Final version 1, RESUSCITATION OUTCOMES CONSORTIUM C ontinuous C hest C ompressions Trial Final version 1,

Describe the rationale for continuous chest compressions (CCC) & 30:2, as they integrate with the upcoming trial. Demonstrate the ROC CCC/30:2 protocol including:  CAB assessment  Efficient application of the AED/defibrillator at the same time chest compressions started  Integrated responder approach and provision of care  Maintenance of compressions including depth, release & rate  Ventilation timing and volume Training Objectives After this program you will be able to:

Final version 1, Traditional CPR—30 chest compressions: 2 ventilations Pauses in CPR chest compressions are associated with a decrease in coronary and cerebral perfusion pressure. Many EMS agencies using CCC—an alternative style of CPR.  Unclear whether survival is higher with CCC or 30:2 CPR. There are no randomized trials.  We do not know if CCC or 30:2 CPR is better.  A randomized controlled trial is the only way to know which approach is better. Continuous Chest Compressions (CCC)

Final version 1, Purpose of the Study To compare the effect of “CCC” CPR versus “30:2” CPR on outcomes following out-of- hospital cardiac arrest.

Final version 1, “CCC” CPR  Alternative style of CPR  Continuous chest compressions with no pauses  Ventilation: One BVM ventilation every 10 chest compressions (10:1), with no pause in compressions “30:2” CPR  Usual style of CPR  Chest compressions with pauses for ventilation  Ventilation: Two BVM ventilations every 30 chest compressions (30:2), with pause in compressions Interventions―Two Styles of Chest Compressions

Final version 1, Randomization By agency groups, for fixed time period (e.g. CCC x 6 months) → cross-over to opposite arm (30:2) Assigned CPR treatment arm (CCC or 30:2) will be the “standard of care” for all patients during study period except... – Peds – Obvious respiratory arrest Afterward, ROC will determine patient eligiblity/ineligibility for inclusion in study – e.g. prisoners, pregnancy, oPt out, DNAR, EMS- witnessed arrest, trauma Modified final version 1,

The CCC Protocol ?  ?  ?  ?  End of Study Protocol Continue Standard ACLS 30 CC’s as AED readied BLS On Scene BVM at10:1 *200 continuous chest compressions (with 1 breath every 10 CC) given over 2 minutes Advanced airway If ALS on-scene IV/IO ASAP + epinephrine Continue same CPR protocol until placement of advanced airway 200 continuous chest compressions* 200 continuous chest compressions* 200 continuous chest compressions* Approximately 2 minutes Approximately 2 minutes Approximately 2 minutes Modified final version 1,

The 30:2 Protocol ?  ?  ?  ?  End of Study Protocol Continue Standard ACLS BLS On Scene BVM at30:2 If ALS on-scene IV/IO ASAP + epinephrine Advanced airway 30 CC’s as AED readied Continue same CPR protocol until placement of advanced airway Approximately 2 minutes Approximately 2 minutes Approximately 2 minutes 5 cycles at 30:2 5 cycles at 30:2 5 cycles at 30:2 Modified final version 1,

CCC versus 30:2 ?  ?  ?  200 continuous chest compressions 200 continuous chest compressions ?  ?  ?  Standard ACLS 5 cycles at 30:2 30:2IV/IO Epinephrine/Vasopressin ASAP CCC 30:2 Turn on AED /monitor, give 30 compressions 5 cycles at 30:2 200 continuous chest compressions 5 cycles at 30:2 Approximately 2 minutes Approximately 2 minutes Approximately 2 minutes Advanced Airway while AED is readied If ALS on-scene IV/IO ASAP + epinephrine Continue same CPR protocol until placement of advanced airway End of Study Protocol Modified final version 1,

Final version 1, If ALS is early on scene... insert IV/IO early  Give epinephrine or vasopressin early CCC gets BVM at 10:1  One breath between every 10th chest compression  Deliver each rescue breath over 1 sec to produce chest rise  No break in chest compressions 30:2 gets standard AHA BVM ventilation  30 chest compressions—break for 2 ventilations  Deliver each rescue breath over 1 sec to produce chest rise Important Points ! ! Modified final version 1,

Final version 1, Choreographing the Perfect Arrest Management Pit Stop Work as a team. Each team member has a pre-assigned responsibility. For example:  CPR  Manage airway/BVM  Attach and operate monitor/defibrillator  Insert IV/IO—give drugs Must rotate CPR compressor every 2 minutes. Assign someone to time compression cycles and record events. Best to choreograph prior to arrival.

Final version 1, Questions & Answers

Final version 1, Assess CAB—confirmed arrest Check time, assign documentation, and turn on monitor/defibrillator Immediately start CPR (check and record time, or delegate timing) Apply defibrillation pads as soon as possible during CPR ASAP BVM at 10:1 or 30:2 Coordinate 2-minute rotations, rhythm checks, and defibrillation (if shock indicated) If ALS on-scene early, start IV/IO during CPR What should we do when we arrive on scene? Modified final version 1,

Final version 1, EMS agencies are randomized by cluster  Assigned treatment arm  Carry out for 3–6 months  Switch  Switch again How do I know whether to do CCC or 30:2?

Final version 1, Shock as required If CPR required after shock, perform in accordance with assigned treatment arm (CCC or 30:2) Afterward, ROC will determine patient eligiblity/ineligibility for inclusion in study What if the patient arrested during my care? Modified final version 1,

Final version 1, What if another individual or agency arrives first and begins CPR?  INCLUDE and perform the protocol if:. » Law enforcement » Bystander » Other individuals or agencies that do not typically or regularly respond to cardiac arrest incidents (e.g., lifeguards, military, security, etc.)  EXCLUDE and continue with standard ACLS (local protocol) if: » Non-ROC EMS provider agency More BLS Questions

Final version 1, The ROC AED or monitor/defibrillator should be applied and compressions begun as soon as possible. What should I do with the AED? Modified final version 1,

Final version 1, Should I count chest compressions or use a timing device? Either approach is acceptable

Final version 1, Yes - if using Medtronic/PhysioControl device No – if using Philips MRX device (it charges fully during analysis) Immediately resume compressions after shock delivered Charge/shock time does not count as part of CPR cycle. Should I compress while the defibrillator is charging? Modified final version 1,

Final version 1, Continue assigned CPR protocol until advanced airway placed Consider other local options for advanced airway What if I am having difficulty with advanced airway insertion? Modified final version 1,

Final version 1, Still VF Give ALPS #1A & #1B Still VF Give ALPS #2 CCC and ALPS may be run concurrently or separately ALPS drug is administered ASAP for persistent or recurrent VF/pulseless VT after ≥ 1 shock OR Integrating CCC and ALPS when ALS is first on-scene ?  ?  ?  ?  End of Study Protocol Continue Standard ACLS CPR Set #1* EMS On Scene CPR Set #3* CPR Set #2* Advanced airway 30 CC’s as Defib readied *Each “CPR Set” consists of 200 continuous chest compressions or 5 cycles at 30:2, over approximately 2 minutes Continue same CPR protocol until placement of advanced airway IV/IO Epinephrine/Vasopressin ASAP Modified final version 1,

Final version 1, May start ALPS during or after CCC completed CCC and ALPS Modified final version 1,

Final version 1, CCC gets BVM at 10:1  One breath between every 10th chest compression  Deliver each rescue breath over 1 sec to produce chest rise  No break in chest compressions 30:2 gets standard BVM ventilation  30 chest compressions—break/2 ventilations  Deliver each rescue breath over 1 sec to produce chest rise CCC vs 30:2 protocol is complete after placement of advanced airway Important Points ! ! Modified final version 1,

Final version 1, The CPR process file is the only way to verify that you did CCC or 30:2 CPR Call ROC hot-line After the Call Document & Download Modified final version 1,

Final version 1, Final Questions