Advances in Resuscitation - CCR, if you're not doing it now, you will be

Allow me to introduce myself. My name is Chris Kaiser, or Ckemtp, and I write the EMS blog http://www.lifeunderthelights.com/ - I am a Nationally Registered Paramedic holding licensure in Illinois, Iowa, and also in Wisconsin. A few months ago I was asked to become a contributor to write for this blog and I jumped at the chance to intermingle my stuff with the venerable names here. Unfortunately, it has taken me a while to get something up here with the work needed to move from my old site to the new site. Today I'm fixing that and I would like to repost this article here with a few updates. I hope you find it educational.

Visitors to my blog probably know that at my ambulance service we tend to bring back a lot of codes. I talk about it a lot. Back in 2004 our medical director, Dr. Michael Kellum, got us involved in a “Demonstration Project” to bring Continuous Compression CPR or Cardiocerebral resuscitation to a rural area. Since that time, the results have been more than dramatic. Depending on what statistics you look at, we may be “Saving” almost 50% of witnessed arrests found to be in ventricular fibrillation.

It’s all explained at http://www.callandpump.org/, but if you want to go right to the whitepaper that explains what we do, why we do it, and how it’s done then you want to go here: http://callandpump.org/assets/Proposal_Current.pdf – This link is explains the demonstration project initiated by Dr. Kellum et al. in the two county area that I work in. This paper was published in 2004 at the beginning of the project.

This is a link to the results published in the Annals of Emergenc Medicine in 2008 – http://www.ncbi.nlm.nih.gov/pubmed/18374452?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

You may be interested in this part:

“RESULTS: In the 3 years preceding the change in protocol, there were 92 witnessed arrests with an initially shockable rhythm. Eighteen patients survived (20%) and 14 (15%) were neurologically intact. During the 3 years after implementation of the new protocol, there were 89 such patients. Forty-two (47%) survived and 35 (39%) were neurologically intact. CONCLUSION: In adult patients with a witnessed cardiac arrest and an initially shockable rhythm, implementation of an out-of-hospital treatment protocol based on the principles of cardiocerebral resuscitation was associated with a dramatic improvement in neurologically intact survival.”

This is good stuff. Remember, the above is only reflective of those included in the study, who are “Witnessed arrest(s) with an initially shockable rhythm”. Anecdotally, I’ve personally attended those that were not in a shockable rhythm and witnessed greater effectiveness as well.

Here’s the short version of our protocols for Witnessed V-Fib Arrest: (and for those of you who want more, email me at: proems1@yahoo.com and I will be happy to send you a copy of the protocols)

We follow an acronym called MCMAID in our resuscitation protocols, it stands for:

Metronome – We carry a metronome in our monitor/defibrillator bags that clicks out at 100 beats per minute. We are to compress at 100bpm. No more, no less. This metronome keeps us on rhythm and reminds us to be on the chest.

Compressions – 100 compressions per minute. Do not stop. Initially, we are to administer 200 compressions (2 minutes) before our first shock. We are to limit any interruptions in compressions absolutely as much as possible, charging our defibrillators while compressions are ongoing and recognizing V-fib through the compressions if possible. Compress hard and deep, completely releasing tension on the chest upon recoil to maximize the compression and decompression of the chest.

Monitor – Place the monitor on the patient using fast patches. Do not stop the 200 compression cycles to determine the rhythm. Shock at max joules biphasic. If you can anticipate V-Fib, charge the defib during the compressions and only stop long enough to clear for the shock. Don’t check the pulse, get right back to compressions.

Airway – Initially, a BLS airway will be placed in the patient and a non-rebreather oxygen mask will be placed on the patient. If the airway must be controlled by more advanced means to protect and ensure a patent airway, now is the time to do so.

Intravenous Access – Most of the time, this is accomplished through the means of the Ez-IO drill that we carry and love. (See: Alternative Circulatory Access Strategies – Hi Ho IO) This can also be obtained through peripheral or EJ IV access.

Drugs – Epinephrine 1:10,000 1mg IVasopression 40 IU, Amiodarone 300mg, then Epinephrine 1:10,000 1mg q 3-5min. If refractory, we may give an additional 150mg Amiodarone IV.

To see the full MCMAID CCR protocol (I put it up in a post) you can see it by clicking here.

Dr. Kellum came down again for our monthly training recently and let us know the latest breakthroughs and orders in the project. He is stressing the importance of End-Tidal CO2 (ETCO2) monitoring and states that no pulse check is necessary without a spontaneous increase in ETCO2. He expects every intubated (or combitubed) patient to have ETCO2 monitoring in place.

He also expects that we will monitor ETCO2 readings as a way to prove effectiveness of compressions. Rescuers who cannot get ETCO2 readings consistent with other personnel when providing compressions shouldn’t be doing compressions.

Rescuers should switch off compressions EVERY ONE MINUTE whenever possible. This is providing some fantastic results in preliminary trials.

He also stated that the effectiveness of the CCR protocols are showing a marked increase in refractory V-fib. He hinted that the protocols might soon show a need for thrombolytic use in treatment of refractory V-Fib.

Stay tuned folks, I am happy as heck to be included in this. I will bring updates, with permission, as many times as I get them. You can find more information on this on http://www.lifeunderthelights.com/. It's truly exciting stuff.