Cardiocerebral Resuscitation: Hands-Only CPR

21 Jan
January 21, 2016

Cardiocerebral ResuscitationOne of the major reasons contributing to dismal survival rates in out-of-hospital cardiac arrest (OHCA) is the lack of bystander initiated cardiopulmonary resuscitation (CPR). Even though the majority of OHCA is witnessed, only 1 in 5 patients will receive bystander initiated CPR [1].  Survey studies have shown that bystanders are not wanting to do mouth-to-mouth resuscitation on strangers. Outside of early defibrillation, only early bystander initiated CPR has consistently been shown to improve neurologically intact survival in OHCA. So what about  Cardiocerebral Resuscitation, also known as “Hands-Only” CPR?

What is Cardiocerebral Resuscitation (CCR)?

  • First implemented in Arizona in 2003
  • Step 1: No Ventilation/Delayed Intubation
  • Step 2: Continuous CPR

Is there Evidence to Support Improved Neurologically Intact Survival with CCR?

Animal Studies

  • Kern et al 2002 [2]
  • Sanders AB et al 2002[3]
  • Wang S et al 2010[4]
  • Mader TJ et al 2010[5]

Summary of Animal Trials: CCR vs Standard CPR had better Coronary Perfusion Pressure, PaO2, ROSC, 24hr Survival, 24hr Survival with Good Neurologic Outcomes

Non-Lay Rescuer Human Studies

Kellum MJ et al 2008[6]:

  • Before and After Study in 2 Counties in Wisconsin
  • 3 years of Standard ABC CPR followed by 3 years of CCR CPR in the prehospital setting
  • Caveats:
    • Before and after observational study which is subject to a variety of confounding influences could affect the validity of the study
    • The quality of CPR and CCR were not assessed in this study
    • Obviously blinding of EMS personnel was not possible
  • Significantly improved survival and neurologically intact survivors in the CCR CPR group

Human CCR

Lay Rescuer Human Studies:

  • Svesson L et al 2010 [7]: No difference in 30d survival
  • ReaTD et al 2010 [8]: No difference in overall survival
  • Iwami T et al 2007 [9]: No difference in neurologically favorable survival at 1 year for CPR ≤15min
  • Kitamura T et al 2011 [11]: Conventional CPR with rescue breathing provided incremental benefit in survival with favorable neurologic outcome compared with compression-only CPR in CPR >15min
  • Ong ME et al 2008 [12]: Patients more likely to survive with any form of bystander CPR than without
  • SOS-KANTO 2007 [13]: Compression only CPR was associated with a higher proportion of adult patients with witnessed OHCA having favorable neurological outcomes than conventional CPR
  • Bobrow BJ et al 2010 [14]: Among patients with OHCA layperson compression-only CPR was associated with increased survival compared with conventional CPR
  • Olasveengen TM et al 2008 [15]: Patients receiving compression-only CPR from bystanders did not have a worse outcome than patients receiving standard CPR

Summary of Human Lay Rescuer Trials: Multiple studies show no difference in survival when adult victims of OHCA receive compression-only CPR versus conventional CPR

What Does Neurologically Intact Survival Mean?

Lets start with the Cerebral Performance Category (CPC) Scoring System:

  • CPC 1: Full Recovery or Mild Disability
  • CPC 2: Moderate Disability but Independent in Activities of Daily Living
  • CPC 3: Severe Disability; Dependent in Activities of Daily Living
  • CPC 4: Persistent Vegetative State
  • CPC 5: Dead

It is important to state that when we are talking about neurologically intact survival we are talking about a CPC Score of 2 or better.  A CPC Score of 2 means moderate disability but can perform activities of daily living.  Another way of saying this is: “So you may walk with a bit of limp, but you can feed yourself, bathe yourself, and wipe our own ass!!!”

Screen Shot 2016-01-17 at 7.44.03 PM

What Does the American Heart Association Say about CCR?

The 2015 AHA/ACC Guidelines now state:

“Untrained lay rescuers should provide compression-only (Hands-Only) CPR, with or without dispatcher guidance, for adult victims of cardiac arrest.  The rescuer should continue compression-only CPR until arrival of an AED or rescuers with additional training.  All lay rescuers should, at a minimum, provide chest compressions for victims of cardiac arrest.  In addition, if the trained lay rescuer is able to perform rescue breaths, he or she should add rescue breaths in a ratio of 30 compressions to 2 breaths.  The rescuer should continue CPR until an AED arrives and is ready for use, EMS providers take over care of the victim, or the victims starts to move.”

So Whats the Bottom Line About CCR?

Conventional CPR with Ventilations should still be the gold standard for medically trained personnel in patients with OHCA, but there seems to be no difference in neurologic outcomes with CCR vs conventional CPR in the lay rescuers.

One Last Thing:

I want to give a shout out to the Texas College of Emergency Physicians Medical Student Committee (TCEP MSC) for setting up a statewide community service run event called the Texas Two Step: How to Save a Life Campaign.

www.texacep.org

  • What it is: Students from all 9 Texas Medical Schools are Organizing a Compression-Only (AHA Curriculum) Mass CPR Training Event Across Multiple Locations throughout 10 Texas Cities
  • When: February 6th, 2016 (National Heart Month)
  • Where: The training locations will be in multiple sites in Austin, College Station, Dallas, El Paso, Fort Worth, Galveston, Houston, Lubbock, and San Antonio
  • Event Page: TCEP Event Page
  • Goal/Mission Statement: The Texas Two Step Campaign will increase public awareness of hands-only CPR and provide skills training to community participants, instructing how to act quickly in the event of cardiac emergencies following two easy steps: 1) Call 911 and 2) Initiate hands-only CPR. They will stress the importance and benefit of performing hands-only CPR (vs. no CPR) until emergency first responders arrive to take over.  They are also working to address and improve the disparity in minority populations understanding of and willingness to perform CPR.  With the primary goal to save lives through community education and skills training, the medical student organizers are working hard to create a successful event that can be replicated on a national level.
  • Involved Parties:
    • Sponsors: TCEP, Health Corps, MaveRx
    • State/National Partners: ACEP, TMA
    • Support Provided By: AHA, Red Cross
    • There will also be local/community sponsors that vary in each city

References:

  1. Ewy AG. Cardiocerebral Resuscitation: The New Cardiopulmonary Resuscitation. Circulation 2005; 111:2134 – 2142. PMID: 15851620
  2. Kern KB et al. Importance of Continuous Chest compressions During Cardiopulmonary Resuscitation: Improved Outcome During a Simulated Single Lay-Rescuer Scenario. Circulation 2002; 105: 645 – 649. PMID: 11827933
  3. Sanders AB et al. Survival and Neurologic Outcome After Cardiopulmonary Resuscitation With Four Different chest Compression-Ventilation Ratios. Ann Emerg Med 2002; 40: 553 – 562. PMID: 12447330
  4. Wang S et al. Effect of Continuous compressions and 30:2 Cardiopulmonary Resuscitation on Global Ventilation/Perfusion Values During Resuscitation in a Porcine Model. Crit Care Med 2010; 38 (10): 2024 – 2030. PMID: 20683258
  5. Mader TJ et al. A Randomized Comparison of Cardiocerebral and Cardiopulmonary Resuscitation Using a Swine Model of Prolonged Ventricular Fibrillation. Resuscitation 2010; 81: 596 – 602. PMID: 20176434
  6. Kellum MJ et al. Cardiocerebral Resuscitation Improves Neurologically Intact Survival of Patients With Out-of-Hospital Cardiac Arrest. Ann Emerg Med 2008; 52 (3): 244 – 252. PMID: 18374452
  7. Svensson L et al. Compression-Only CPR or Standard CPR in Out-Of-Hospital Cardiac Arrest. NEJM 2010 363 (5): 434 – 42. PMID: 20818864
  8. Rea TD et al. CPR with Chest Compression Alone or With Rescue Breathing. NEJM 2010; 363 (5): 423 – 33. PMID: 20818863
  9. Iwami T et al. Effectiveness of Bystander-initiated Cardiac-Only resuscitation for Patients with Out-Of-Hospital Cardiac Arrest. Circulation 2007; 116 (25) 2900 – 7. PMID: 18071072
  10. Kitamura T et al. Bystander-Initiated Rescue Breathing for Out-Of-Hospital Cardiac Arrest of Non-Cardiac Origin. Circulation 2010; 122 (3): 293 – 9. PMID: 20606122
  11. Time-Dependent Effectiveness of Chest Compression-Only and conventional Cardiopulmonary Resuscitation for Out-Of-Hospital Cardiac Arrest of Cardiac Origin. Resuscitation 2011; 82 (1): 3 – 9. PMID: 21093974
  12. Ong ME et al. Comparison of Chest Compression Only and Standard Cardiopulmonary Resuscitation for Out-Of-Hospital Cardiac Arrest in Singapore. Resuscitation 2008; 78 (2): 119 – 26. PMID: 18502559
  13. SOS-KANTO Study Group. Cardiopulmonary Resuscitation by Bystanders with Chest Compression Only (SOS-KANTO): An Observational Study. Lancet 2007; 369 (9565): 920 – 6. PMID: 17368153
  14. Bobrow BJ et al. Chest Compression-only CPR by Lay Rescuers and Survival from Out-Of-Hospital Cardiac Arrest. JAMA 2010 304 (13): 1447 – 54. PMID: 20924010
  15. Olasveengen TM et al. Standard Basic Life Support vs. Continuous Chest Compressions Only in Out-Of-Hospital Cardiac Arrest. Act Anaesthesiol Scand 2008; 52 (7): 914 – 9. PMID: 18702753
  16. Panchal AR et al. Chest Compression-Only Cardiopulmonary Resuscitation Performed by Rescuers for Adult Out-Of-Hospital Cardiac Arrest Due to Non-Cardiac Etiologies. Resuscitation 2013; 84 (4): 435 – 9. PMID: 22947261

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

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Salim Rezaie

Clinical Associate Professor of EM and IM at University of Texas Health Science Center at San Antonio (UTHSCSA)
Creator & Founder of R.E.B.E.L. EM
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2 replies
  1. Rogue Medic says:

    Conventional CPR with Ventilations should still be the gold standard for medically trained personnel in patients with OHCA, but there seems to be no difference in neurologic outcomes with CCR vs conventional CPR in the lay rescuers.

    Why add an intervention (ventilations) for no benefit?

    You provide evidence that EMS had better outcomes when they did not add ventilations, so why add an intervention (ventilations) that appears to cause harm?

    In the absence of evidence of benefit or safety, the only ethical approach is to limit ventilations to children and those with respiratory causes of cardiac arrest.

    .

    Reply
    • Salim Rezaie says:

      Hey there,
      Be very careful how you interpret the results of the CCR in EMS study….first of all this is a single study….still waiting to see that this is externally validated….Also this is a before and after observational study which is subject to a variety of confounding influences that affect the validity of this one study. Probably, the most important caveat is that the quality of CPR in both groups were not assessed in this non-blinded study which adds a huge component of bias.

      Salim

      Reply

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