Gordon A. Ewy, MD

1
CCC CPR Should be Delivered by Bystanders and
First Responders A Sure way to Beat the Odds!

• Gordon A. Ewy, MD
• Professor and Chief, Cardiology
• University of Arizona College of Medicine
• Director
• University of Arizona Sarver Heart Center
• University of Arizona, Tucson, AZ

THE UNIVERSITY OF ARIZONA Sarver Heart Center

No conflict of interest - - Intellectual conflict
2
Why CCC-CPR for Cardiac Arrest?

• Bystander initiated CPR is critically important
• Bystanders more willing to initiate CCC CPR
• Easier to teach and easier to learn
• Arterial blood is fully oxygenated with cardiac
  arrest
• Forward blood flow is so marginal, that stopping
  CC for anything, including so called Rescue
  Breathing is deleterious
• MTM increases vomiting (50 incidence)
• Assisted ventilation increases intrathoracic
  pressure, decreasing venous return
• Gasping common and beneficial! If present will
  continue and if not present it is more likely to
  resume with CCC CPR
• Obstructed airway may have the same effect as
  inspiratory impedance valve
• CCC-CPR improves survival

3
Why CCC-CPR for Cardiac Arrest?

• Bystander initiated CPR is critically important

Out-of-Hospital Cardiac Arrest Gothenburg, Sweden
Discharged alive Bystander CPR 25
No bystander CPR 8
Herlitz et al Brit Heart J 199472 408-412
4
Early ( lt4 min) CPR vs. Late Bystander CPR

• In 17 studies, the odds ratio for improved
  survival with early bystander CPR averaged 4.5!
• AHA Statement Circulation 1991 83 1832-1847

5
Why CCC-CPR for Cardiac Arrest?

• Bystander initiated CPR is critically important
• Bystanders more willing to initiate CCC CPR

6
Survey of lay individuals Would you do CPR on a
stranger?
100 80 60 40 20 0
Definitely
400 more more likely do bystander CPR if they
did not have to do MTM rescue breathing
68
Responders
15
CC MTM
CC only
Locke, et al University of Arizona CPR Research
Group Arch Intern Med 1995155938-943
7
Why CCC-CPR for Cardiac Arrest?

• Bystander initiated CPR is critically important
• Bystanders more willing to initiate CCC CPR
• Easier to teach and to learn

8
Cardiology Patient Page
Ewy, Gordon A. Circulation 2007116e566-e568
Staying Alive ! Beetles 100/min
9
Why CCC-CPR for Cardiac Arrest?

• Bystander initiated CPR is critically important
• Bystanders more willing to initiate CCC CPR
• Easier to teach and to learn
• Arterial blood is fully oxygenated with cardiac
  arrest

10
Why CCC-CPR for Cardiac Arrest?

• Bystander initiated CPR is critically important
• Bystanders more willing to initiate CCC CPR
• Easier to teach and to learn
• Arterial blood is fully oxygenated with cardiac
  arrest
• Forward blood flow is so marginal, that stopping
  CC for anything, including so called Rescue
  Breathing is deleterious

11
Cardiac Arrest

• Why is it that every time I press on his chest
  he opens his eyes, and every time I stop and
  breathe for him he goes back to sleep?

12
Lay individuals interrupt chest compressions for
an average of 16 seconds to deliver the
recommended 2 quick rescue breaths
Single Rescuer CPR
Lay Public 16 1 seconds Assar D,
Chamberlain D, Colquhoun M, Donnelly P Handley
AJ, Leaves S, Kern KB. Resuscitation.
2000457-15.
13
Ventilation No one Can Perform to the
Guidelines?
Single Rescuer CPR
Lay Public 16 1 seconds Assar et al.
Resuscitation 2000 457-15
Medical Students 14 1 seconds Heidenreich et
al. Resuscitation 200462283-289
Paramedics 10 1 seconds Higdon et al.
Resuscitation 20067134-39
14
Why CCC-CPR for Cardiac Arrest?

• Bystander initiated CPR is critically important
• Bystanders more willing to initiate CCC CPR
• Easier to teach and to learn
• Arterial blood is fully oxygenated with cardiac
  arrest
• Forward blood flow is so marginal, that stopping
  CC for anything, including so called Rescue
  Breathing is deleterious
• MTM increases vomiting (50 incidence)

15
Mouth to Mouth Ventilation During CPR Increased
Vomiting

• Mouth-to-mouth ventilation can cause
  regurgitation in nearly 50 of patients, probably
  because of gastric insufflation
• Ruben H Brit J Anaesth 1964, 36542-549
• Lawes, EG, Baskett PJF Intensive Care Med
  198713379-382

16
Why CCC-CPR for Cardiac Arrest?

• Bystander initiated CPR is critically important
• Bystanders more willing to initiate CCC CPR
• Easier to teach and to learn
• Arterial blood is fully oxygenated with cardiac
  arrest
• Forward blood flow is so marginal, that stopping
  CC for anything, including so called Rescue
  Breathing is deleterious
• MTM increases vomiting (50 incidence)
• Assisted ventilation increases intrathoracic
  pressure, decreasing venous return

17
Hyperventilation Common

• 37/minute average hospital
• 37/minute average EMS ambulance

18
Why CCC-CPR for Cardiac Arrest?

• Bystander initiated CPR is critically important
• Bystanders more willing to initiate CCC CPR
• Easier to teach and to learn
• Arterial blood is fully oxygenated with cardiac
  arrest
• Forward blood flow is so marginal, that stopping
  CC for anything, including so called Rescue
  Breathing is deleterious
• MTM increases vomiting (50 incidence)
• Assisted ventilation increases intrathoracic
  pressure, decreasing venous return
• Gasping common beneficial! If present will
  continue and if not more likely to resume with
  CCC CPR

19
First minute of cardiac arrest they continue
breathing!
Minute 2 5 Gasping!
Delays recognition of cardiac arrest!
Submitted
20
Gasping in Humans(Arizona SHARE Program)

• Dispatch recording 39 witnessed and unwitnessed
  (Clark et al. 55 witnessed arrest)
• EMS witnessed arrest 33
• EMS arrival time lt 7 minutes 20
• EMS arrival time 7-9 minutes 14
• EMS arrival time gt 9 minutes 8
• Survival Gasping 28, Not 8 (Same as reported
  by Clark et al.
• Survival with CPR Gasping 39, Not 9

Bobrow et al. Submitted
Clark et al. Ann Emergency Med 1992211464
21
In My Humble View

• One of the major thrusts of ECCU should be to
  educate the public--to recognize cardiac arrest
• Including information about breathing and gasping
  as well as CCC CPR and the use of AED
• About the futility of calling 911 and just
  standing there

Gordon A. Ewy, MD
22
In My Humble View

• One of the major thrusts of ECCU should be to
  educate the public to recognize cardiac arrest
• Unexpected collapse
• Not responsive
• Continued breathing occurs
• Gasping common, and if CCC CPR is begun gasping
  will continue or recur
• Important to call 911 and initiate Hands Only
  CPR

Gordon A. Ewy, MD
23
Why CCC-CPR for Cardiac Arrest?

• Bystander initiated CPR is critically important
• Bystanders more willing to initiate CCC CPR
• Easier to teach and to learn
• Arterial blood is fully oxygenated with cardiac
  arrest
• Forward blood flow is so marginal, that stopping
  CC for anything, including so called Rescue
  Breathing is deleterious
• MTM increases vomiting (50 incidence)
• Assisted ventilation increases intrathoracic
  pressure, decreasing venous return
• Gasping beneficial! If present will continue and
  if not more likely to resume with CCC CPR
• Obstructed airway may have the same effect as
  inspiratory impedance valve

24
Airway Obstructed
Airway Patent
Netter, F Ciba Clinical Symposia 19742617
25
Resuscitation 39 (1998) 179-188

• 30 seconds VF, 6 minutes CPR
• 152 with only 4 secs interruption for
  ventilations
• CCC with occluded airway
• 6 minutes VF
• 152 P02 82 3, PCO2 29 15, pH 7.4 CPP 21 mm
  Hg
• CCC PO2 29 15, PCO2 82 7, pH 7.2 CPP 22 mm Hg
• 24 hour survival 10/10 vs. 9/10 ns

26
Why CCC-CPR for Cardiac Arrest?

• Bystander initiated CPR is critically important
• Bystanders more willing to initiate CCC CPR
• Easier to teach and to learn
• Arterial blood is fully oxygenated with cardiac
  arrest
• Forward blood flow is so marginal, that stopping
  CC for anything, including so called Rescue
  Breathing is deleterious
• MTM increases vomiting (50 incidence)
• Assisted ventilation increases intrathoracic
  pressure, decreasing venous return
• Gasping beneficial! If present will continue and
  if not more likely to resume with CCC CPR
• Obstructed airway may have the same effect as
  inspiratory impedance valve
• CCC-CPR improves survival

27
SOS-KANTOSurvival in the subset of patients with
witnessed arrest and shockable rhythm
25 20 15 10 5 0
P lt 0.05
24/124
19
30 Day Neurologically normal survival
23/205
11
CC MTM
CC Alone
Nagao et al. for the SOS-KANTO,The Lancet 2007
369 920
28
In Cardiac Arrest

• Your hands are their heart--if you stop chest
  compressions their heart stops

and blood flow to their brain stops"
29
Uncle Ewy
Hands Only Compression Only CPR
30
Some Oxygenation is Necessary

• We are not saying that oxygen delivery is not
  important during cardiac arrest
• We have shown that CCC CPR provides adequate
  oxygen delivery as arterial blood fully
  oxygenated at the time of cardiac arrest
• We are saying that forward blood flow is so
  marginal that stopping for any reason is harmful,
  because it stops blood flow and oxygen delivery
• We are saying that excessive ventilations are
  harmful

Circulation 20011042465 Circulation
1997951635 Circulation 1997962102
31
Some humans can hold their breath for over 8
minutes!

• Diver Tom Sietes of Germany holds the world
  record for holding his breath--8 minutes and 47
  seconds.
• Thus there is plenty of oxygen in the blood, even
  with a normal cardiac output to maintain
  consciousness
• At the low cardiac output during resuscitation,
  there is enough oxygen for several minutes.

32
Why Individuals Are Reluctant to Perform
Bystander CPR

• Fear/concern harming person 20
• Fear/concern not performing properly 20
• Fear/concern legal consequences 20
• Fear/concern mouth-to-mouth contact 20
• Physically unable to perform CPR 20

M.C. Guy and S.J. Coons Center for Health
Outcomes and Pharmacoeconomic Research University
of Arizona College of Medicine Survey 1,500.
50 response
33
Incidence of Bystander CPR Could be Increased to
80

• Eliminating the need for mouth-to-mouth contact
• Training in simpler method of doing CPR
• Far greater harm if they do nothing
• Informing them about the protections from legal
  liability

M.C. Guy and S.J. Coons Center for Health
Outcomes and Pharmacoeconomic Research University
of Arizona College of Medicine Survey 1,500.
50 response
34
Three Phase Time Sensitive Model of Untreated
Ventricular Fibrillation
Electrical Phase Minute 0 to minute 4 or 5
Circulatory Phase Minute 4 or 5 to minute 10 to 15
Metabolic Phase After minute 10 to 15
35
Cardiocerebral Resuscitation for Cardiac Arrest
Single shock No pulse check nor rhythm
analysis after shock
EMS arrival
Single shock No pulse check nor rhythm
analysis after shock
Single shock No pulse check nor rhythm
analysis after shock
200 chest compressions
200 chest compressions
200 chest compressions
200 chest compressions
CC- Only
1
Analysis
Analysis
Passive insufflation of O2, Oral pharyngeal
airway, Non-rebreather mask, High flow
oxygen Frees second person to start I.V.
1 Consider intubation
36
Cardiocerebral ResuscitationWitnessed collapse
and shockable rhythm
50 40 30 20 10 0
1 hypothermia included
36/89
40
p 0.002
Neurologically intact survival
14/92
15
CPR 3 years
CCR 3 years
Kellum, et al, Ewy Ann Emerg Med 2008
37
An Observation

• Knowing that they would not have to perform
  mouth-to-mouth ventilations, police with AEDs
  appeared more likely to respond to patients with
  cardiac arrest

Mike Kellum, MD
38
Mike Kellum, MD
39
ORIGINAL CONTRIBUTION
JAMA 20082991158-1165
40
Cardiocerebral ResuscitationWitnessed collapse
and shockable rhythm
23/131
OR 8.6 (1.8-42.0)
20 15 10 5 0
17.6
Survival to Hospital Discharge
2/43
4.7
CPR
CCR
Bobrow, Clark, Ewy et al. 2 Metropolitan FD
2005-2007 JAMA 2008 March
41
Blood Gases During VF
Baseline VF Cardiopulmonary
Resuscitation
0-8 minutes
8 minutes on
Baseline 7 min 10 min 12 min
14 min

• 7.4 7.5 7.5 7.4
  7.4
• 7.4 7.4 7.2
  7.2 7.2
• 82 65 192
  208 206
• 66 60 73
  76 81
• 42 33 33 32 31
• 43 42 68
  71 64

Vent Insuff
pH
p02
Vent Insuff
Vent Insuff
pCO2
42
After 10 minutes of VF if no gasping, new
approach!
5-6 min VF
3-4 min VF
43
5 and 6 minutes untreated VF
4 and 5 minutes untreated VF
Submitted