autopulse
DESCRIPTION
A/Prof Marcus OngConsultant, Senior Medical Scientist& Director of ResearchDepartment of Emergency MedicineSingapore General HospitalTRANSCRIPT
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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