CARDIOCEREBRAL RESUSCITATION

     Ewy GA, Kern KB. Recent advances in cardiopulmonary resuscitation: Cardiocerebral resuscitation. J Am Coll Cardiol 53(2):149–57, Jan 13, 2009.

     Cardiocerebral resuscitation (CCR) is a new approach for resuscitation of patients with cardiac arrest. It is composed of three components: 1) continuous chest compressions for bystander resuscitation; 2) a new emergency medical services algorithm; and 3) aggressive post-resuscitation care. The CCR method has been shown to dramatically improve survival in the subset of patients most likely to survive cardiac arrest: those with witnessed arrests and shockable rhythms on arrival of EMS.

     The CCR method advocates continuous chest compressions without mouth-to-mouth ventilations for witnessed cardiac arrest. It advocates either prompt or delayed defibrillation, based on the three-phase time-sensitive model of ventricular fibrillation (VF) articulated by Drs. Myron Weisfeldt and Lance Becker. For bystanders with access to AEDs and EMS personnel who arrive during the electrical phase (i.e., the first 4–5 mins. of VF arrest), the delivery of a prompt defibrillator shock is recommended. However, EMS personnel most often arrive after the electrical phase—in the circulatory phase of VF arrest. During the circulatory phase of VF arrest, the fibrillating myocardium has used up much of its energy stores, and chest compressions that perfuse the heart are mandatory prior to and immediately after a defibrillator shock. Endotracheal intubation is delayed, excessive ventilations are avoided, and early-administration epinephrine is advocated.

COMMENT

     CCR has been one of the exciting advances in the treatment of cardiac arrest. It was only a few years ago, before the AHA 2005 guidelines, when the emphasis was on establishing an advanced airway, continuous ventilation, giving medications (often down the ET tube) and multiple "stacked" shocks with careful rhythm interpretations between—all with long pauses in already-poorly performed chest compressions. All of that has changed, and outcomes have improved as a result.