1. Final version 1, 03-30-2011 RESUSCITATION OUTCOMES CONSORTIUM C ontinuous C hest C ompressions Trial Final version 1, 03-30-2011

2. 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:

3. Final version 1, 03-30-2011 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)

4. Final version 1, 03-30-2011 Purpose of the Study To compare the effect of “CCC” CPR versus “30:2” CPR on outcomes following out-of- hospital cardiac arrest.

5. Final version 1, 03-30-2011 “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

6. Final version 1, 03-30-2011 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, 09-19-2011

7. 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, 09-19-2011

8. 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, 09-19-2011

9. 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, 09-19-2011

10. Final version 1, 03-30-2011 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, 09-19-2011

11. Final version 1, 03-30-2011 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.

12. Final version 1, 03-30-2011 Questions & Answers

13. Final version 1, 03-30-2011 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, 09-19-2011

14. Final version 1, 03-30-2011 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?

15. Final version 1, 03-30-2011 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, 09-19-2011

16. Final version 1, 03-30-2011 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

17. Final version 1, 03-30-2011 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, 09-19-2011

18. Final version 1, 03-30-2011 Should I count chest compressions or use a timing device? Either approach is acceptable

19. Final version 1, 03-30-2011 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, 09-19-2011

20. Final version 1, 03-30-2011 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, 09-19-2011

21. Final version 1, 03-30-2011 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, 09-19-2011

22. Final version 1, 03-30-2011 May start ALPS during or after CCC completed CCC and ALPS Modified final version 1, 09-19-2011

23. Final version 1, 03-30-2011 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, 09-19-2011

24. Final version 1, 03-30-2011 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, 09-19-2011

25. Final version 1, 03-30-2011 Final Questions