INTRO: This is BayCare HealthChat. Another podcast from BayCare Health System.

Caitlin Whyte (Host): Welcome to BayCare HealthChat. I'm Caitlin Whyte. CPR and CCR are two important lifesaving skills that everyone can learn. So joining us this episode is Dr. Juan Gallego, the Medical Director and Emergency Department Chief at BayCare’s St. Joseph's Hospital. He's going to be with us today to discuss the goals of CPR and CCR, and some scenarios in which you might have to use these skills in the real world.

Juan Gallego, MD (Guest): Thank you, Caitlin, for having me, and I'm happy to be here and do this talk and answer any kind of questions. Let me actually pose a question to you first and foremost. Let's say you're at, at Target or your favorite shopping place doing some last-minute shopping and you're standing in the checkout line. An adult male in front of you, maybe 60-ish in appearance kind of suddenly collapses on the ground. Unresponsive. What do you do in that situation?

Host: Oh gosh. Okay. Well Target is my favorite shopping place, so good start there. Let's see someone collapses right in front of me.

Dr. Gallego: You don't want to wait for someone else to do something that's not the right answer.

Host: True. True. I know that is usually it. I think I probably have my phone out. I'd probably call 9-1-1, make sure they are alerted, alert a staff member. You know, I was a high school lifeguard, so I think I would try to run through those tips and probably see if I, or someone else can try and start CPR, I think.

Dr. Gallego: Great, great. And absolutely 9-1-1 is absolutely the correct answer and CPR. Kind of, well, it was the correct answer and I guess we'll kind of get into that in a little bit. Right?

Host: Okay. Yeah. Yeah. So, well, let's talk about CPR first, then talk us through what I would do if I knew CPR and what the goal of it is.

Dr. Gallego: Great. Yeah. So the goal of CPR is basically to maintain blood flow to the vital organs because in cardiac arrest, the heart has stopped. And what that means is basically that the vital organs are not receiving any blood flow or oxygen. And your organs, your brain can only survive so long without any kind of what we call perfusion or delivery of blood and oxygen to those vital organs. So, the American Heart Association actually developed CPR, which is cardiopulmonary resuscitation way back in 1960 with the goal, of course, to educate the public and, and also in the hospital setting as well to bridge the gap between definitive therapy and the time that it takes to get that definitive therapy. So, providing chest compressions, keeping the brain and heart alive and the vital organs alive until you're able to get definitive therapy, which in some cases is defibrillation where we shock the heart with electricity to sort of jump start those cells to get back into a normal rhythm.

Host: So you said that CPR isn't necessarily the only option anymore or the go-to option now that CCR is a thing. Why is that?

Dr. Gallego: Well, so let me rephrase that. It is the go-to option, especially in certain scenarios, scenarios, such as drowning, any kind of respiratory arrest. So, if somebody looks like they're having a drug overdose and what we'll get into those in a little bit, as far as that goes, but the majority of cardiac arrest, the more majority of the time when somebody goes down in front of you, collapses and they're an adult, the most common reason, 90% of the time, for the most part, is going to be a cardiac reason, such as an abnormal rhythm that's decreasing blood flow to their brain. So, CPR for the last again, 61 years or so, the focus has been on doing chest compressions, but interrupting those chest compressions to deliver breaths.

That's where there've been a bit of an emphasis on the pulmonary component of CPR. Hence the name cardiopulmonary resuscitation, but thankfully, you know, 60 years is a long time and there's been plenty of time for us to do research and testing. And you'd be surprised what the research has shown over the last few years regarding traditional CPR. What they found was that the out-of-hospital cardiac arrest survivability was only 14% and that's unacceptably low. So, that's kind of what sparked that question, why is survivability so low? And that's kind of where we kind of came into sort of delving a little bit deeper as far as why that's so low and there's a couple of reasons.

So, the first reason is that lack of bystander-initiated CPR. So, in other words, bystanders were hesitant or even reluctant to do any CPR. And this is although most cardiac arrests are witnessed, we're talking about this happens usually where somebody is standing around, but only one in five people, studies have shown, have actually received CPR. I'll give you a guess of why that is.

Host: I mean, yeah, it's probably like the scenario at the top. You kind of assume someone else is going to jump in. Right?

Dr. Gallego: That is actually great. That was one of the big problems. And the other interesting thing that these research groups have found out was that people are very reluctant to do mouth to mouth resuscitation on a stranger.

Host: Oh, wow. Interesting

Dr. Gallego: Yeah. Yeah. So and some of these researchers, they found only 15% of people were willing to do mouth to mouth resuscitation on a stranger and other anonymous surveys that actually included CPR instructors and physicians were reluctant to do these as well. And that's despite these people being trained and knowing that bystander CPR is about, you know, we're going to have five times more likely for people to survive if you do it. So, that's definitely concerning data. Also think about this too. I mean, and these studies were done before COVID-19.

Host: Must have only gotten worse, right?

Dr. Gallego: Correct. Yeah. If I was a betting, man, I'd say the reluctance to perform at the mouth is even more pervasive now.

Host: Oh my gosh. Absolutely. That is so scary.

Dr. Gallego: So that was the only one reason I'm going to tell you the other reason why CPR has really kind of fallen by the wayside in some, in these particular types of cases. And it has to do really with biomechanics and the physiology of CPR. So, when an adult suddenly collapses, like I said, most of the time it's due to ventricular fibrillation where the heart is actually just sort of fibrillating. It's an abnormal rhythm, if you will. The heart is not contracting and delivering blood flow. So, CPR or traditional CPR, like we talked about cardiopulmonary resuscitation results in excessive interruptions of chest compressions in order to deliver breaths. And it's these interruptions that are actually lethal. And this, again, like now we're going to get into it is the concept of the basis for CCR, which stands for cardio cerebral resuscitation.

Host: Well walk us through that. What is CCR? How does it work and how is it different than CPR?

Dr. Gallego: Yeah, absolutely. So cardiopulmonary resuscitation, the pulmonary part means you're delivering oxygen to the lungs with mouth-to-mouth technique, whereas CCR or cardio cerebral resuscitation means heart and brain. So in other words, you're just doing compressions. You're not delivering breaths and that's where the CCR differs from the CPR in that first five or 10 minutes after cardiac arrest, the rescuer really doesn't have to give breath to the patient at all. So, instead the focus really shifts to performing chest compressions fast and hard at a rate of about a hundred a minute. One clinical trial actually showed that this technique saved 30% more lives compared to traditional CPR.

Host: Oh my gosh. That is a significant amount.

Dr. Gallego: It is. It is. And there's actually some science behind that too.

Host: Well, yeah, let's get into that science then. Why is CCR more effective than CPR?

Dr. Gallego: Great question. So there's actually two main reasons why CCR works. One is that the constant compressions maintain a constant blood pressure, that ensures the fact that blood flow is going to the vital organs. In CPR, when the rescuer turns from the chest compressions to give those breaths, the blood pressure quickly drops near to zero and the blood stops flowing to the brain and the vital organs. So, blood pressure is being built up slowly over the course of your compressions. And then when you go to do those breaths, it suddenly drops to zero. Secondly, ventilation actually counteracts the effectiveness of the chest compressions. When a rescuer is breathing for a patient, he or she is forcing air into the lungs. And that increases the pressure inside the chest. This increase in pressure prevents the, what we call venous return or the return of blood flow to the heart. And results in less filling of the heart. So, if there’s less blood coming back to the heart, there’s going to be less output from the heart. And that translates to less perfusion or delivery of blood flow to the heart and brain.

So a constant blood flow to the brain with the compressions alone increases those chances of survival. And that’s one of the reasons why those studies found in CCR patients, they have a higher survivability, but they’re also more likely to be neurologically intact with that survivability.

Host: Wow. That’s interesting.

Dr. Gallego: It’s pretty interesting. And also a couple of more concepts that kind of really demonstrate why CCR is a more effective, is that what you’re doing, chest compressions and circulating blood to the brain and heart, the chest compressions themselves also create a vacuum. If you simply open their mouth, when you’re doing the compression, this generates that negative pressure and it sucks air into them.

So, it’s almost like they’re passively getting some air into their system already. And the other thing that rescuers need to realize is that when the heart stops beating due to cardiac arrest, the blood has enough oxygen to support the organs for about five or 10 minutes. So actually, Caitlin, I'll ask you a quick question. How long can you hold your breath under water?

Host: Gosh well it's been a while since my lifeguarding days. Probably not that long anymore. Let's see. I mean, maybe like a minute. Does that sound about right?

Dr. Gallego: If you sit there and hold your breath right now, it's probably for at least a couple of minutes and it's the same concept, right? Because you're not taking in any air, but your heart's still beating and you're delivering oxygenated blood to your brain and your vital organs. You're not going to pass out after 10 seconds of holding your breath. We can look at the world record for breath holding, it's 24 minutes, which is amazing. Yeah.

Host: What? That is wild.

Dr. Gallego: Now I can't hold my breath for 24 minutes. I'm probably good at two, maybe even three, if I'm lucky, but it proves the point that your blood has plenty of oxygen dissolved within it. And that, along with that vacuum effect that I talked about with the chest compressions, make it really kind of unnecessary to deliver breaths during resuscitative efforts and maybe even harmful for a few clinical scenarios.

Host: Well, this is so important to know Doctor, where can people learn this new method of CCR? I mean, can you just head down to a rec center or something like that?

Dr. Gallego: So that's, it's a great question. And CCR is essentially hands only CPR. So if you just go to, I mean, we have internet, we have our smart phones. Anyone can just do a search on CPR and you can learn these techniques on YouTube, you can watch videos on them. But I think the best way is of course is a hands-on way to learn these things. And you can learn appropriate technique. It's kind of difficult to learn the technique just by hearing a podcast or watching a video.

We can tell you all day long. Well, this is how you position your hands, this is how deep the compressions have to be, but doing it in person is so much more. That's probably the best way. So I mean, you can, these courses are all over the place. You can take a course on BLS of CPR, BLS stands for basic life support, which is essentially CPR and CCR.

And you can learn those important skills, kind of like you did as a lifeguard. You can learn them at schools. You can learn them in colleges, universities, hospitals. I mean, there's, there's lots of, lots of different ways to learn these.

Host: Well, yeah. How do you know how to differentiate between the two? Like when CPR might be better than CCR or the other way around.

Dr. Gallego: There are a few scenarios. So everything we basically talked about thus far really pertains to the adults because as I mentioned, adults are much more likely to experience cardiac arrest due to a cardiac cause. Kids are different. When an infant or a child experiences arrest, it is usually due to a respiratory or a non-cardiac cause. So, traditional CPR would be indicated for a pediatric victim. And there are also other scenarios when CPR should be done in adult population as well. So, if it's a suspected drowning or a drug overdose or any arrest that is felt to be secondary to a respiratory or breathing problem. Then that's when CPR is recommended because it does provide that sort of pulmonary part of the resuscitation, but otherwise CCR, or maybe easier to remember as hands only CPR is definitely the way to go for teenagers and adults if you don't suspect any of these forementioned scenarios.

Host: Well as we close out, like I said, such critical vital information here, Doctor, is there anything else we didn't touch on that you find important?

Dr. Gallego: Just as some take home points. If you're listening to this podcast and you're, interested in the, in the concept or the information to take a course, learn the technique. They're very easy. If you witness an arrest, you step up do the compressions, whether it's CCR or hands only CPR in the adults and teens that like we mentioned, or traditional CPR in the other scenarios, but don't let the mouth to mouth deter you. If it's an all or none issue for you, at least do the chest compressions.

And again, you place the heel of your hand in the center of a person's chest. Your other hand on top of it, you press down hard, then relax, allowing for a full chest recoil and then repeat. And you're doing that about a hundred times a minute and that simple maneuver can save the life of a stranger, a friend, or even a loved one.

Host: Well, that is so true. We've all seen CPR on TV. Maybe even some of us have seen it done in person, but either way, it's a critical skill. So easy to learn. Thank you again for reminding us, Doctor. To learn more about heart and vascular services offered at BayCare visit BayCareHeart.org. Please remember to subscribe, rate and review this podcast and all of the other BayCare podcasts. For more health tips and updates, follow us on your social channels. This has been another episode of BayCare HealthChat. I'm Caitlin Whyte. Stay well.