Cardiocerebral resuscitation (CCR) provides a better outcome than cardiopulmonary resuscitation (CPR) with fewer interruptions in chest compressions and delayed ventilation. CCR focuses on continuous chest compressions, early defibrillation, and limiting pauses. Studies show higher rates of survival to hospital discharge and neurological intact survival with CCR compared to CPR. The key elements of CCR are minimizing interruptions in chest compressions through avoiding pulse checks and shorter analysis periods.

1. From CPR to CCR-
why the change ?
Dr. Imran Ahmed
DM. (Cardiology)
Kolkata, India

4. Major Determinants of Survival
From Cardiac Arrest
Early / Effective CPR
Early Defibrillation

5. Three-Phase Model of
Resuscitation
0 2 4 6 8 10 12 14 16 18 20
Arrest Time (min)
Circulatory
Phase
Electrical
Phase
Metabolic
Phase
0
100%
Myocardial ATP
Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8

7. Outcomes of Rapid Defibrillation by Security
Officers after Cardiac Arrest in Casinos
Survival rate 74 % in patients who
received first shock within 3 minutes
Survival rate 49 % in patients who
received first shock after 3 minutes
Intervals of no more than 3 minutes from
collapse to defibrillation are necessary to
achieve the highest survival rates
Valenzuela et al NEJM 2000; 343: 1206

8. How Compressions move blood

10. 5 sec
80
160
mmHg
Time (sec)
40
120
0
Standard CPR: 30:2
Interruption of chest compression/relaxation directly effects the level of CPP

11. From CPR to CCR-
why the change ?
Simultaneous aortic (red) and right atrial (blue) pressure tracings are
shown. With the initiation of chest compressions, it takes some time for
the coronary perfusion pressures (aortic diastolic minus the right atrial
diastolic pressure) to increase. The chest compression rate is 100/min.
Standard CPR: 30:2
Ewy GA, Circulation 2005;111:2131-2142

13. Pausing Chest Compressions (CC)
to Shock Impacts survival
(Yu - Circulation 106:368; 2002)
Increasing the pause
Reduces success rate
Of resuscitation
–Edelson(2005) 87% - 9.7 sec
– 20% - 22.5 sec
•More deaths
•Longer time to Return of Spontaneous Circulation
(ROSC)

15. Drawbacks of mouth to mouth ventilations
• Bystanders not willing to perform mouth to mouth
• Long interruptions of chest compression
• Intrathoracic pressure is increased
• Can lead to gastric regurgitations
• Not necessary in those who are gasping initially –
CC suffices
Virkunnen I. J Int Med. 2010, 260:39-42

16. Summary of 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

17. Survival in Tucson AZ
with Cardiocerebral Resuscitation(2.8x)
HospitalDischargeSurvival
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

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

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

20. 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

21. 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

22. CCR is REALLY SIMPLE stuff !
Continuous Chest Compressions
Quality Chest Compressions
Uninterrupted Chest Compressions
 Quality is crucial – MUST be monitored by the other
pumper
 Rate (use metronome) of 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

24. 2005 AHA Guidelines
“For adult OHCA that is not
witnessed, rescuers may give a
period of CPR before checking
the rhythm and attempting
defibrillation” (Class IIb)

25. CCR vs. ACLS
FUNDAMENTAL DIFFERENCES
For Adult Non-Traumatic Cardiac Arrest
Order in which interventions are performed
Specified Continuous Cardiac Compressions
Faster more forceful compressions
Compressions Before and After Defibrillation
Early IV Epinephrine
Delay intubation for first 3 rounds
Airway: Face Mask 02
No Atropine for first 3 rounds

26. EPINEPHRINE
Attempt to administer early IV epinephrine
Intraosseous administration fastest
Tobias JD, Ross AK (2010). "Intraosseous
infusion". ANALGESIA 110 (2): 391–401

27. Fundamentals
Think 3 cycles: each = 200 CC + analysis ±
shock
Compressions started immediately upon arrival
All victims are initially presumed shockable
Therefore all get the same Rx during first 2
minutes (McMAID)
All get 200 Chest Compressions (CC) before
analysis
First rhythm (after 200 CC) is either shockable or
not
Resume Chest Compressions (CC) Immediately
after analysis ± shock – DO NOT pay attention to

28. Cardiocerebral Resuscitation (CCR)
200 chest
compressions
200 chest
compressions
Single shock
without pulse
Check or rhythm
analysis
BVM or Passive
Insufflation 15L 02
Begin IV
Analysis
200 chest
compressions
Single shock if
Indicated without
pulse check or
rhythm analysis
Analysis
Single shock if
Indicated without
pulse check or
rhythm analysis
Resume Standard ACLS
Consider Endotracheal
Intubation
200 chest
compressions
CCC
Only•
EMS
arrival
Administer 1 mg
IV Epinephrine
Analysis
• If adequate bystander chest compressions are
provided, EMS providers perform immediate
rhythm analysis

29. Protocol
Oral Pharyngeal (OP) airway
Non-rebreather face mask @15 L/min
200 compressions
IV access
Epinephrine 1mg IVP
One shock, 3-5 seconds, no pulse
checks.

30. Begin second round of 200
compressions
Amiodarone 300mg IVP (anti-
arrhythmic)
Shock x1 at max joules
No pulse checks, not off chest more
than 5 seconds.
Protocol

31. Begin third round of 200 compressions
Epinephrine 1mg IVP
Shock x1
Rapid Sequence Intubation (RSI).
Ventilate at 6 breaths/minute (BPM)
Insert ET tube during the fourth round of
200 chest compressions after the 3rd
round shock
Protocol

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

33. 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

34. 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

35. 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

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

37. 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

38. 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

39. Even seconds without
Chest Compressions
are deadly

40. First 2 minutes
How to analyze ± Shock
Practice this – – –
ONLY the Code Commander looks at the rhythm.
Be sure to switch Pumpers after shock
Epi

41. 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

42. 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.

43. 9.2
28.1
3.6
10.9
Results
Survival from Out of Hospital Cardiac ArrestSurvivaltoHospitalDischarge(%)
30
25
20
15
10
5
0
All cardiac arrests Witnessed with VF
(55/598)
(61/1686)
(36/128)
(38/348)
CCR
ALS

44. Witnessed VF Survival
Passive Oxygen Insufflation vs.
BVM Ventilation
(17/35)
48%
(12/60)
20%
50%
40%
30%
20%
10%
0%
Survival
BVM
Ventilation
Passive
Oxygen Insufflation

45. 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

46. Our Goal Should be what is seen in animals
(60-70+ survival)
24-HourGoodNeuroSurvival
100
80
60
40
20
0
80%
13%
Standard CPR CCC CPR
Kern, Hilwig, Berg, Sanders, Ewy. Circulation 2002

50. Adult Basic Life Support
• Minimize the frequency
and duration of
interruptions in
compressions (Class IIa).
• Once chest compressions
have been started, a
trained rescuer should
deliver rescue breaths by
mouth-to-mouth or bag-
mask to provide
oxygenation and
ventilation.

51. Adult Basic Life Support
• Rescuer fatigue may lead to inadequate
compression rates or depth.
• When 2 or more rescuers are available it is
reasonable to switch chest compressors
approximately every 2 minutes (or after about 5
cycles of compressions and ventilations at a
ratio of 30:2) to prevent decreases in the
quality of compressions (Class IIa).
• Every effort should be made to accomplish this
switch in 5 seconds.

52. Adult Basic Life Support
• As long as the patient does not have an
advanced airway in place, the rescuers
should deliver cycles of 30 compressions
and 2 breaths during CPR.
• The rescuer delivers ventilations during
pauses in compressions and delivers each
breath over 1 second (Class IIa).
• The healthcare provider should use
supplementary oxygen (O2 concentration
40%, at a minimum flow rate of 10 to 12
L/min) when available.

53. Adult Basic Life Support
• Excessive ventilation is
unnecessary and can cause gastric
inflation and its resultant
complications, such as
regurgitation and aspiration (Class
III).
• Rescuers should avoid excessive
ventilation (too many breaths or
too large a volume) during CPR
(Class III).

54. Adult Basic Life Support
Cricoid Pressure
• Cricoid pressure might be used in a
few special circumstances (eg, to
aid in viewing the vocal cords
during tracheal intubation).
• Routine use of cricoid pressure in
adult cardiac arrest is not
recommended (Class III).

55. Example of cardiopulmonary resuscitation prearrival instructions for an adult who has
suddenly collapsed.
Lerner E B et al. Circulation 2012;125:648-655
Copyright © American Heart Association

60. Therapeutic Hypothermia

61. No More Mouth to Mouth Breathing!

62. Conclusions
• CCR provides uninterrupted perfusion to
heart and brain essential for neurologically
intact survival
• CCR has led to dramatic improvements in
survival vs CPR
• More aggressive post resuscitation care with
hypothermia / emergent cath-PCI is required
to save even more victims of cardiac arrest