Cardiocerebral and cardiopulmonary resuscitation - 2017 update

Abstract

Sudden cardiac arrest is a major public health problem in the industrialized nations of the world. Yet, in spite of recurrent updates of the guidelines for cardiopulmonary resuscitation and emergency cardiac care, many areas have suboptimal survival rates. Cardiocerebral resuscitation, a non-guidelines approach to therapy of primary cardiac arrest based on our animal research, was instituted in Tucson (AZ, USA) in 2002 and subsequently adopted in other areas of the USA. Survival rates of patients with primary cardiac arrest and a shockable rhythm significantly improved wherever it was adopted. Cardiocerebral resuscitation has three components: the community, the pre-hospital, and the hospital. The community component emphasizes bystander recognition and chest compression only resuscitation. Its pre-hospital or emergency medical services component emphasizes: (i) urgent initiation of 200 uninterrupted chest compressions before and after each indicated single defibrillation shock, (ii) delayed endotracheal intubation in favor of passive delivery of oxygen by a non-rebreather mask, (iii) early adrenaline administration. The hospital component was added later. The national and international guidelines for cardiopulmonary resuscitation and emergency medical services are still not optimal, for several reasons, including the fact that they continue to recommend the same approach for two entirely different etiologies of cardiac arrest: primary cardiac arrest, often caused by ventricular fibrillation, where the arterial blood oxygenation is little changed at the time of the arrest, and secondary cardiac arrest from severe respiratory insufficiency, where the arterial blood is severely desaturated at the time of cardiac arrest. These different etiologies need different approaches to therapy.

Keywords: Bystander CPR; out‐of‐hospital cardiac arrest; primary cardiac arrest; respiratory arrest.

Figure 1

Three components of cardiocerebral resuscitation for primary out‐of‐hospital cardiac arrest secondary to a shockable rhythm. In 2003, the community and prehospital components were initiated in Arizona (USA). In 2007, the hospital component was added. ACLS, advanced cardiac life support; AED, automated external defibrillator; CO‐CPR, chest compression only cardiopulmonary resuscitation.

Figure 2

Cardiac blood volume shifts following ventricular fibrillation (VF) arrest and cardiopulmonary resuscitation. Following VF arrest, blood from the high‐pressure arterial system shifts to the low‐pressure venous system, resulting a decreased left ventricular volume but a marked increase in right ventricular volume, and in pericardial restraint. Application of chest compressions decreases pericardial restraint, perfuses the heart and brain, and increases the chances of a perfusing rhythm following defibrillation. CO‐CPR, chest compression only CPR; CPR, cardiopulmonary resuscitation.

Figure 3

Survival of patients with OHCA in Arizona before and after bystander CO‐CPR was taught and advocated.

Figure 4

Pre‐hospital cardiocerebral resuscitation protocol for emergency medical services (EMS) first initiated in Tucson (AZ, USA).

Figure 5

Survival of patients with out‐of‐hospital cardiac arrest (OHCA) and a shockable rhythm improved in each region where cardiocerebral resuscitation emergency medical services protocols were instituted. The dark columns indicate the percent survival of patients with out‐of‐hospital cardiac arrest (OHCA) and a shockable rhythm when the paramedics arrived when the paramedics were followed the then American Heart Association (AHA) Guidelines for Emergency Medical Services (EMS). The gray columns indicate percent survival in each of these areas following the EMS institution Cardiocerebral Resuscitation.