Airway & Respiratory, Cardiac & Resuscitation, Patient Care, Training

New CCR Technique Proves Successful

Issue 6 and Volume 35.

Imagine that your service could significantly increase the percentage of cardiac arrest patients walking out of the hospital neurologically intact. Better yet, imagine you could accomplish these results with just a little training and slight changes to CPR methods.
That’s what has been demonstrated by preliminary data for patients found in initially shockable rhythms in Madison, Wis., and several nearby counties.1 In predominantly rural Rock and Walworth counties, resuscitation rates were just 15% prior to the 2005 implementation of cardiocerebral resuscitation (CCR). However, after CCR was initiated, they rose to 48%.

In the nearby city of Madison, the program was started in 2007 with double-digit survival rates. With public involvement, the survival continues to grow. This article describes the Madison efforts and identifies what we believe have been key components to our resuscitation success.


In early 2007, Madison (Wis.) Fire Department Medical Director Darren Bean, MD, learned about a resuscitation project Richard Barney, MD, and Michael Kellum, MD, were conducting in Walworth and Rock counties. The project centered on changes in CPR that were creating dramatic improvements in outcomes for patients found in a shockable rhythm by EMS.

The most exciting part of Barney and Kellum’s project was not just that 40% of the patient population was walking out of the hospital neurologically intact post-arrest, but that it was occurring in a primarily rural area with BLS first response and delayed ALS response. Bean soon learned that the key to achieving these results was high-quality compressions with no interruptions except for defibrillation. So, he decided to implement this system of CCR in Dane County, Wis., which is home to the city of Madison.

The Madison program was modeled after one developed in Tucson, Ariz., by Gordon Ewy, MD, which was based on research Ewy conducted at the University of Arizona Sarver Heart Center. That research found compressions were occurring only 43% of the time during a normal resuscitation.2,3 Further evaluation revealed that compressions were withheld in our system for a number of reasons, including pulse checks, rhythm checks, IV access and airway procedures.

These interruptions resulted in a significant period of no circulation or forward movement of blood in patients. It was further found that oxygenation of the blood when a patient experienced sudden cardiac arrest was normal or very near normal. Ewy proved that the key components to a successful outcome are uninterrupted compression and defibrillation of an oxygenated myocardium.

A New Approach
To achieve optimal results, our system—and many others throughout the country—have found that EMS providers must assess compressions immediately upon their arrival and continue care based on early assessment. If high-quality compressions are occurring, the crews should immediately defibrillate shockable rhythms. If no or poor-quality compressions are found on arrival, EMS should immediately begin compressions at a rate of 100 per minute for two minutes.

Ventilations aren’t administered under these circumstances, and airway management consists only of inserting an oral pharyngeal airway and applying oxygen via a non-rebreather mask at 15 L per minute to support passive negative pressure ventilation. Our crews have been taught to perform compressions in a manner that ensures full recoil off the patient’s chest after each compression, allowing maximal ventricular filling. We’ve also found that it’s valuable for providers to utilize a metronome, or another feedback system, to ensure attainment of the optimum compression rate.

The physical demands of this type of compression regimen require a team approach to prevent fatigue and poor technique. Therefore, the Madison program protocol included frequent changes in individuals performing the compression. Although some systems and guidelines recommend changing rescuers every two minutes, we’ve found it best—if possible—to switch compressors every minute.

To minimize time off the chest, rhythm analysis and defibrillation shouldn’t take more than five seconds. This requires manual defibrillation and charging the unit prior to stoppage of compressions (with charging times to begin at approximately the 185th compression mark). After the first shock, immediately resume compressions at the 100-compressions-per-minute rate.

Establishment of IV or intraosseous (IO) access should be performed without interrupting compressions during the second set of compressions, followed by defibrillation if indicated. Again, 200 compressions should be repeated for two full minutes prior to any active ventilation. Once IV/IO access is secured, we administer 1 mg of epinephrine and 40 units of vasopressin; 300 mg of amiodarone is administered during the second round of 200 compressions; and another 1 mg of epinephrine is given during the third round of 200 compressions.

After six minutes of compressions, our crews secure the airway with an endotracheal tube or a laryngeal mask airway (LMA), the King LT Airway or Combitube. Whichever method is used, it’s critical that no interruptions occur in the performance of compressions, and the most skilled members of the resuscitation team should perform them.

Proper Ventilation
Once the airway is secured, the ventilator makes sure the patient isn’t hyperventilated. To do this, we require the use of end-tidal CO2 (EtCO2) monitoring, which helps providers maintain an EtCO2 of 40 mmHg. The ventilation rate is maintained at a rate of six per minute to start eucapnia. Once patients have a return of spontaneous circulation and an altered level of conscious post-resuscitation, initiation of induced hypothermia is considered.

To realize the best possible organization and timing during resuscitation, our crews utilized the acronym McMAID, which stands for metronome, compressions, monitor, airway, IV and drugs.4 A “code commander” is established, and this effective technique is assigned to this provider, who oversees resuscitation and guarantees no interruptions in compressions, as well as tracking treatment and timing of interventions performed by the resuscitation team.

Implementation & Training
Initially, all five of the Dane County paramedic-level services were trained in the CCR techniques, as were all EMTs. Training began with updating the systems’ protocols and was followed by lectures and discussions on the new CCR techniques. To ensure readily accessible information, a screen capture of the lecture along with protocol review and several research articles were placed on the department’s online learning management system. Working with the city cable channel, ALS and BLS videos were developed to provide clear demonstrations of all techniques and important information. These were then made available to all emergency responders.

It was discovered early in the program that frequent repetition and feedback were required to prevent a return to pervious timing and techniques. To support this, each crew decided to review and practice the McMAID mnemonic, utilizing brief, daily simulations. In addition, the medical director reviewed every cardiac arrest and ECG recording to identify any interruption in compressions and delays in the delivery of defibrillation. This information was then reviewed with the paramedics and fire companies who responded to the call.

Bean and Dane County Medical Director Paul Stiegler, MD, expanded the training program to include city and county law enforcement personnel. Historically, area law enforcement personnel had been hesitant to begin resuscitation prior to EMS arrival. To address this, Bean trained Madison police officers at their annual in-service. With the assistance of Stiegler and area EMS services, all county law enforcement professionals received CCR training.

In August 2008, Wake County (N.C.) EMS Medical Director Brent Myers, MD, MPH, FACEP, provided education on induced hypothermia as part of the CCR program. He presented two sessions and reviewed system protocols for the procedure.
As a part of optimal care, an unconscious adult patient who has a return of spontaneous circulation and adequate blood pressure should be cooled to a temperature of 32–34° C.

Prehospital providers initiate this process with chilled IV fluids—NSS cooled to 40° C—and placing ice packs on the groin, axilla and around the neck. This is continued upon admission to the ED.7

Going Public
Once all emergency responders were trained in CCR, the program was expanded to the public. This expansion was completed in two parts. The first part involved training 9-1-1 center dispatchers in CCR techniques and changing pre-arrival instructions to provide CCR instructions instead of CPR instructions. The second part began with a meeting of the Dane County American Red Cross Chapter in late 2007 at which time they agreed to take on the important task of citizen orientation and training. In early 2008, the National American Red Cross approved a CCR pilot project for Dane County.

In early 2008, Bean also trained members of the Madison mayoral staff and key community stakeholders to develop support and commitment for the program. Over the next year, thousands of community members were trained in CCR techniques. Red Cross staff and Dane County EMS providers brought CCR training to several community-wide programs.

The city of Madison has experienced a significant number of successes during the past two years. At this time, data is being analyzed and the final outcome is incomplete. For 2008, the success rate was 38% for all Dane County ALS agencies, and the preliminary numbers show a slightly higher rate in city limits.

CCR works—plain and simple. The resuscitation results experienced by our services and other organizations that have implemented the process of continuous chest compressions, and have trained and focused on not interrupting compressions, have seen dramatic improvements in resuscitation. These results, combined with community involvement, are similar to the success seen in the laboratory setting.2 There hasn’t been a more critical improvement in resuscitation since the implementation of CPR itself. More research is needed to clearly document and refine these preliminary successes experienced by participants, but combining CCR and induced hypothermia will no doubt improve outcomes experienced by responders in the prehospital setting. JEMS

Author’s Note: On May 10, 2008, Madison (Wis.) Fire Department Medical Director Darren Bean, MD, was tragically lost when his medical helicopter crashed while returning from a patient transport. Without his dedication and commitment, this program would not have experienced its tremendous success. He’s missed by all who knew him, and this program is a small part of his legacy.


  1. Kellum MJ, Kennedy KW, Ewy GA. Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest. Am J Med. 2006;119:335–340.
  2. Ewy GA. Cardiocerebral resuscitation: the new cardiopulmonary resuscitation. Circulation. 2005;111:2134–2142.
  3. Valenzula TD, Kern KB, Clark LL, et al. Interruptions of chest compressions during emergency medical systems resuscitation. Circulation. 2005;112:1259–1265.
  4. Kellum MJ. Improving performance of emergency medical services personnel during resuscitation of cardiac arrest patients: the McMAID approach. Curr Opin Crit Care. 2009;15:216–220.
  5. Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008;299:1158–1165.
  6. Ewy GA. Do modifications of the American Heart Association guidelines improve survival of patients with out-of-hospital cardiac arrest? Circulation. 2009;119:2542–2544.
  7. ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112:IV1-203.


This article originally appeared in June 2010 JEMS as “CCR Saves Lives: Simples changes to traditional CPR methods lead to dramatic success.”

Code Commander Steps
> Turn on metronome;
> Assign two compressors;
> Turn on monitor;
> Secure airway with oral airway/NRB mask:
> Check patency; and
> Immediately ventilate (six/min) if hypoxemic arrest.
> IV/IO;
> Administer drugs.