advances in automated cpr

Advances in Advances in Automated CPR Automated CPR

A/Prof Marcus OngConsultant, Senior Medical Scientist& Director of ResearchDepartment of Emergency MedicineSingapore General HospitalAdjunct Associate ProfessorDuke-NUS Graduate Medical SchoolOffice of Research

Chain of Survival

Courtesy of Life Support Training Centre, Singapore General Hospital

IntroductionIntroduction

The problem with standard CPR (STD-CPR): provides only

1/3 of normal blood supply to the brain and 10-20% to the

heart

Although defibrillation is the definitive treatment for

ventricular fibrillation, its success is dependent on effective

CPR

Aortic diastolic (red) and right atrial (yellow) pressures during CPR (2 ventilations in 4-second period)

CPP at 5:1 Ratio

CPP at 15:2 Ratio

Chest Compressions and Chest Compressions and Coronary Perfusion PressureCoronary Perfusion Pressure

2006 ACLS Guidelines2006 ACLS Guidelines

l Chest compressions 30:2l 100 per minute

Thumper Model 1007 Mechanical CPR System

Thumper Model 1007 Mechanical CPR System

X-CPR (automatic simultaneous X-CPR (automatic simultaneous sternothoracic CPR, SST-CPR, sternothoracic CPR, SST-CPR,

device) device)

Lund University CardiopulmonaryLund University CardiopulmonaryAssist System (LUCAS)Assist System (LUCAS)

AutoPulseAutoPulse

The AutoPulse™ (Revivant Corporation, Sunnyvale, CA) is a non-invasive Load Distributing Band device.

Distributing force over the entire chest improves the effectiveness of chest compressions.

Less harm, elimination of rescuer fatigue, more consistent, and eliminating the need to stop CPR during rescuer changes and patient transfers

IntroductionIntroduction

Pilot human clinical study: LDB-CPR increased CPP more than manual chest compression (mean±S.D, 20±12 mmHg versus 15±11 mmHg, P<0.015)

Animal study: produced 36% of normal coronary flow compared to 13% by manual CPR

When epinephrine administered, generated levels of flow to the heart and brain equivalent to normal flow.

Casner et al., retrospective chart review San Francisco Fire Department

Paramedic captain vehicles , adult cardiac arrests, (mean + SD response time interval of 15 +/- 5 min).

Sixty-nine AutoPulse™ matched to 93 manual-CPR-only

cases. AP higher rate of ROSC than patients treated with manual CPR (39% vs. 29%, p= 0.003).

IntroductionIntroduction

Use of an Automated, Load-Distributing

Band Chest Compression Device for Out-of-

Hospital Cardiac Arrest Resuscitation

JAMA 2006 June 295(22): 2629-2637

Ong MEH, Ornato JP, Edwards DP, Best AM,

Ines CS, Hickey S, Williams D, Clark B, Powell R, Overton J,

Peberdy MA.

MethodsMethods

Phased, non-randomized, observational study

Before and after replacement of standard CPR with the LDB-

CPR device in adult OHCA victims treated by paramedics

in Richmond, Virginia

Richmond metropolitan area: population of approximately

200 000, representative of a mid-size North American city

MethodsMethods

Eligibility:

Absence of pulse

Unresponsiveness

Apnea

Exclusion:

Patients pronounced dead without attempting CPR

Obvious major trauma

Children below age 18

Prisoners

Mentally disabled

Pregnant women

Primary outcome

Return of spontaneous circulation (ROSC)

Secondary outcomes

Survival to hospital admission

Survival to hospital discharge

Neurological (functional) status on hospital discharge

Definitions followed the Utstein recommendations

MethodsMethods

Resuscitation attemptedN = 381

Resuscitation not attempted (pronounced dead on scene,

DNR etc)N = 1256

Presumed cardiac etiologyN =284

Non-cardiac etiologyN = 255

LDB-CPR phaseN= 284

STD-CPR phaseN= 499

STD-CPR phaseAbsence of signs of circulation and/or considered for resuscitation (age 18)

N= 1475

LDB-CPR phaseAbsence of signs of circulation and/or considered for resuscitation (age 18)

N= 819

Resuscitation attemptedN = 657

Presumed cardiac etiologyN = 499

Device appliedN= 210

Device not appliedN= 74

(Reason missing =2)

Not indicatedN= 50

Not availableN= 14

Mechanical failureN= 4

Inability to fitN= 4

Cease resuscitationN= 22

ROSCN= 20

En routeN= 8

Utstein reporting template for data elementsUtstein reporting template for data elements

Study patients by phasesStudy patients by phases

1 Jan 2001 to 31 Mar 2003 499 (STD-CPR)

1 Apr 2003- 19 Dec 2003 160(Phase-in)

20 Dec 2003 to 31 Mar 2005 284(LDB-CPR)

Patient Demographics (N=908)Patient Demographics (N=908)

STD-CPR LDB-CPR P value (n=499) (n=284)

Age (mean) (S.D) 68.1 (15.6) 67.3 (16.2) 0.49Male gender 53.9% 56.7% 0.45At Residence 81.6% 78.2% 0.26Bystander witnessed 34.5% 33.5% 0.77EMS witnessed 12.6% 18.7% 0.03Bystander CPR 31.7% 30.5% 0.73VF 20.4% 23.3% 0.80VT 0.6% 0.7%Asystole 54.5% 51.9%PEA 24.5% 24.1%

Patient Demographics (N=908)Patient Demographics (N=908)

STD-CPR LDB-CPR P value (n=499) (n=284)

Defibrillated 10.2% 8.3 0.38Response time (s) (SD) 393 (171) 367 (144) 0.03Hypothermia 0 (0%) 10 (3.5%) <0.01 AutoPulseTM 0% 74.2%

20.2

34.5

0

5

10

15

20

25

30

35

40

STD-CPR (n=499) LDB-CPR (n=278)

ROSC (%) by phasesROSC (%) by phases

OR 2.08, 95%CI [1.49, 2.89]

Comparison of ROSC by PhasesComparison of ROSC by Phases

Logistic regression model adjusting for response time and whether EMS witnessed

Adjusted OR : 1.94, 95%CI [1.38, 2.72]

11.1

20.9

0

5

10

15

20

25

STD-CPR (n=485) LDB-CPR (n=277)

Survival to Admission (%) by PhasesSurvival to Admission (%) by Phases

OR 2.11, 95%CI [1.41, 3.17]

Comparison of Survival toComparison of Survival toAdmission by PhasesAdmission by Phases

Logistic regression model adjusting for response time and whether EMS witnessed

Adjusted OR : 1.88, 95%CI [1.23, 2.86]

2.9

9.7

0

2

4

6

8

10

12

STD-CPR (n=486) LDB-CPR (n=278)

Survival to Discharge (%) by PhasesSurvival to Discharge (%) by Phases

OR 3.63, 95% CI [1.90, 7.23]

Comparison of SurvivalComparison of Survivalto Discharge by Phasesto Discharge by Phases

Logistic regression model adjusting for response time, EMS witnessed and whether post-resuscitation hypothermia was used

Adjusted OR: 2.32, 95%CI [2.23, 2.40]

OR for survival with post-resuscitation hypothermia: 3.58, 95% CI [3.43, 3.73]

CPC/OPC by PhasesCPC/OPC by Phases

STD-CPR LDB-CPR P value (n=101) (n=96)

CPC 1 (%) 5 (5.6) 13 (15.1) 0.36CPC 2 (%) 3 (3.4) 3 (3.5)CPC 3 (%) 2 (2.3) 2 (2.3)CPC 4 (%) 3 (3.4) 3 (3.5)CPC 5 (%) 76 (85.4)

OPC 1 (%) 2 (2.3) 4 (4.7) 0.40OPC 2 (%) 4 (4.5) 10 (11.6)OPC 3 (%) 4 (4.5) 4 (4.7)OPC 4 (%) 3 (3.4) 3 (3.5)OPC 5 (%) 76 (85.4) 65 (75.6)

Number Needed to TreatNumber Needed to Treatfor outcome ‘survival to discharge’for outcome ‘survival to discharge’

Risk Lower 95% Upper 95%

RR of death 0.93 0.89 0.97LDB-CPR vs STD-CPR

Absolute 0.07 0.03 0.11Risk Reduction

NNT to save a life 15 9 33

Relationship between response timeand survival to hospital discharge by phasesfor patients not witnessed by EMS

STD-CPR LDB-CPR

Ambulance response

time interval

[min]

Survival N (%, 95% CI)

Survival N (%, 95% CI)

<86/323

(1.9, 0.9 - 4.0)15/185

(8.1, 5.0 – 13.0)

>83/103

(2.9, 1.0 - 8.2) 1/37

(2.7, 0.5 – 13.8)

Survival to hospital discharge for manualand A-CPR stratified by 3 month periods

Manual chest compression vs use of an automated

chest compression device during resuscitation

following out-of-hospital cardiac arrest: a

randomized trial.

Jama. Jun 14 2006;295(22):2620-2628.

Hallstrom A, Rea TD, Sayre MR, et al.

Reconciling the resultsReconciling the results

Different EMS systems and study populations?

Different study methodologies?

Response time?

Different protocols and application of the

device?

Is mechanical CPR better than manual CPR?

Device should not be seen as the ‘miracle’ solution to

cardiac arrest

Multiple factors will affect cardiac arrest outcomes

The AutoPulseTM should be seen as a possible new

component of an overall resuscitation strategy

Challenge is to incorporate this in current treatment

protocols seamlessly

Reconciling the resultsReconciling the results

Interruptions Interruptions to CPR during to CPR during

device device deploymentdeployment

QCPR variables (1QCPR variables (1stst 5 mins) after 5 mins) after Autopulse ImplementationAutopulse Implementation

Variables (n=52) Manual CPR (n=23)

AutoPulse (n=29)

Compression ratio 33.26 (20.19) 34.86 (21.49)

Compression rate/min 128.00 (14.19) 102.93 (28.00)

Compression/min 39.78 (24.26) 34.76 (23.98)

NFT 76.29 (39.92) 150.82 (83.89)

NFR 0.25 (0.13) 0.50 (0.28)

Resuscitation Resuscitation Protocol -Protocol -

AutoPulseAutoPulseTMTM

IncorporatedIncorporated

Pit Crew Philosophy to Integration of AutoPulseTM into Resuscitation Protocol

Efficient method of utilizing all available resources Each crew member has a defined role and

position relative to patient. AutoPulseTM readied for application while manual

compressions are being performed. DO NOT STOP AutoPulseTM during the

defibrillation shock

Deployment Sequence

Doctor 1 Nurse 1 Nurse/Doctor 2 Check responsiveness -- hello hello no response

Check breathing -- no breathing bag and

mask 2 breaths Check pulse -- no pulseinstruct nurse 2

to start manual CPR (30:2)

Run to get the AutoPulseTM machine

Cut clothes and left sleeve Start manual CPR (30:2)

Doctor 1 Nurse 1 Nurse/Doctor 2 Start cardiac monitor Put defibrillation pad---1st to the chest (apex) Slot in the AutoPulseTM machine Put on the 2nd defib pad and assess rhythm

Help to cut clothes (right sleeve) Turn on AutoPulseTM machine When doctor is ready to take the machine hand the AutoPulseTM to the doctor

Carry patient up with Nurse / Doctor 2.

Remove shirt Help to strap AutoPulseTM

Continue manual CPR Carry patient up n1 so doc 1 can slot in the AutoPulseTM (patient’s neck and head) Strap on the belt of AutoPulseTM by Open up the bands Enclose it over the

patient Lift up the band straight Ensure that band

tightens over the Chest of patient and not the abdomen

Then press the start (green) button

Is it VF?

No Yes

No need to stop compressions during shock delivery.

Charge according to protocol Stand clear and deliver shock Put on AutoPulseTM

Deployment Sequence

Doctor 1 Nurse 1 Nurse/Doctor 2 Intubate patient Check position Set IV cannula (if no other doctor available) ***If 2ND doctor is available, then Doctor 1 intubates and Doctor 2 sets IV line. Change to continuous CPR on the AutoPulseTM

Help prepare for intubation Ventilate and hold tube while doctor checks position then anchor the tube Prepare intubation set Help to connect oxylog

Insert IV line if appropriate Prepare resus drugs then give a) 1st dose of adrenaline and atropine (for SGH, give PIVOT drugs as 1st drug as appropriate) as instructed by Doctor 1. b) help to set IV line if drugs are ready c) run IV drip

Deployment Sequence

IS IT VF/ PULSELESS VT?

NO(ASYSTOLE/PEA) YES

* Restart AutoPulseTM

* Follow asystole/PEA Protocol* Give 2nd dose of adrenaline

* Restart AutoPulseTM

* Charge defib* Give 2nd dose of adrenaline* Stand clear* Deliver shock* CPR for 1 min* Follow VF protocol

SINUS RHYTHM CHECK PULSE

Pulse present * Do not restart AutoPulseTM

Check BP Start inotropes

NO PULSE

Deployment Sequence

Summary

• Using this concept, and following this

guide, deployment of the

AutoPulseTM will only in very rare

circumstances take more than 60

seconds

• Hands-off time will not be longer

than approximately 20 seconds.

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