C ontinuous C hest C ompressions Trial

Final version 1, 03-30-2011RESUSCITATION OUTCOMES CONSORTIUM

Continuous Chest Compressions Trial

Final version 1, 03-30-2011


• Describe the rationale for continuous chest compressions (CCC) & 30:2, as they integrate with the upcoming trial.

• Demonstrate the ROC CCC/30:2 protocol including: CAB assessment Efficient application of the AED/defibrillator at the same time chest

compressions started Integrated responder approach and provision of care Maintenance of compressions including depth, release & rate Ventilation timing and volume

Training ObjectivesAfter this program you will be able to:


• Traditional CPR—30 chest compressions: 2 ventilations

• Pauses in CPR chest compressions are associated with a decrease in coronary and cerebral perfusion pressure.

• Many EMS agencies using CCC—an alternative style of CPR. Unclear whether survival is higher with CCC or 30:2 CPR.

• There are no randomized trials. We do not know if CCC or 30:2 CPR is better. A randomized controlled trial is the only way to know which

approach is better.

Continuous Chest Compressions (CCC)


Purpose of the Study

To compare the effect of “CCC” CPR versus

“30:2” CPR on outcomes following out-of-

hospital cardiac arrest.


• “CCC” CPR Alternative style of CPR

Continuous chest compressions with no pauses

Ventilation: One BVM ventilation every 10 chest compressions (10:1), with no pause in compressions

• “30:2” CPR Usual style of CPR

Chest compressions with pauses for ventilation

Ventilation: Two BVM ventilations every 30 chest compressions (30:2), with pause in compressions

Interventions―Two Styles of Chest Compressions


Randomization• By agency groups, for fixed time period (e.g. CCC

x 6 months) → cross-over to opposite arm (30:2)

• Assigned CPR treatment arm (CCC or 30:2) will be the “standard of care” for all patients during study period except . . .

– Peds

– Obvious respiratory arrest

• Afterward, ROC will determine patient eligiblity/ineligibility for inclusion in study

– e.g. prisoners, pregnancy, oPt out, DNAR, EMS-witnessed arrest, trauma

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The CCC Protocol

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End of Study Protocol

Continue Standard

ACLS

30 CC’s asAED readied

BLS OnScene

BVM at 10:1

*200 continuous chest compressions (with 1 breath every 10 CC) given over 2 minutes

Advanced airway

If ALS on-scene IV/IO ASAP + epinephrine

Continue same CPR protocol

until placement of advanced

airway

200 continuouschest

compressions*

200 continuouschest

compressions*

200 continuouschest

compressions*

Approximately2 minutes



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The 30:2 Protocol

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Continue Standard

ACLS

BLS OnScene

BVM at 30:2 If ALS on-scene IV/IO ASAP + epinephrine

Advanced airway

30 CC’s asAED readied



airway




5 cycles at 30:2

5 cycles at 30:2

5 cycles at 30:2

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CCC versus 30:2

? ~ ? ~ ? ~200

continuous chest compressions

200continuous chest

compressions

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StandardACLS

5 cycles at 30:2

30:2 IV/IO Epinephrine/Vasopressin ASAP

CCC

30:2

Turn on AED/monitor,give 30 compressions

5 cycles at 30:2

200continuous chest

compressions

5 cycles at 30:2




AdvancedAirway

while AED is readiedIf ALS on-scene IV/IO ASAP + epinephrine



airway


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• If ALS is early on scene . . . insert IV/IO early Give epinephrine or vasopressin early

• CCC gets BVM at 10:1 One breath between every 10th chest compression Deliver each rescue breath over 1 sec to produce chest rise No break in chest compressions

• 30:2 gets standard AHA BVM ventilation 30 chest compressions—break for 2 ventilations Deliver each rescue breath over 1 sec to produce chest rise

Important Points!M

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Final version 1, 03-30-2011Final version 1, 03-30-2011

Choreographing the Perfect Arrest Management Pit Stop• Work as a team.

• Each team member has a pre-assigned responsibility. For example: CPR Manage airway/BVM Attach and operate monitor/defibrillator Insert IV/IO—give drugs

• Must rotate CPR compressor every2 minutes.

• Assign someone to time compression cycles and record events.

• Best to choreograph prior to arrival.


Questions & Answers

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• Assess CAB—confirmed arrest

• Check time, assign documentation, and turn on monitor/defibrillator

• Immediately start CPR (check and record time, or delegate timing)

• Apply defibrillation pads as soon as possible during CPR

• ASAP BVM at 10:1 or 30:2

• Coordinate 2-minute rotations, rhythm checks, and defibrillation (if shock indicated)

• If ALS on-scene early, start IV/IO during CPR

What should we do when we arrive on scene?

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• EMS agencies are randomized by cluster Assigned treatment arm Carry out for 3–6 months Switch Switch again

How do I know whether to do CCC or 30:2?


• Shock as required• If CPR required after shock, perform in accordance

with assigned treatment arm (CCC or 30:2)• Afterward, ROC will determine patient

eligiblity/ineligibility for inclusion in study

What if the patient arrested during my care?

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• What if another individual or agency arrives first and begins CPR?

INCLUDE and perform the protocol if:.» Law enforcement» Bystander» Other individuals or agencies that do not typically or regularly

respond to cardiac arrest incidents(e.g., lifeguards, military, security, etc.)

EXCLUDE and continue with standard ACLS (local protocol) if:» Non-ROC EMS provider agency

More BLS Questions


• The ROC AED or monitor/defibrillator should be applied and compressions begun as soon as possible.

What should I do with the AED?

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Should I count chest compressions or use a timing device?

Either approach is acceptable


• Yes - if using Medtronic/PhysioControl device

• No – if using Philips MRX device (it charges fully during analysis)

• Immediately resume compressions after shock delivered

• Charge/shock time does not count as part of CPR cycle.

Should I compress while the defibrillator is charging?

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• Continue assigned CPR protocol until advanced airway placed

• Consider other local options for advanced airway

What if I am having difficulty with advanced airway insertion?

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Final version 1, 03-30-2011Final version 1, 03-30-2011

Still VFGive ALPS #1A & #1B

Still VFGive ALPS #2

• CCC and ALPS may be run concurrently or separately

• ALPS drug is administered ASAP for persistent or recurrent VF/pulseless VT after ≥ 1 shock

OR

Integrating CCC and ALPS when ALS is first on-scene

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Continue Standard

ACLS

CPR Set#1*

EMS OnScene

CPR Set#3*

CPR Set#2*

Advanced airway

30 CC’s asDefib readied

*Each “CPR Set” consists of 200 continuous chest compressionsor 5 cycles at 30:2, over approximately 2 minutes



airway

IV/ IO Epinephrine/ Vasopressin ASAP

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• May start ALPS during or after CCC completed

CCC and ALPS

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• CCC gets BVM at 10:1 One breath between every 10th chest compression Deliver each rescue breath over 1 sec to produce chest rise No break in chest compressions

• 30:2 gets standard BVM ventilation 30 chest compressions—break/2 ventilations Deliver each rescue breath over 1 sec to produce chest rise

• CCC vs 30:2 protocol is complete after placement of advanced airway

Important Points!M

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• The CPR process file is the only way to verify that you did CCC or 30:2 CPR

• Call ROC hot-line

After the CallDocument

&Download

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Final Questions

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C ontinuous C hest C ompressions Trial

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