The document discusses the change from traditional CPR to Cardiocerebral Resuscitation (CCR). CCR emphasizes continuous chest compressions without interruptions and deemphasizes ventilation. Studies have found CCR increases survival rates compared to CPR by up to 3 times by minimizing interruptions in blood flow through continuous, high-quality chest compressions without stopping for ventilation. CCR focuses on circulating oxygenated blood to the heart and brain as the priority for cardiac arrest patients rather than additional oxygenation through ventilation.

2. “Call and Pump”

3. From CPR to CCR- why the
change ?

4. CPR (2010) emphasizes:
Circulation
Airway
Breathing
CCR (Cardiocerebral Resuscitation) emphasizes:
Circulation (uninterrupted compressions)
Deemphasizes ventilation

5. Cardiocerebral Resuscitation
• Cardiocerebral Resuscitation (CCR) is a new approach
to the resuscitation of patients with out-of-hospital
cardiac arrest (OHCA).
• First major component of CCR is continuous
Chest compressions
• Second component of CCR is a new ACLS treatment
algorithm for emergency medical services.
• Third component has recently been added to CCR,
namely aggressive post-resuscitation care

6. •The old CPR technique called for rescuers
to give 30 chest compressions followed by
two quick emergency breaths into the mouth
of the victim,
•"It takes about halfway through that chest-
compression cycle to build up a marginal
pressure to the heart and brain,

7. •As soon as you stop, that pressure almost
immediately falls to zero. After giving
ventilation, it takes halfway though next
cycle to get the pressure back up -- so you
are constantly chasing your tail.“
•Cardiac arrest victims have oxygen
dissolved in their blood.

8. • Their immediate problem isn't getting more
oxygen into the blood, it's getting that
blood to the brain and to the heart.
• When first responders used a professional
version of the new technique, Bobrow and
colleagues found, they saved three times
more lives than they did with standard life-
support techniques.

9. • A cardiac arrest is a sudden catastrophic
electrical problem where the heart cannot
beat at all. Cardiac arrest equals sudden
death. You die unless you are resuscitated.“
• In adults, a collapse is almost always due to
cardiac arrest.
• If someone suddenly collapses, you can help,
but if you do nothing, that person will almost
certainly die,

10. • position the victim with head tilted back so the airway is
open,
• immediately start rapid, forceful chest compressions. Lock
your hands together one on top of the other, put the heel of
the lower hand in the center of the victim's chest, and push
hard and fast, 100 times per minute.
• If you are lucky enough to have an AED [automated external
defibrillator], attach it to the victim and follow the
commands."

11. • "You can't make anything worse. All you can do is
help," Bobrow says. "Keep up the compressions
until help arrives. If you get tired, have another
person take over for a while.
• Don't worry about mouth-to-mouth resuscitation
or compression-to-breath ratios, Bobrow says.
And don't worry about pushing too hard. The
chest has to be depressed about 2 inches. Even if
you crack the victim's ribs, you'll be doing much
more good than harm.

12. The Metabolic Phase (~>10 minutes)
Survival decreased
Science searching for more successful treatments
3-Phase Time-Sensitive Model of
Cardiac Arrest Due to VF
The Electrical Phase (0 to ~5 minutes)
Early defibrillation life-saving
The Circulatory Phase (~5 to ~10 minutes)
Intubation and immediate AED can be detrimental
Compressions first may be life saving
Weisfeldt ML, Becker LB. JAMA 2002;288:3035

13. • Place the heel of one hand in the
centre of the chest
• Place other hand on top
• Interlock fingers
• Compress the chest
– Rate 100 min-1
– Depth 4-5 cm (1.5 to 2 inch)
– Equal compression : relaxation
CHEST COMPRESSIONS

14. How Compressions move blood

15. 5 sec
80
160
mmHg
Time (sec)
40
120
0
Coronary Perfusion Pressures
Cerebral Perfusion
Pressures
No Cerebral
Perfusion
Single rescuer performing 30:2 with realistic 16 sec.
interruption of chest compressions for MTM ventilations
Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525

16. 0
5 sec
80
160
mmHg
Time (sec)
40
120
Coronary Perfusion Pressures
Continuous Cerebral Perfusion Pressures
Single rescuer performing
continuous chest compressions
Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525
Perfusion with continuous compressions

17. pathophysiology of Resuscitation
 Chest compressions are the single most important intervention
!!!!
Optimal QUALITY is essential
Interruptions are deadly → continuous
 Ventilation can be deadly
Don’t 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
Defibb is better than chest compressions only in the <4 mins

21. 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

22. 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

23. Survival in Tucson AZ
with Cardiocerebral Resuscitation(2.8x)
Hospital
Discharge
Survival
40%
30%
20%
10%
0%
CPR CCR
9%
28/314
25%
34/136
Terry Valenzuela MD AHA Resuscitation Science Symposium 2006
11/03-8/06
1997-1999

24. Survival in Kansas City
Pre-Hospital Return of Spontaneous Circulation (ROSC)
Pre-Hospital
ROSC
100%
80%
60%
40%
20%
0%
CPR CCR
15%
52%
Bobrow and SHARE study group

25. Survival in WISCONSIN with Normal Brains
Three Year Results (2.7x)
Cardiocerebral Resuscitation
Witnessed collapse with shockable rhythm
Neurologically
intact
survival
50%
40%
30%
20%
10%
0%
CPR CCR
15%
40%
p = 0.001
14/
92
36/
89

26. CCR is REALLY SIMPLE
Continuous Chest Compressions
Quality Chest Compressions
Uninterrupted Chest Compressions
 Quality is crucial
 Rate 100 / min
 Depth adequate
 Recoil absolutely crucial
You can ONLY stop Chest Compressions (CC) for
Switching pumpers (every minute) 2-3 seconds
 Analysis - Is shock indicated (every 200 CC)? 2-3 seconds
Shocking 5-7 sec

27. First 2 minutes
Monitor
Airway
IV
Drugs
Mc MAID
Metronome
Chest Compressions

28. First 2 minutes
M c MAID - Metronome / Chest Compressions
 Get the Metronome – know how to start it
 Chest Compression (CC) Rate is critical
 CC rates < 90 → inadequate output
 CC rates > 120 → inadequate output
 Without a metronome pumpers compression
rates of 130-150 are common

29. First 2 minutes
Mc 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)
 Shock energy will be preset to maximum Joules
(360 J)
 Place pads without interrupting compressions

30. First 2 minutes
McM A ID - Airway (initial)
 Delegate someone to do this
 Insert Oral Pharyngeal Airway
 O2 via Non-rebreather mask
 Ensure airway patency

31. First 2 minutes
McMA I D - IV - vascular access
Use Interosseous (IO) whenever a delay is anticipated

32. 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

33. First 2 minutes
Metronome Monitor Airway IV Drugs
McMAID
Practice this until one can,
as a team,
routinely do it in 2 minutes
With 2 and more persons on scene
CC

34. 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

35. 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.

36. Possible Reasons for 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

37. CCR Post-Resuscitation Care
• 25% of those initially resuscitated survive to leave the hospital.
• one-third die from central nervous system damage, another one-third die
from myocardial failure, and the final one-third from a variety of causes
including infection and multi organ failure
• approach emphasized providing therapeutic hypothermia to all who
remained comatose post resuscitation use of mild (32°C to 34°C)
therapeutic hypothermia for comatose post-resuscitated cardiac arrest
victims is accepted by many resuscitation scientists.
• performing early coronary angiography and percutaneous coronary
intervention (PCI) in any patients with possible myocardial ischemia as a
contributing factor to their cardiac arrests

38. Even seconds without
Chest Compressions
are deadly