Advances in Resuscitation – CCR If you’re not doing it now, you will be

Visitors to my old 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 protocol (I put it up in a post) you can see it by clicking here.

Today Dr. Kellum came down again for our monthly training 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.

  • Pingback: MCMAID Resuscitation Protocol – Life Under the Lights

  • http://www.999medic.com Medic999

    You know what?
    Its so frustrating being a paramedic in the UK, who has done so much reading about CCR. I first heard about it about 5-6 months ago and have been telling everyone who I can about it and the reported amazing benefits that this technique is getting, but I cant do anything about it until the European Resus Council implements the changes (which I know will come, but its just a matter of when!).
    All I can do at the moment is ensure that when I am doing CPR and when me colleagues are doing compressions, the hands are off the chest as little as possible.

    • Ckemtp

      I’ll send ya a copy of my protocols over e-mail. Maybe tomorrow or the next day I’m going to post up some tips that medics who aren’t blessed with an awesome medical director can use to increase their resuscitation success. It may be frustrating, but you can make a change today and still be in the good graces.

      Anyone else who wants a copy of the protocols can e-mail me too

  • http://thehappymedic.com the Happy Medic

    Metronome. Love it. We sing. Well, not sing so much as hum the stayin' alive song like AHA teaches the school moms. Works great. We're also working on that macho mentality of “No I'm good for another cycle” instead of swapping out compressors.
    Stopping for a tube or a line was foolish of us, but we didn't know any better. We always wondered why BLS was doing so much better than ALS in these “complex” patients.

    I am a believer in pulse checking at rhythm change however. Back in school we learned that the ejection fraction during compressions is an average of 16% of capacity. That said, a rate of 40 at 80% is better than a rate of 100 at 16%, and if the heart and compressions are out of step we're making it worse.
    That's when the pediatrician teaching CPR in neonates with a rate under 60 paused and said, “never thought of that.”
    The key here is artificial circulation until mechanical and chemical means can be established to continue our original efforts. What you are doing is working, let's keep doing it!

    And, if we add in therapeutic hypothermia, which is showing promise over a 12-24 hour period (neuro intact discharge home of VF with ROSC pre-hospital from 26% to 57% in one study) we could start having a major impact on this population.

    Keep us up to date CK! And bravo to your proactive Medical Director.

  • http://www.firedaily.com Fire Daily

    Great post. Having been off the box for a bit of time, I wasn't aware that a 50% Vfib save rate was even attainable. Amazing!

    With changes coming seemingly every 18 months, makes me wonder how much more differently we might be treating the arrest patient in say, 5 years…

    By the way, you may have heard another tune to compress to, although best to keep it to yourself- “Another One Bites the Dust” also gets that 100 per minute rate….

  • http://www.lifeunderthelights.com Ckemtp

    Or the tune “Staying Alive”. Let's not forget that song!

    Funny story, I've been on at least 5 codes where people have started singing the “Da da dump dump dump” bass line to that song and have gotten my “Funny look”

  • http://www.firedaily.com Fire Daily

    Great post. Having been off the box for a bit of time, I wasn't aware that a 50% Vfib save rate was even attainable. Amazing!

    With changes coming seemingly every 18 months, makes me wonder how much more differently we might be treating the arrest patient in say, 5 years…

    By the way, you may have heard another tune to compress to, although best to keep it to yourself- “Another One Bites the Dust” also gets that 100 per minute rate….

  • http://www.lifeunderthelights.com Ckemtp

    Or the tune “Staying Alive”. Let's not forget that song!

    Funny story, I've been on at least 5 codes where people have started singing the “Da da dump dump dump” bass line to that song and have gotten my “Funny look”

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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  • Comments
    Ckemtp
    I Got Attacked – A Paramedic Speaks About Public Trust
    I somewhat agree, though I assure you I didn't set out to waste your time. I probably should have broken this down into two separate points as the second point was the one I most wanted to emphasize. My bad on this one, I'll do better next time. Thanks for the feedback. If you'd like,…
    2014-12-16 20:25:00
    hawk4080
    I Got Attacked – A Paramedic Speaks About Public Trust
    Wow. That was a total waste to read.
    2014-12-16 19:20:00
    retired ems medic
    I Got Attacked – A Paramedic Speaks About Public Trust
    The radios should have had a trouble button to eliminate the need to key the Mike and talk. Maybe the dispatchers need to be rotated out to the streets to get out of the mode of just getting the calls out and only half listening to the radio.
    2014-12-16 14:50:00
    HybridMedic
    I Got Attacked – A Paramedic Speaks About Public Trust
    We use "Signal C" as a code to relay a crew in distress. Takes a second for the dispatchers to confirm it, but it sends the nearest engine, battalion chief, fire investigator (who are sworn LEO's) and makes an officer in distress call to Memphis Police. The arrival of all those resources is quite... Dramatic.
    2014-12-15 14:29:00
    exmedic
    Welcome to the Club
    Not me anymore
    2014-12-15 09:17:00

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