CCR the **New** PreHospital CPR

[CadetProgramGuy]

Taken from isuhawkeye's website:  www.halbrookassociates.com
The new PreHospital CPR.  What is your thoughts, concerns, ect?

Today the American Heart Association made a big announcement. Only a year after the highly anticipated roll out of the 2005 ECC guidelines the standards which were intended to be revolutionary, and long lasting have changed. In 2005 the Committees that dictate the standards of the American heart association changed the way that they do business. Rather than make decisions by consensus, the doctors, educators, and scientists decided that they would use science to make their decisions. This change paved the way for the 2005 guidelines. At the time research indicated that the historical 5:1, and 15:2 compression to ventilation ratio was not moving enough blood through the body. In fact one study indicted that it took nearly 30 compressions to build enough pressure in the vascular system to start to move blood through the body. This same study also showed that pausing to give ventilations eliminated all of that built up pressure.

With that study in mind several prominent researchers argued that the future of CPR did not include ventilations. One such scientist is Doctor Gordon Ewy. Dr. Ewy and the University of Arizona have created an alternative to CPR. This new program is entitled CCR (Cardio Cerebral Resuscitation). CCR though controversial has been highly successful. The Phoenix fire department has boasted a significant increase in cardiac arrest survival. This program has been so widely successful that Kansas City's MAST (EMS SERVICE) has implemented these protocols with several more major entities evaluating the continued success.

Today the American Heart Association announced a change to all levels of CPR instruction. The AHA has added the concept of "Hands only CPR". Check out the links, and videos.

This is certainly an exciting time for prehospital care.

Thanks to isuhawkeye for the original posting to his website.

[DC]

I was skeptical of this when the Red Cross started teaching it a few years ago. I know the body has a small reserve of oxygen, but after several minutes of this wouldn't you just be circulating unoxygenated blood, and not doing any good at all?

[JesusFreak]

I remember seeing this on Fox News yesterday and  I thought to myself,"This is weird. I never knew they changed it." When I went to my CAP meeting, I was thinking about telling those in GES about that. But I think it's strange how it's changed. But I think it's  good because we don't have to do mouth to mouth, for those who don't have CPR masks.

[♠SARKID♠]

CCR?  Somehow I don't think that listening to "Fortunate Son" is going to bring anybody back from the dead. 

I'm glad this has come along.  The American Heart Association has stated that CCR is as good as CPR.  Thats always been my dislike of CPR, the mouth to mouth part.  Theres just too great a chance for infection and frankly, I don't carry a CPR mask with me wherever I go.  What I think is best though is that it will be a lot easier.  CCR doesn't require you to make sure you have the nose plugged, properly tilted head, and tight seal on the mouth.  Its easier to perform and easier to learn which means that more people can have the ability to save a life.

Looks like we have a new topic for our next squadron safety briefing.

[DC]

But this will take all the fun out of resusitation! I won't have to pack around a set of OPAs and an AMBU bag everywhere now...  (jk).

And does anyone notice that CPR is getting harder? First it's 5 to1, then 15 to 2, then 30 to 2, now they want just straight compressions, sheesh! Pretty soon being triathlete will be a requirement to be an EMT!

Seriously though, anything that will improve patient care.

[FW]

Just remember, these new procedures are for "adults" only. For children and infants, it's still "CPR".  So, don't through away those masks yet.

[isuhawkeye]

thanks for all of the comments on my article. 

For those of you who are worried about he physical demands of CCR, and CPR check out the following

This thing is the wave of the future (depending on whose study you read)
http://www.zoll.com/product.aspx?id=84

[DC]

thanks for all of the comments on my article. 

For those of you who are worried about he physical demands of CCR, and CPR check out the following

This thing is the wave of the future (depending on whose study you read)
http://www.zoll.com/product.aspx?id=84I saw an article on those a while back. It might work for hospitals, maybe EMS, but I don't think anything will replace manal CPR or this new CCR in the first minutes of a cardiac arrest.

[mikeylikey]

So do I understand this correctly, CCR= heart attack, while CPR=drowning and asphyxiation??

[fyrfitrmedic]

thanks for all of the comments on my article. 

For those of you who are worried about he physical demands of CCR, and CPR check out the following

This thing is the wave of the future (depending on whose study you read)
http://www.zoll.com/product.aspx?id=84

Definitely depends on whose study you read... a couple of the studies being performed using AutoPulse in the field were terminated early because of "concerns".

Autopulse in some ways resembles a redesigned Thumper.

[Bear Walling]

I dunno about this whole compressions only technique. When I went through EMT class I remember that if a person isn't breathing, then thats the major problem.

I'll have to see the results in the field before I make any definate 'thats bad' or 'thats good' comments.

[SARMedTech]

Just for the sake of throwing another wrench into the works, CCR (or Continuous Compression Resusitation)  is intended (so says the AHA) for when you witness your patient collapse and go pulse-less and breathless. This is because the thinking is (even though I believe its a bunch of crap) that "most" people have around 4 minutes worth of oxygen in their blood when they crunk and circulating that without supplementary O2 (ie mouth to mouth or BVM). I disagree with this and think it is a over generalization which can be dangerous, but then we should all carefully follow what the AHA says since it cant seem to figure out what study it wants to follow.

My friend who is a newly minted EMT was just taught 30:2 for every victim whether adult or child, but there is also a new study that shows that there is now significant difference between 30:2, 15:2 and 5 :2 (or 3:1 for newborns) in terms of clinical effectiveness.  CCR in my opinion is garbage about the only thing it has going for it is the fact that MIGHT get people who dont want to put their mouths on someone elses to still do something to help that person. Of course moving some partially oxygenated blood is better than nothing, but again, this is intended for when you witness the collapse and the AHA has a bunch of "rule outs" for when this should not be used. And remember, the rate of compression with this method needs to be 100 compressions per minutes. That is significantly faster than most people are used to doing it when they think of CPR or practice it in a class. I know this is going to cause sniggering from the peanut gallery, but the mantra or CPR is "fast and deep." If you are not getting near that 100 compression mark every minute and not compressing the chest (in an adult patient) between 2 and 2 and 1/2 inches, your CPR is not being as effective as it needs to be.

Also, for those that are still afraid to put your mouth on a patient (which may have more validity now than it did with the AIDS scare due to the resurgence of TB due to travel to Eastern Europe and Southeast Asia and underserved populations in the US like Appalachia and Native Reserves) there is a nice gadget which is often called a "CPR Key" which can allow you to perform mouth to mouth (which is, in my opinion, the best bet especially since most people who are not clinicians are clumsy with BVMs or Ambu Bags) without the concern of coming into contact with aerasol-ized droplets of saliva. Basically, the little widget comes in a whole rainbow of designer colors for you discerning SAR folks and has a small, flattened tube which fits into the mouth of the downed person. It has a sort of flapper valve which when sealed around their mouth, prevents "back spray." Again, this is not the concern it was once believed to be with AIDS/HIV patients but with TB on the rise, may be a genuine concern that causes many people to make the choice not to go bare mouth to mouth. Im not really a fan of it either and so always carry a CPR mouth mask on my key chain. For those of you who are not clinicians (nurses, EMTs, etc) but who use ambu type devices (BVMs) you may be wasting your time. If you are not experienced with them and are not getting a good seal, have the head angle right,etc, you are often wasting your time and precious minutes for the victim.

And yes, my Masters thesis is on methods of emergency medical assistance which can be offered by lay bystanders in mass casualty situations and their effectiveness, etc. I switched from emergency management to a MPH with an emergency management emphasis.

[SARMedTech]

Also, I would emphasize that the AHA needs to get its ducks in a row. CCR, which they originally called CCC (continuous chest compressions) but changed the acronym to have a sound more familiar to the CPR crowd, is intended for use by lay bystanders and not by trained and licensed clinicians who have more effective "tools in their kit" as it were. Originally touted as "better than CPR" CCR is now being offered as a "better than nothing" alternative because it eliminates all of the ratio variables as well as having to go "mouth on" with a dying person. For those of you who dont like this thing (and I dont) don't worry. The AHA will change it again in about 3 months. I personally know a cardiologist who was a huge advocate of CCR or CCC when it was first developed and now believes it to be a largely worthless method of last resort when other skills are not known or when a person choses not to "commit" by doing mouth to mouth or doesnt have a CPR barrier mask of some sort. Im still a 15:2 fan myself. It causes less fatigue in someone who does not perform or practice CPR regularly and offers more chances to switch to compressions from doing breaths if you are working with a partner trying to save a victim. Right now I say the AHA is the "WORST PERSON IN THE WORLLLLDD!!!!" for confusing the hell out of the American people and consequently causing a lot of people who might otherwise help to do nothing because they are confused. Also, if any of you are EMTs and have seen how CPR is actually often done in the field, you might begin to wonder just how important those golden ratios are. Most of us who have ridden in ambulances have seen medics pumping a chest with one hand and doing some other intervention with the other and I've seen plenty of video of patients who were revived without perfectly rationed compressions and breaths. Also, CPR in itself is a bit of a misnomer since it leaves out the fact that you are not in fact really trying to resuscitate but rather to profuse and in that case you are trying to keep oxygen to the brain, which is what the AHA leaves out of most equations. "Yeah, lets save the heart, but screw the brain....even if they are a vegetable, we still saved their lives.!!!" If you're a clinician and have to take CPR, you probably have to take AHA...if not I recommend something like the National Safety Council. The AHA makes a lot of money of certifying and re-certifying all of these changing standards, especially to their instructors who pay to take the "train the trainer" course and then teach the courses for no pay.  No, Virginia, I am not a fan of the AHA, but they have successfully monopolized the field of CPR in as much as their is a great deal of profit to be made from it.

[isuhawkeye]

guys

please read the source material before you rant. 

the AHA does not call it CCR.  Dr.  Gordon Ewy, and his test sites in phoenix call it CCR.  in their full scale deployment (not study) over sever years, and thousands of cardiac arrests have DOUBLED their survival to discharde numbers. 

again.  please reference the cite material most notibly the position paper published in the lancet

[isuhawkeye]

mechanical CPR devices

the zoll auto pulse has had 2 studies conducted.  the first was very favorabe while the second showed a significant increase in mortality.  as we look at those studies we must consider that both were payed for by the manufacturer, and that the sample size was very small.  I believe only 100 patients in one of the study.

secondly the auto pulse is not much like the michigan thumper.  the zoll is a battery powered constricting band design. 

the lucass device on the other hand is an air driven piston device very similar to the thumper.  this device has received some very positive reviews in norwegian studies.

hope that helps

sorry for the errors on this message.  I'm on my cell phone

[flyerthom]

thanks for all of the comments on my article. 

For those of you who are worried about he physical demands of CCR, and CPR check out the following

This thing is the wave of the future (depending on whose study you read)
http://www.zoll.com/product.aspx?id=84

Remember the thumper? I've seen this geezer squeezer used. Seems to do well.

[sardak]

First off, the American Heart Association calls it "Hands Only CPR" -  to show there are no breaths or mechanical adjuncts.

It's ONLY to be used on "adults who experience out-of-hospital sudden cardiac arrest."

Here is the link to the AHA journal article explaining the rationale for this method:
http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.189380

Links to Hands-Only CPR are here:
http://handsonlycpr.eisenberginc.com/faqs.html

http://handsonlycpr.eisenberginc.com/resources.html

Mike

[Hoser]

What the AHA calls it is of no importance. What does matter is that it works. Prior to my retirement, my Fire Dept, which served a suburb of Kansas City, MO allowed me to work with MAST for 25 years.  I have seen first hand that the new CCR does in fact work. MAST's save rate is up nearly exponentially since they wrote the new standards into their protocols. It's not like this procedure is some sort of state secret. The media got a hold of it and in typical media fashion they puffed up like toads and made alot of noise about it. That's all.
If EMS or other health care professionals can't adapt to changing standards they don't belong in the field. My guess is that in a few years something new will turn up and the standards will change again. Remember Bretyllium?

[fyrfitrmedic]

thanks for all of the comments on my article. 

For those of you who are worried about he physical demands of CCR, and CPR check out the following

This thing is the wave of the future (depending on whose study you read)
http://www.zoll.com/product.aspx?id=84

Remember the thumper? I've seen this geezer squeezer used. Seems to do well.

I've used the geezer squeezer in the field; when i worked rural EMS years ago it came in handy.

As for the Autopulse, I played with one at FDIC East a few years back but haven't used one in the field.

[SARMedTech]

But this will take all the fun out of resusitation! I won't have to pack around a set of OPAs and an AMBU bag everywhere now...  (jk).

And does anyone notice that CPR is getting harder? First it's 5 to1, then 15 to 2, then 30 to 2, now they want just straight compressions, sheesh! Pretty soon being triathlete will be a requirement to be an EMT!

Seriously though, anything that will improve patient care.

Actually, its the compression rate, not the compression to breath ratio, that becomes tiring. Whether you are doing compressions in groups of 15 or 30, if they are done properly at a rate of 100 per minute, your going to get pretty tired if you do this for 20 or 25 minutes. The fact is, that most lay performers of CPR are doing little besides wearing themselves out. Of course there are exceptions, but by and large, someone who hasnt been taught that compressions really need to be deep to be effective or  gets squeamish at the sound or the way an effective compression looks, is just flailing a patient without any real effect. One study which I believe was performed by the University of New Mexico shows that most lay CPR rescuers get 1 or 2 effective compressions out of every 20. Im all for people trying because if they dont the person has no chance, but we really need to settle on one standard and stick to it.

This also emphasizes my point that most "field necessary" CPR is nowhere near as organized as it is taught. The rescuer(s) lose track of compressions, forget to check pulse and breathing, begin to tire out and their breaths and especially compressions become less and less effective. Also, while compressions become easier after the initial "crunch" of sternal/costal cartilage, they also become less effective which is one of the reasons for the rate of 100 compressions per minute.

We should also remember that CPR without the use of AED has an effective "revival" rate of less than 7%. So if you dont have an AED, remember that you really are try to profuse, not revive.


Remember the chain of survival:

early activation of 911, early CPR, early shocks, early transport to definitive care.