By MILLAN ZORITA and JOSHUA WELLS
On August 4, 2008, in Glendale, Arizona, Phoenix (AZ) Fire Department (PFD) Captain John Vardian, a veteran of Ladder 26, and his crew had just finished ventilating the roof of a two-story apartment building on fire when he began to feel weak. Nonetheless, he waited as his crew stepped off the roof; it was his custom for him to be the last off the roof. He sat down on the parapet for a second to rest, and then climbed down the ladder, only feeling weaker. Ladder Engineer Troy Cammack dragged Vardian, on the verge of collapse, 150 yards to Rescue 26. While PFD medics tended to Vardian, he experienced what he later called “the worst chest pain” he could possibly imagine. Shortly after getting into the Rescue, his heart stopped and he lost consciousness.
Crews from Engines 26 and 930 removed his turnout jacket and began compressions, pushing two inches deep at the center of his chest. Fifteen compressions became 30, 30 became 100, and 100 became 200—all without interruptions or ventilations. The PFD firefighters used a new cardiopulmonary resuscitation (CPR) protocol developed by Dr. Gordon A. Ewy and colleagues at the Sarver Heart Center at the University of Arizona (UA) called CardioCerebral Resuscitation (CCR). CCR calls for 200 continuous compressions before defibrillation in an unwitnessed arrest; the protocol initially disregards ventilation. PFD firefighters worked on Vardian enthusiastically, and with good reason. They had been using the CCR protocol for several years, and the tremendous results they had seen gave them confidence.
What Vardian faced that day is the “dragon” that kills more firefighters each year than any other cause: sudden cardiac arrest (SCA). According to National Fire Protection Association studies, more firefighters die from SCA than internal trauma and asphyxiation combined. Furthermore, SCA is the number-one cause of death for civilians in the United States. Every day, 1,000 people die from out-of-hospital SCA. EMS efforts are typically futile: 95 percent or more die.1
WHAT IS CCR, AND WHAT ARE ITS RESULTS?
CCR is a new CPR protocol that emphasizes nearly continuous compressions, a single defibrillation at maximum energy, with a de-emphasis on assisted ventilations (see Figure 1). Additionally, the advanced life support (ALS) algorithm for CCR emphasizes 200 chest compressions before and immediately after a single shock alternating with epinephrine only. Intubation is significantly delayed; it is not considered critical for victim resuscitation. All of this is contrary to what paramedics and EMTs have been taught for years and, additionally, runs contrary to the established protocols of the American Heart Association (AHA).
Figure 1. CardioCerebral Resuscitation (CCR) |
But it works, sometimes spectacularly. Three academic studies have been published regarding CCR success rates using witnessed cardiac arrests with a shockable rhythm. The first study, from Wisconsin, compared one year’s worth of CCR data to the data of the previous three years of AHA 2000 guidelines CPR. The results showed a threefold improvement in survival. Neurologically intact survival rates for witnessed arrests with a shockable rhythm rose from 15 to 45 percent.2
A Kansas City, Missouri, study showed that survival of a presumed cardiac out-of-hospital arrest improved from 7.5 to 13.9 percent with CCR. Return of spontaneous circulation (ROSC) improved for the subset of witnessed cardiac arrest patients with an initial shockable rhythm from 37.8 to 59.6 percent. Survival to hospital discharge improved from 22.4 to 43.9 percent, with 88 percent of these being neurologically intact.3 In Arizona, where CCR began, a third study published in the Journal of the American Medical Association showed a threefold increase in survival rates—from five to 18 percent—in the Phoenix metropolitan area.4
BYSTANDER COMPRESSION-ONLY CCR
A critical component of SCA victim survivability is bystander CPR. From time of the initial 911 call, first responders typically don’t arrive on scene in less than five minutes. This does not bode well for cardiac arrest victims, as survivability decreases significantly by 10 percent for every minute the patient is untreated after collapse. Hence, the presence of quality, timely bystander CPR is essential for success in cardiac arrests in an EMS system.
Unfortunately, arriving on the scene of an SCA often involves taking over from ineffective or even absent CPR. Bystander CPR rates are low across the country—typically around 25 percent. The two main reasons for lack of bystander CPR are forgetting (complicated) CPR training and unwillingness to perform mouth-to-mouth ventilations. Both of these are quite understandable.
CCR gives an alternative to bystanders, called Continuous Chest Compression (CCC) or Compression Only CPR (CO-CPR). Essentially, this involves the bystander or rescuer calling 911, opening the airway, and performing continuous chest compressions until help arrives. It provides an elegantly simple solution to the complexity and revulsion of performing mouth-to-mouth ventilations. According to researchers at the UA CPR Research Group, bystanders are four times more likely to perform CO-CPR than conventional CPR.5 More importantly, the results are better. Analysis of human data from a national out-of-hospital CPR registry documented no survival advantage to ventilations plus compressions when compared with providing chest compressions alone during bystander resuscitation.6 In Arizona, where CO-CPR has been advocated and taught since 2004, the survival of patients with out-of-hospital cardiac arrest was twice as high when bystanders performed CO-CPR as when they provided standard CPR.7
WHY DOES CCR WORK?
Two factors are identified as having a significant impact on survival rates in sudden cardiac arrest: effective bystander CPR and short response times. A department can start teaching and promoting continuous compression CPR in its community and, using CO-CPR protocols in its 911 dispatch caller instructions, making bystanders more effective. Coupled with increased bystander participation rates, effective compressions lead to successful outcomes, as previously mentioned. Shorter response times (consistently under five minutes) are out of reach for most fire and EMS systems. The CCR protocol is designed to address delayed response times to cardiac arrests, enabling fire and EMS crews to be more effective in their treatment when they do arrive on scene. The electrical phase of ventricular fibrillation (VF) (the duration of VF that will respond to a defibrillator shock) is prolonged by bystander CPR. When resuscitation specialists described the Three Phase Time Sensitive Model of untreated VF, they provided insight to the foundation of CCR and an understanding of its success. This model describes an accurate physiological response to cardiac arrest in the body.
We now know that cardiac arrest is not the same from beginning to end. There are actually several distinct phases over time. During the first four to five minutes of a primary cardiac arrest, the fibrillating heart is most likely to respond to a defibrillator shock. During this “electrical phase,” defibrillation is the most effective treatment. This is why the availability of automated external defibrillators (AEDs) in public places such as airports and casinos has been so effective. However, after about five minutes, the fibrillating heart has used up most of its energy and, because blood is not being pumped into the arterial system, blood shifts from the high pressure arterial system to the low pressure venous system, causing the right side of the heart to become overloaded while the left ventricle—the actual powerhouse that pumps blood throughout the body—is relatively empty of blood.
Although the heart continues to fibrillate, it is not pumping even at a marginal level by this point. Electrical shocks (defibrillation) delivered here most often result in asystole (flatline) or pulseless electrical activity. This is the “hemodynamic phase” and is typically the point where fire and EMS responders begin to arrive on the scene of a sudden cardiac arrest. The way to solve this problem is to perform quality, continuous chest compressions for a period of time. This will supply blood and, therefore, energy to the heart and increase the preload in the left ventricle; one could consider it as “priming the pump” before delivering a shock. This is the goal of CCR: to revitalize the heart enough that defibrillating it will convert it into a perfusing rhythm with spontaneous circulation. Untreated, a heart rarely continues to fibrillate after 10 minutes. This is the “metabolic phase”; there currently is little that can be done in this phase by prehospital providers that is effective.
In SCA, there are two critical physiological components that serve to somewhat suspend time: cerebral perfusion and cardiac perfusion. Since the arterial blood is fully oxygenated at the time of a primary cardiac arrest, the most important maneuver is to move this blood forward to the brain and the heart by chest compressions. When chest compressions are interrupted for any reason, blood flow to the brain stops. The idea, then, is to perfuse the heart and brain adequately with the existing supply of oxygen and energy.
The heart is perfused by the coronary arteries during diastole or when the heart is relaxed, not contracted. This is in contrast to the rest of the body, which is perfused when the heart contracts, or during systole.
Humans normally breathe through negative chest pressure: The diaphragm contracts downward, decreasing the pressure in the chest cavity, and air is sucked into the lungs. Conventional CPR uses positive pressure ventilation (PPV): A bag valve mask blows air into the lungs under pressure. This increases intrathoracic pressure, or pressure in the chest cavity, which is mechanically the opposite of what the body does normally. Unfortunately, this increased pressure in the chest cavity interferes with blood returning to the chest and heart, decreasing flow to the heart and the brain. This is compounded by the fact that physicians as well as paramedics during the excitement of a cardiac arrest have a tendency to hyperventilate—that is, squeeze and bag much too fast! CCR solves these problems by avoiding PPV and simply opening the airway. The compressions of the chest move some air into and out of the airway and lungs.
The other component to survival is to maintain enough consistent pressure in the arteries leading to the brain (adequate arterial pressure). Chest compressions do not produce much pressure in and of themselves. However, when repeated, continuous compressions build up a head of pressure in the blood vessels leading to the brain; the brain will get what it needs. It’s been demonstrated that cerebral perfusion is the critical component in survival to discharge successes. Any interruption in compressions causes blood pressure to drop significantly. The brain does not receive even the minimal amount of oxygen it needs to stay alive, even during cardiac arrest. Traditional guidelines interrupt compressions to deliver ventilations during CPR, lowering arterial perfusion pressure and causing inadequate cerebral perfusion. For years, this has led to poor neurological outcomes and death.
CCR requires that the patient’s airway be opened. The chest compressions may move some air in and out of the lungs. Some agency protocols require a nonrebreather oxygen mask placed on the patient. This is called passive insufflation; there is evidence that it increases survival rates. However, CCR is strict about ventilations. There should be no PPV, for the reasons previously noted, until after three series of chest compressions and defibrillations.
WHY IS CCR SO IMPORTANT TO THE FIRE SERVICE?
The most distinctive feature of the CCR protocols is how they potentiate the fire service and first responders as the crucial element for resuscitation. As Dr. Ewy says, “The battle for life and death is won or lost in the field, long before the patient ever sees a physician.” This CCR feature applies to all models of EMS service delivery in the fire service: from volunteer engine companies to suppression companies trained only to a first responder level to fully integrated paramedic engines to forest service-based units. The elements of survival in the CCR universe involve compressions, defibrillation, and response time. All of these elements are accessible to every fire service agency in the nation.
Previously, it was understood that effective treatment for cardiac arrest involved ALS skills that included advanced airway maneuvers (intubations), medication administration, and rhythm analysis. Recent studies have shown that ALS treatments are not very effective in the prehospital care phase of resuscitation. The days of first responders waiting around for the paramedics to show up and take the lead in cardiac arrests are over.
The prehospital studies done all over the country, along with animal studies done at UA, have generated volumes of new information. The core message is that if you can arrive as early as possible and provide good quality compressions with the CCR protocol, you can make THE difference in the survival outcomes for the out-of-hospital cardiac arrest patient. The paramedics that arrive eight to 10 minutes later are not going to have the opportunity to make the difference in the outcome; they may continue effective treatment, but the patient stands very little chance of survival if first responders haven’t taken the lead with quality compressions and timely shocks.
If you are trained, have an AED, and arrive during the electrical phase of cardiac arrest, you can make a difference when you defibrillate a heart into a perfusing rhythm. If you arrive a little later (during the hemodynamic phase), using the CCR protocol will perfuse and load the heart so that the shock you later deliver will be effective. If you witness an arrest, the shock is delivered first. For an unwitnessed arrest, provide three cycles of 200 compressions followed by a single shock (if indicated). Either way, the CCR protocol has proven itself time and time again to provide better outcomes than conventional care.
There is no reason to believe that every fire department in the country can’t be THE effective delivery platform for resuscitation medicine; it is that simple. SCA patients don’t need paramedics right away—they need you. It doesn’t matter whether you are a volunteer firefighter, a deputy fire marshal doing your rounds, or a basic life support ladder company in a big city. If you can arrive quickly and start CCR, you will be the first, and most essential, component of a patient’s resuscitation.
HOW TO PROCEED
Fire departments interested in pursuing CCR will likely encounter a few obstacles. Depending on how their EMS systems are set up, they would most likely need approval from their state or regional EMS regulatory authority, usually the state department of health. Furthermore, they would need to find partnerships with their local EMS and ambulance providers and establish agreements with area hospitals. If a fire department provides ALS care, it would need approval from its medical control to implement CCR.
None of this is easy, but none of it is impossible. The best way to proceed is to learn more about CCR and why its success rate is so high. Also, the Arizona Department of Health Services has a wealth of information on CCR in its Save Hearts in Arizona Registry & Education program (learn more at www.azshare.gov); it is easily CCR’s top promoter among government agencies.
Since the PFD adopted the CCR protocol, its survival-to-discharge rates have tripled; Vardian arrested a total of six times that day. However, he is back on duty today in no small part because of the research and protocols developed by Dr. Ewy and his team, which were subsequently implemented by firefighters throughout the state of Arizona.
ENDNOTES
1. Ann Emergency Medicine, 2005; 45: 504.
2. Kellum, Kennedy; Ewy. Cardiocerebral Resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am Journal of Medicine, 119:335-40, 2006.
3. Garza, Gratton; Salomone. Improved patient survival using a modified resuscitation protocol for out-of-hospital cardiac arrest. Circulation. 119 (19):2597-2605, 2009.
4. Bobrow, Clark; Ewy. Minimally interrupted cardiac resuscitation by emergency medical services providers for out of hospital cardiac arrest. JAMA 229:1, 158-65, 2008.
5. Locke, et al, Arch Intern Med, 1995, 155:938-943.
6. Van Hoeyweghen RJ; Bossaert LL; Mullie A; et al. Quality and efficiency of bystander CPR: Belgian Cerebral Resuscitation Study Group. Resuscitation. 1993; 26: 47–52.
7. Bobrow, et al, JAMA 2010:304:1514.
● MILLAN ZORITA has been a firefighter for the Sedona (AZ) Fire District (SFD) for more than eight years. He received paramedic training at Glendale Community College and has a B.A. from Williams College. He is a founding member of the SFD’s EMS Committee, which helps manage training, apparatus, policy, and equipment for the department’s EMS program.
● JOSHUA WELLS has been a firefighter/paramedic for the Sedona (AZ) Fire District (SFD) since 2005. He began his career as a resident firefighter in Vail, Colorado, in 2004. He has a B.S. from Northern Arizona University, an A.A.S. in fire science from Coconino Community College, and an A.A.S. in paramedicine from Yavapai College. Wells led the promotion of CCR by implementing community programs, promoting “CPR Across America,” and teaching at various fire conferences across the United States.
Fire Engineering Archives
