the field of cardiac resuscitation, reviewed CCR and described ideal postresuscitation care. The "3 pillars" of CCR were described:

1. Compression-only CPR by anyone who witnessed the event.

2. CCR by emergency medical service personnel, assumed to be arriving > 5 minutes postarrest.

  1. 200 chest compressions (at 100/minute), delay intubation; second person to apply defibrillation pads and initiate passive oxygen insufflation (eg, 100% oxygen via facemask)

  2. Single shock if indicated, immediately followed by 200 more chest compressions (no pulse check after shock)

  3. Check for pulse and rhythm; note that this pulse check occurs 4 minutes after the CCR has begun

  4. EPI intravenously or intraosseously as soon as possible to improve central circulation, coronary circulation, and diastolic blood pressure

  5. Repeat (b) and (c) 3 times; intubate if no return of spontaneous circulation after 3 cycles; note that neither bag-valve-mask ventilation nor intubation occurs until 12 minutes after the CCR has begun

  6. Continue resuscitation efforts with minimal interruptions of chest compressions until resuscitation is successful or the person is pronounced dead

Viewpoint

In summary, the traditional mantra in emergency medicine of "A-B-C" has been turned upside-down by CCR. Aggressive management of the airway in those who have cardiac arrest is being relegated to a far lower priority. Good chest compressions and early EPI administration are the most important interventions when ventricular fibrillation is present in the circulation phase of cardiac arrest. Future studies will need to evaluate whether these concepts are applicable to nonshockable rhythms as well, although intuitively this seems reasonable. Finally, those who survive cardiac arrest should be treated with induced hypothermia, and pending more studies, they may benefit from early coronary angiography and PCI as well.

Abstract

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