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Year : 2009  |  Volume : 53  |  Issue : 6  |  Page : 637-640 Table of Contents     

Cardio Cerebral Resuscitation: Is it better than CPR ?

1 Prof & Senior Adviser, Dept of Anaesthesia and Critical Care, Command Hospital (CC), Lucknow - 226002, India
2 Graded Specialist, Dept of Anaesthesia and Critical Care, Command Hospital (CC), Lucknow - 226002, India

Date of Web Publication3-Mar-2010

Correspondence Address:
TVSP Murthy
Anaesthesiology, Neuro and Liver Transplant Anaesthesia, Dept of Anaesthesiology and Intensive Care, Command Hospital (CC), Lucknow - 226002
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Source of Support: None, Conflict of Interest: None

PMID: 20640089

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The guidelines for cardiopulmonary resuscitation (CPR) have been in place for decades; but despite their international scope and periodic updates, there has been little improvement in survival rates in out-of-hospital cardiac arrest for patients who did not receive early defibrillation. Instituting the new cardio cerebral resuscitation protocol for managing prehospital cardiac arrest improved survival of adult patients with witnessed cardiac arrest and an initially shockable rhythm.

Keywords: Cardio cerebral Resuscitation, CPR, Prehospital cardiac arrest

How to cite this article:
Murthy T, Hooda B. Cardio Cerebral Resuscitation: Is it better than CPR ?. Indian J Anaesth 2009;53:637-40

How to cite this URL:
Murthy T, Hooda B. Cardio Cerebral Resuscitation: Is it better than CPR ?. Indian J Anaesth [serial online] 2009 [cited 2021 Feb 27];53:637-40. Available from: https://www.ijaweb.org/text.asp?2009/53/6/637/60236

   Introduction Top

Cardiac arrest highlights one of the critical inter­actions between the heart and the brain, and it remains a leading cause of death. The concept of cardio cere­bral resuscitation as an alternative to traditional car­diopulmonary respiration (CPR) for out-of-hospital cardiac arrest is fast evolving into a reality. Because cardio cerebral resuscitation results in improved sur­vival and cerebral function in patients with witnessed cardiac arrest with a shockable rhythm, it should re­place CPR for out-of-hospital cardiac arrest and CPR should be reserved for respiratory arrest. [1]

The need for replacement: CCR in place of CPR

Despite the development and periodic updating of guidelines for CPR and emergency cardiovascular care from the American Heart Association (AHA) sur­vival rates for victims of out-of-hospital cardiac arrest are dismal and have remained essentially unchanged in the recent past. [2],[3]

The traditional CPR approach has three major drawbacks:

• Most bystanders to a person who unexpectedly collapses are willing to activate emergency medical ser­vices (EMS) but are not willing to initiate rescue efforts because they do not want to perform mouth-to mouth assisted ventilation. Bystanders are more willing to per­form chest-compression-only resuscitation for a per­son who unexpectedly collapses an approach that all agree is dramatically better than doing nothing.

• Interrupting chest compressions for ventilation during cardiac arrest decreases survival.

• Positive pressure ventilation during CPR for cardiac arrest increases intrathoracic pressures, which decreases venous return to the thorax and subsequent perfusion of the heart and the brain. [4], [5]

Cardiocerebral Resuscitation Eliminates Ventila­tion

In contrast to CPR, cardio cerebral resuscitation eliminates mouth-to-mouth ventilation for bystander­initiated resuscitation efforts, dramatically decreases the role of positive pressure ventilation by EMS respond­ers, and emphasizes chest compressions prior to and immediately after a single shock for cardiac arrests not witnessed by EMS personnel.

The evidence base

In a human study, investigators from Japan found that among witnessed victims of out-of-hospital cardiac arrest who had a shockable rhythm upon the ar­rival of EMS personnel, chest-compression-only re­suscitation resulted in better survival than did chest com­pressions plus mouth-to-mouth ventilation. [6]

What the public should be taught about resusci­tation

The message that needs to be promulgated is two­fold but nevertheless simple: firstly - cardio cerebral resuscitation is for cardiac arrest, and secondly CPR with ventilation is recommended for respiratory arrest. The lay public should be taught that an unexpected collapse in an adult is, in all likelihood, a cardiac arrest, to be differentiated from obvious respiratory arrest, such as choking or drowning, where assisted ventilations may be appropriate. [4]

Coronary Perfusion Pressure Is Essential During Prolonged Cardiac Arrest

In the absence of early defibrillation, survival be­yond the first 5 minutes of ventricular fibrillation (VF) arrest is predominantly dependent on adequate coro­nary and cerebral perfusion pressures, both of which are generated by chest compressions. It is well estab­lished that in the absence of early defibrillation or by­stander-initiated resuscitation efforts, survival is rare.

The decades-old recommendation of two venti­lations before each 15 chest compressions has recently been acknowledged not to be optimal, as this ratio was changed from 2:15 to 2:30 in the 2005 AHA guidelines to increase the recommended number of chest com­pressions. However, this change did not address the major problem, which is bystanders' reluctance to ini­tiate resuscitation if ventilation is involved, regardless of the ventilations-to-compressions ratio. The greatest impediment to the initiation of bystander resuscitation is the public's aversion to and/or the complicated na­ture of performing mouth-to-mouth resuscitation. [5],[6]

The Role of Gasping or Agonal Respirations:

When a person collapses with VF, or if VF is induced in an animal model, gasping is present in a sig­nificant number of individuals and animals. This abnor­mal breathing, which varies in duration, can be either fortunate or unfortunate. When chest compressions are promptly initiated, gasping is fortunate in that the sub­ject is likely to continue to gasp and provide self venti­lation (negative intrathoracic pressure) [7].

However, gasping also may be unfortunate in that most laypersons interpret it as an indication that the subject is still breathing, causing them not to initiate bystander resuscitation or call for EMS personnel as soon as they should. Education will be essential to en­sure prompt initiation of bystander chest compressions in patients who gasp with cardiac arrest, as well as to ensure that chest compressions are not stopped be­cause of continued gasping.

Implementing Cardiocerebral Resuscitation Into EMS Protocols

In emergency medical service protocols, layper­sons are to be taught to "be a lifesaver." They are to be instructed to call emergency as soon as possible and then to begin chest compressions alone. If an automated external defibrillator (AED) is available, they should obtain it and follow its directions. Rescue breathing is not recommended. The technique for chest compres­sions is ideally taught with emphasis on a metronome­guided rate of 100 per minute. Additionally, full chest recoil after each compression is specifically empha­ sized. [8]

Guidance from the three phases of cardiac arrest

Adoption of the cardio cerebral resuscitation tech­nique will prompt some changes in EMS protocols; these are best understood in the context of the three phases of cardiac arrest due to VF. The three-phase time-dependent conception of cardiac arrest due to VF was articulated by Weisfeldt and Becker. [9],[10],[11]

The electrical phase is the first phase, lasting about 5 minutes. The most important intervention dur­ing this phase is defibrillation. This is why the availability of AEDs and programs to encourage their use have saved lives in a wide variety of settings, including air­planes airports, casinos, and the community [12]

The circulatory phase is next. It varies in dura­tion but runs approximately from minute 5 to minute 15 of VF arrest. During this time, generation of adequate cerebral and coronary perfusion pressure before and after defibrillation is critical to neurologically normal survival. Ironically, if an AED is the first intervention ap­plied during this phase, the subject is much less likely to survive. If preshock chest compressions are not pro­vided, defibrillation during the circulatory phase almost always results in a pulseless rhythm, asystole, or pulseless electrical activity. The previous stacked-shock protocol for the use of AEDs resulted in prolonged interruption of essential chest compressions, not only for rhythm analy­sis before shocks but also for rhythm analysis after shocks during this circulatory phase of cardiac arrest.

Successful resuscitation from these pulseless rhythms requires not only preshock chest compressions but also prompt, effective post shock resumption of chest compressions.

The metabolic phase occurs late (sometime af­ter15 minutes) in cardiac arrest due to VF. This is when resuscitative efforts are least successful and is the phase for which new innovative concepts are needed.

Changes in cardiac life-support protocols

One reason why survival of out-of-hospital car­diac arrest has been so poor is that paramedics, who almost always arrive after the electrical phase of car­diac arrest due to VF, spend only half their time doing chest compressions. [13] Interruptions are frequent be­cause EMS personnel have been following existing guidelines. One of the more unfortunate recommenda­tions of the old guidelines is the emphasis on stacked defibrillation, which results in a lack of chest compres­sions during prolonged and repeated analysis by AEDs during the circulatory phase of cardiac arrest due to VF-delays that have proved to be lethal. Similarly endotracheal intubation by EMS rescuers causes delay and disruption of the chest compressions. It also causes adverse effects related to positive pressure ven­tilation and frequent hyperventilation. In contrast, cardio cerebral resuscitation discourages endotracheal intu­bation during the electrical and circulatory phases of cardiac arrest due to VF . [13],[14]

Defibrillator pad electrodes are applied and the patient is given 200 chest compressions and then a single defibrillation shock that is immediately followed by 200 more chest compressions before the rhythm and pulse are analyzed. These additional 200 chest compres­sions applied after the shock but before rhythm and pulse analysis represent another important aspect of cardio cerebral resuscitation. Therefore, chest com­pressions were immediately initiated until an arterial pressure was established .[9]

A new approach to oxygenation

It has been documented that positive pressure ventilation during VF arrest is detrimental, concluding that "there is an inversely proportional relationship be­tween mean Intrathoracic pressure, coronary perfusion pressure, and survival from cardiac arrest. Adverse ef­fects of positive pressure ventilation include an increase in intrathoracic pressure as well as the inability to de­velop a negative intrathoracic pressure during the re­lease phase of chest compression. Positive pressure ventilation inhibits venous return to the thorax and right heart, resulting in decreased coronary and cerebral pressures. Additionally, hyperventilation and increased intrathoracic pressure have adverse effects on intracra­nial pressure and cerebral perfusion pressure. These ef­fects are compounded by the fact that ventilation rates by physicians and paramedic rescuers are often much faster than the rate recommended by the guidelines, even after extensive retraining.

During cardiac arrest, faster ventilation rates increase the mean intrathoracic pressure and further impede for­ward blood flow. [1] Accordingly, cardio cerebral resuscita­tion recommends opening the airway with an oropharyn­geal device, placement of a nonrebreather mask, and ad­ministration of high-flow (about 10 L/min) oxygen. [15]

Uninterrupted perfusion of the heart and brain prior to defibrillation during prolonged cardiac arrest is es­sential to neurologically normal survival. It is our con­viction that the widespread implementation of cardio cerebral resuscitation for cardiac arrest will dramati­cally improve survival. This may mandate a paradigm shift away from advanced cardiac life support and ba­sic life support, which emphasize standardization of content and format rather than institution- or agency­ specific protocols and training. [16],[18]

   References Top

1.Ewy G. A new approach for out-of-hospital CPR: a bold step forward. Resuscitation 2003; 58:271-272.  Back to cited text no. 1      
2.Kern K, Valenzuela T, Clark L, et al. An alternative ap­proach to advancing resuscitation science. Resuscita­tion 2005; 64:261-268.  Back to cited text no. 2      
3.Ewy G. Cardiocerebral resuscitation: the new cardiopul­monary resuscitation. Circulation 2005; 111:2134-2142.  Back to cited text no. 3      
4.Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral re­suscitation improves survival of patients with out-of­hospital cardiac arrest. Am J Med 2006; 119:335-340.  Back to cited text no. 4      
5.American Heart Association guidelines for cardiopul­monary resuscitation and emergency cardiovascular care. Circulation 2005; 112(Suppl IV):IV-1-IV-211.  Back to cited text no. 5      
6.International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resusci­tation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2005; 67:181-341.  Back to cited text no. 6      
7.Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. Importance of continuous chest compression during cardiopulmonary resuscitation:improved outcome dur­ing a simulated single lay-rescuer scenario. Circula­tion.2002;105:645- 649  Back to cited text no. 7      
8.8.. Nagao K, Sakamoto T, Igarashi M, et al. Chest com­pression alone during bystander cardiopulmonary re­suscitation [abstract]. Circulation 2005; 112(Suppl II):II-324  Back to cited text no. 8      
9.Rea T, Eisenberg M, Becker L, et al. Temporal trends in sudden cardiac arrest: a 25-year emergency medical ser­vices perspective. Circulation 2003; 107:2780-2785.  Back to cited text no. 9      
10.Eckstein M, Stratton S, Chan L. Cardiac arrest resusci­tation evaluation in Los Angeles: CARE-LA. Ann Emerg Med 2005; 45:504-509.  Back to cited text no. 10      
11.Weisfeldt M, Becker L. Resuscitation after cardiac ar­rest: a 3-phase time-sensitive model. JAMA 2002; 288:3035-3038.  Back to cited text no. 11      
12.The Public Access Defibrillation Trial Investigators. Pub­lic-access defibrillation and survival after out-of-hospi­tal cardiac arrest. N Engl J Med 2004;351:637- 646.  Back to cited text no. 12      
13.Berg RA, Hilwig RW, Kern KB, et al. Automated external defibrillation versus manual defibrillation for prolonged ventricular fibrillation: lethal delays of chest compres­sions before and after countershocks. Ann Emerg Med 2003; 42:458-467.  Back to cited text no. 13      
14.Aufderheide TP. The problem with and benefit of venti­lations: should our approach be the same in cardiac and respiratory arrest? Curr Opin Crit Care 2006; 12:207- 212.  Back to cited text no. 14      
15.Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyper­ventilation- induced hypotension during cardiopulmo­nary resuscitation. Circulation 2004; 109:1960-1965.  Back to cited text no. 15      
16.Ewy GA. Cardiocerebral resuscitation should replace cardiopulmonary resuscitation for out-of-hospital car­diac arrest. Curr Opin Crit Care 2006; 12:189-192.  Back to cited text no. 16      
17.Gordon A Ewy. Cardiac arrest-guideline changes ur­gently needed. The Lancet 2007: Volume 369, Issue 9565, 882-884.  Back to cited text no. 17      
18.Daniel P. Davis, Cardiocerebral Resuscitation: A Broader Perspective, Journal of the American College of Cardi­ology: 2009, Volume 53, Issue 2,158-160.  Back to cited text no. 18      


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