Continuous Chest
Compressions Trial
Final version 1, 03-30-2011
RESUSCITATION OUTCOMES CONSORTIUM
Final version 1, 03-30-2011
Training Objectives
After this program you will be able to:
• 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
Final version 1, 03-30-2011
Continuous Chest Compressions (CCC)
• 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.
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-ofhospital cardiac arrest.
Final version 1, 03-30-2011
Interventions―Two Styles of Chest
Compressions
• “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
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
Modified final version 1, 09-19-2011
– Obvious respiratory arrest
• Afterward, ROC will determine patient
eligiblity/ineligibility for inclusion in study
– e.g. prisoners, pregnancy, oPt out, DNAR, EMSwitnessed arrest, trauma
Final version 1, 03-30-2011
The CCC Protocol
Continue same
CPR protocol
until placement
of advanced
airway
BLS On
Scene
Approximately
2 minutes
30 CC’s as
AED readied
Approximately
2 minutes
Approximately
2 minutes
200 continuous
200 continuous
200 continuous
?~
?~
?~
?~
chest
chest
chest
compressions*
compressions*
compressions*
BVM at 10:1
Continue
Standard
ACLS
If ALS on-scene IV/IO ASAP + epinephrine
Modified final version 1, 09-19-2011
Advanced airway
End of Study
Protocol
*200 continuous chest compressions (with 1 breath every 10 CC) given over 2 minutes
The 30:2 Protocol
Continue same
CPR protocol
until placement
of advanced
airway
BLS On
Scene
30 CC’s as
AED readied
?~
Approximately
2 minutes
Approximately
2 minutes
Approximately
2 minutes
5 cycles
at 30:2
5 cycles
at 30:2
5 cycles
at 30:2
?~
?~
?~
Continue
Standard
ACLS
BVM at 30: 2 If ALS on-scene IV/IO ASAP + epinephrine
Modified final version 1, 09-19-2011
Advanced airway
End of Study
Protocol
CCC versus 30:2
CCC
Approximately
2 minutes
200
200
Approximately
2 minutes
200
? ~ continuous chest ? ~ continuous chest ? ~ continuous chest
compressions
compressions
compressions
Turn on AED/monitor,
give 30 compressions
while AED is readied
30:2
Approximately
2 minutes
If ALS on-scene IV/IO ASAP + epinephrine
?~
5 cycles at 30:2
?~
5 cycles at 30:2
Continue same
CPR protocol
until placement
of advanced
airway
Standard
ACLS
? ~ 5 cycles at 30:2
30:2 IV/IO Epinephrine/Vasopressin ASAP
Modified final version 1, 09-19-2011
Advanced
Airway
End of Study
Protocol
!
Important Points
• 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
Modified final version 1, 09-19-2011
 30 chest compressions—break for 2 ventilations
 Deliver each rescue breath over 1 sec to produce chest rise
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.
Final version 1, 03-30-2011
Questions & Answers
Final version 1, 03-30-2011
What should we do when we
arrive on scene?
• 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
Modified final version 1, 09-19-2011
• 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
Final version 1, 03-30-2011
How do I know whether to do
CCC or 30:2?
• EMS agencies are randomized by cluster




Assigned treatment arm
Carry out for 3–6 months
Switch
Switch again
Final version 1, 03-30-2011
What if the patient arrested during
my care?
Modified final version 1, 09-19-2011
• 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
Final version 1, 03-30-2011
More BLS Questions
• 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
Final version 1, 03-30-2011
What should I do with the AED?
Modified final version 1, 09-19-2011
• The ROC AED or monitor/defibrillator should be applied and
compressions begun as soon as possible.
Final version 1, 03-30-2011
Should I count chest compressions
or use a timing device?
Either approach is acceptable
Final version 1, 03-30-2011
Should I compress while the
defibrillator is charging?
• Yes - if using Medtronic/PhysioControl device
• No – if using Philips MRX device (it charges fully
during analysis)
Modified final version 1, 09-19-2011
• Immediately resume compressions after shock
delivered
• Charge/shock time does not count as part of
CPR cycle.
Final version 1, 03-30-2011
What if I am having difficulty with
advanced airway insertion?
Modified final version 1, 09-19-2011
• Continue assigned CPR protocol until advanced airway
placed
• Consider other local options for advanced airway
Final version 1, 03-30-2011
Integrating CCC and ALPS when
ALS is first on-scene
• CCC and ALPS may be run concurrently or separately
• ALPS drug is administered ASAP for persistent or
recurrent VF/pulseless VT after ≥ 1 shock
Still VF
Give ALPS #1A & #1B
EMS On
Scene
Modified final version 1, 09-19-2011
30 CC’s as
Defib readied
Still VF
Give ALPS #2
Continue same
CPR protocol
until placement
of advanced
airway
OR
?~
CPR Set
#1*
?~
CPR Set
#2*
?~
CPR Set
#3*
?~
Continue
Standard
ACLS
IV/IO Epinephrine /Vasopressin ASAP
Advanced airway
*Each “CPR Set” consists of 200 continuous chest compressions
or Final
5 cycles
at 30:2, over approximately 2 minutes
version 1, 03-30-2011
End of Study
Protocol
CCC and ALPS
Modified final version 1, 09-19-2011
• May start ALPS during or after CCC completed
Final version 1, 03-30-2011
!
Important Points
• 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
Modified final version 1, 09-19-2011
 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
Final version 1, 03-30-2011
After the Call
Document
&
Download
• The CPR process file is the only way to verify that you did CCC or
30:2 CPR
Modified final version 1, 09-19-2011
• Call ROC hot-line
Final version 1, 03-30-2011
Final Questions
Final version 1, 03-30-2011