Ewy and Kern, both leaders in the field of cardiac resuscitation, reviewed CCR and described ideal postresuscitation care. The "3 pillars" of CCR were described:
A. Compression-only CPR by anyone who witnessed the event.
B. CCR by emergency medical service personnel, assumed to be arriving > 5 minutes postarrest.
- 200 chest compressions (at 100/minute), delay intubation; second person to apply defibrillation pads and initiate passive oxygen insufflation (eg, 100% oxygen via facemask)
- Single shock if indicated, immediately followed by 200 more chest compressions (no pulse check after shock)
- Check for pulse and rhythm; note that this pulse check occurs 4 minutes after the CCR has begun
- EPI intravenously or intraosseously as soon as possible to improve central circulation, coronary circulation, and diastolic blood pressure
- Repeat (2) and (3) 3 times; intubate if no return of spontaneous circulation after 3 cycles; note that neither bag-valve-mask ventilation nor intubation occurs until 12 minutes after the CCR has begun
- Continue resuscitation efforts with minimal interruptions of chest compressions until resuscitation is successful or the person is pronounced dead
In summary, the traditional mantra in emergency medicine of "A-B-C" has been turned upside-down by CCR. Aggressive management of the airway in those who have cardiac arrest is being relegated to a far lower priority. Good chest compressions and early EPI administration are the most important interventions when ventricular fibrillation is present in the circulation phase of cardiac arrest. Future studies will need to evaluate whether these concepts are applicable to nonshockable rhythms as well, although intuitively this seems reasonable. Finally, those who survive cardiac arrest should be treated with induced hypothermia, and pending more studies, they may benefit from early coronary angiography and PCI as well.