The cardiocerebral resuscitation protocol for treatment of out-of-hospital primary cardiac arrest

Abstract

Out-of-hospital cardiac arrest (OHCA) is a significant public health problem in most westernized industrialized nations. In spite of national and international guidelines for cardiopulmonary resuscitation and emergency cardiac care, the overall survival of patients with OHCA was essentially unchanged for 30 years--from 1978 to 2008 at 7.6%. Perhaps a better indicator of Emergency Medical System (EMS) effectiveness in treating patients with OHCA is to focus on the subgroup that has a reasonable chance of survival, e.g., patients found to be in ventricular fibrillation (VF). But even in this subgroup, the average survival rate was 17.7% in the United States, unchanged between 1980 and 2003, and 21% in Europe, unchanged between 1980 and 2004. Prior to 2003, the survival of patients with OHCA, in VF in Tucson, Arizona was less than 9% in spite of incorporating previous guideline recommendations. An alternative (non-guidelines) approach to the therapy of patients with OHCA and a shockable rhythm, called Cardiocerebral Resuscitation, based on our extensive physiologic laboratory studies, was introduced in Tucson in 2003, in rural Wisconsin in 2004, and in selected EMS areas in the metropolitan Phoenix area in 2005. Survival of patients with OHCA due to VF treated with Cardiocerebral Resuscitation in rural Wisconsin increased to 38% and in 60 EMS systems in Arizona to 39%. In 2004, we began a statewide program to advocate chest compression-only CPR for bystanders of witnessed primary OHCA. Over the next five years, we found that survival of patients with a shockable rhythm was 17.7% in those treated with standard bystander CPR (mouth-to-mouth ventilations plus chest compression) compared to 33.7% for those who received bystander chest-compression-only CPR. This article on Cardiocerebral Resuscitation, by invitation following a presentation at the 2011 Danish Society Emergency Medical Conference, summarizes the results of therapy of patients with primary OHCA treated with Cardiocerebral Resuscitation, with requested emphasis on the EMS protocol.

Figure 1

The three components of Cardiocerebral Resuscitation for primary cardiac arrest; the Community component consists of “Check” to see if the person has a cardiac arrest, “Call” to activate the Emergency Medical Services (EMS), and “Compress” for chest compression-only CPR. If an automated external defibrillator (AED) is readily available, its use should be encouraged. The EMS component consists of a revised advanced cardiac life support protocol (ACLS). The Hospital component is a hospital that has been designated as a Cardiac Receiving Center or equivalent. Figure reproduced from the Journal of the American College of Cardiology (JACC), with permission.

Figure 2

Survival of patients with out-of-hospital cardiac arrest due to ventricular fibrillation treated with EMS component of Cardiocerebral Resuscitation in rural Wisconsin and 60 Emergency Medical Systems (EMS) in Arizona [13,15].

Figure 3

Survival to hospital discharge in Arizona of patients with out-of-hospital cardiac arrest between the beginning of 2005 and the end of 2009 who received bystander guidelines recommended standard cardiopulmonary (Std-CPR) or compression only cardiopulmonary (CO-CPR) [23].

Figure 4

The Emergency Medical Services (EMS) protocol of Cardiocerebral Resuscitation. CCC is continuous chest compressions, O2 is oxygen, ACLS is advanced cardiac life-support, IV/IO is intravenous or interosseous, ROSC is return of spontaneous circulation.