The 2016 CT state EMS protocol update emphasizes minimally interrupted, high-quality CPR. It changes adult CPR to continuous compressions for 2 minutes without pausing for breaths. For cardiac arrests, CCR is recommended for the first 8 minutes using passive ventilation before transitioning to active ventilations. Resuscitation should be performed on scene until ROSC or termination of efforts, except in special circumstances. The protocol introduces team-focused CPR with designated compressor, airway, and vascular roles to optimize efficiency. It also provides a CPR checklist for the code commander. Mechanical CPR may be considered in settings where high-quality manual CPR is difficult.

1. 2016 CT STATE EMS PROTOCOL
CCR/CPR UPDATE

2. Change to CPR/CCR
• Emphasis on:
– Starting compressions sooner
– Minimally interrupted compressions
– High performance CPR

3. Change to CPR/CCR
• No more 30:2 for Adults
– Pediatric – follow standard AHA CPR
• Instead:
– Cycles of 2 minutes uninterrupted compressions
– Check rhythm every 2 minutes
– Ventilate every 10th compression on the upstroke
• Do not interrupt compressions to ventilate
• Don’t overventilate – will cause gastric distention
• Consider using pediatric BVM

5. CCR
• CCR still for first 8 minutes in presumed
cardiac etiology
– NOT for respiratory arrest, opiate OD, pediatrics,
or trauma
– Passive ventilation with OPA and NRB will usually
be used at first
– May transition to active ventilations once
sufficient personnel/resources are present
• This could be immediate, at 2 minutes, 8 minutes or
any point in between

6. No More “20 Minute Then Transport”
• Resuscitation performed on scene until ROSC or termination of
efforts EXCEPT for ‘special circumstances’
– “Special Circumstances” not well defined in protocol but think “can
the hospital do something to fix this that I can’t?” Ex:
• Hypothermia (central rewarming)
• Pulmonary embolism (lytics, ECMO, IR)
• Pregnancy with potentially viable fetus (perimortem c-section)
• Etc.
• Still AT LEAST 20 minutes ALS resuscitation before considering
termination
– Definitively manage airway prior to termination
– Should continue resuscitation if ROSC is likely such as in cases with:
• Witnessed arrest and early CPR
• Reversible cause
• etCO2 >15mmHg
• Persistent vfib/v-tach
• Etc.

7. Changes to ALS Arrest Management
• Antiarrhythmics now “per AHA ACLS guidelines”
• Medics should use etCO2 with BLS and ALS airway to
assess CPR quality and for signs of ROSC
• Bicarb indications (now 2 mEQ/kg IV)
– Suspected excited delerium
• New indication – that patient you were restraining who isn’t
breathing any more…
– Suspected pre-existing metabolic acidosis
– Known tricyclic OD (tox protocol also includes other Na
channel blockers such as cocaine and Benadryl)
– Should insert an advanced airway before bicarb
• Bicarb works by creating CO2
• May be harmful in a ‘closed system’ (i.e. ineffective ventilations)

8. Team Focused CPR
• Send a rescuer in ahead (with just gloves) to start
compressions
• Pre-defined roles and positions
– Different ways to set this up depending on resources
– Goal is efficiency
• The example described in the protocols follows
but may be adapted
– Protocol example assumes at least 4 ALS providers on
scene
– Strive for multiple ALS providers to fill roles
– ALS provider may need to fill multiple roles

9. Team Focused CPR

10. Team Focused CPR

11. Team Focused CPR
Compressor #1 and #2
• One on each side of chest
– May be new to most but can really help
– One starts compressions, the other applies
AED/Defibrilator
– Seamlessly alternate (every one minute mid-cycle
or every 2 minutes) to avoid fatigue
– ‘Hover’ hands during interruptions
– Pre-charge manual defib before analysis
– Assist with mask seal/ventilation when not
compressing

12. Team Focused CPR
Airway and Vascular
• Airway (at patient’s head)
– Inserts OPA, applies NRB
– 2 handed BVM mask seal – off-cycle compressor
or airway assistant squeezes bag
– Inserts advanced airway after 8 minutes
– May have 2nd “airway assistant”
• Vascular/Meds
– Just like the name implies
– Stays out of the ‘CPR triangle’

13. Team Focused CPR
Team Leader
• Most of us use this already but
– Clear job responsibilities help to maintain consistency
and high performance in the resuscitation
• Job assignment:
– Coaches CPR metrics
– Calls for compressor change every minute
– Calls for rhythm analysis every 2 minutes and
immediate shock if indicated
– Monitor CPR quality (depth, rate, interruption) and
use of metronome (100-120 bpm)
– May have to do other tasks (e.g. Airway or Vascular)

14. Team Focused CPR
Code Commander
• Ideally highest level provider
– May have to do double duty as team leader
• Coordinates patient treatment decisions
– Can interface with OLMC without disruption to
resuscitation
• Communicates with family/loved ones
– Essential, especially if termination will be
considered
• Completes CPR Checklist (new to most)

15. CPR Checklist Example
 Code Commander and pit crew roles defined
 Chest compression interruptions minimized
 Compressors rotated minimum every 2 minutes
 Metronome set between 100-120 bpm
 AED/Defib applied
 O2 flowing and attached to NRB/BVM
 EtCO2 waveform present
 IV/IO access established
 Possible causes considered
 Gastric insufflation limited and gastric decompression
considered
 Family present and ongoing communication provided

16. Pit Crew CPR
• https://youtu.be/RNiNKluuIqE?t=25s

17. Mechanical CPR
• 2015 AHA Evidence review:
– 2 large RCTs compared the use of LUCAS against
manual compressions for patients with OHCA
– Together enrolled 7060 patients
– Neither demonstrated a benefit for mechanical CPR
over manual CPR with respect to early (4-hour) and
late (1- and 6-month) survival
– The PARAMEDIC study demonstrated a negative
association between mechanical chest compressions
and survival with good neurologic outcome (Cerebral
Performance Category 1–2) at 3 months as compared
with manual compressions

18. Mechanical CPR
• 2015 AHA Recommendation:
– “The evidence does not demonstrate a benefit with the use of
mechanical piston devices for chest compressions versus manual
chest compressions in patients with cardiac arrest.”
– “Mechanical piston devices may be considered in specific
settings where the delivery of high-quality manual compressions
may be challenging or dangerous provided that rescuers strictly
limit interruptions in CPR during deployment and removal of the
devices.” Ex:
• Limited rescuers available
• Prolonged CPR
• During hypothermic cardiac arrest
• In a moving ambulance
• In the angiography suite
• During preparation for extracorporeal CPR [ECPR]),

19. Mechanical CPR
• Hartford Hospital Expectations if using
mechanical CPR:
– Apply only after first 8 minutes manual CPR
– At least yearly training and competency evaluation
– MUST be able to reliably apply with less than 5
second (at most 10 second) interruptions in CPR
• Time this in training; Team leader watch for this in real
life
– Discontinue and revert to manual CPR if device or
application problems occur

20. Questions?