Autopulse

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A/Prof Marcus Ong
Consultant, Senior Medical Scientist
& Director of Research
Department of Emergency Medicine
Singapore General Hospital

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Autopulse

  1. 1. Advances in Automated CPR A/Prof Marcus Ong Consultant, Senior Medical Scientist & Director of Research Department of Emergency Medicine Singapore General Hospital Adjunct Associate Professor Duke-NUS Graduate Medical School Office of Research
  2. 2. Chain of Survival Courtesy of Life Support Training Centre, Singapore General Hospital
  3. 3. Introduction <ul><li>The problem with standard CPR (STD-CPR): provides only 1/3 of normal blood supply to the brain and 10-20% to the heart </li></ul><ul><li>Although defibrillation is the definitive treatment for ventricular fibrillation, its success is dependent on effective CPR </li></ul>
  4. 4. Aortic diastolic (red) and right atrial (yellow) pressures during CPR (2 ventilations in 4-second period)
  5. 5. Chest Compressions and Coronary Perfusion Pressure CPP at 5:1 Ratio CPP at 15:2 Ratio
  6. 6. 2006 ACLS Guidelines <ul><li>Chest compressions 30:2 </li></ul><ul><li>100 per minute </li></ul>
  7. 7. Thumper Model 1007 Mechanical CPR System
  8. 8. X-CPR (automatic simultaneous sternothoracic CPR, SST-CPR, device)
  9. 9. Lund University Cardiopulmonary Assist System (LUCAS)
  10. 10. AutoPulse <ul><li>The AutoPulse™ (Revivant Corporation, Sunnyvale, CA) is a non-invasive Load Distributing Band device. </li></ul><ul><li>Distributing force over the entire chest improves the effectiveness of chest compressions. </li></ul><ul><li>Less harm, elimination of rescuer fatigue, more consistent, and eliminating the need to stop CPR during rescuer changes and patient transfers </li></ul>
  11. 12. Introduction <ul><li>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) </li></ul><ul><li>Animal study: produced 36% of normal coronary flow compared to 13% by manual CPR </li></ul><ul><li>When epinephrine administered, generated levels of flow to the heart and brain equivalent to normal flow. </li></ul>
  12. 13. <ul><li>Casner et al., retrospective chart review San Francisco Fire Department </li></ul><ul><li>Paramedic captain vehicles , adult cardiac arrests, (mean + SD response time interval of 15 +/- 5 min). </li></ul><ul><li>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). </li></ul>Introduction
  13. 14. <ul><li>Use of an Automated, Load-Distributing Band Chest Compression Device for Out-of-Hospital Cardiac Arrest Resuscitation </li></ul><ul><li>JAMA 2006 June 295(22): 2629-2637 </li></ul><ul><li>Ong MEH, Ornato JP, Edwards DP, Best AM, </li></ul><ul><li>Ines CS, Hickey S, Williams D, Clark B, Powell R, Overton J, Peberdy MA. </li></ul>
  14. 15. Methods <ul><li>Phased, non-randomized, observational study </li></ul><ul><li>Before and after replacement of standard CPR with the LDB-CPR device in adult OHCA victims treated by paramedics in Richmond, Virginia </li></ul><ul><li>Richmond metropolitan area: population of approximately 200 000, representative of a mid-size North American city </li></ul>
  15. 16. Methods <ul><ul><li>Eligibility: </li></ul></ul><ul><ul><li>Absence of pulse </li></ul></ul><ul><ul><li>Unresponsiveness </li></ul></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Exclusion: </li></ul></ul><ul><ul><li>Patients pronounced dead without attempting CPR </li></ul></ul><ul><ul><li>Obvious major trauma </li></ul></ul><ul><ul><li>Children below age 18 </li></ul></ul><ul><ul><li>Prisoners </li></ul></ul><ul><ul><li>Mentally disabled </li></ul></ul><ul><ul><li>Pregnant women </li></ul></ul>
  16. 17. <ul><ul><li>Primary outcome </li></ul></ul><ul><ul><li>Return of spontaneous circulation (ROSC) </li></ul></ul><ul><ul><li>Secondary outcomes </li></ul></ul><ul><ul><li>Survival to hospital admission </li></ul></ul><ul><ul><li>Survival to hospital discharge </li></ul></ul><ul><ul><li>Neurological (functional) status on hospital discharge </li></ul></ul><ul><ul><li>Definitions followed the Utstein recommendations </li></ul></ul>Methods
  17. 18. Utstein reporting template for data elements Resuscitation attempted N = 381 Resuscitation not attempted (pronounced dead on scene, DNR etc) N = 1256 Presumed cardiac etiology N =284 Non-cardiac etiology N = 255 LDB-CPR phase N= 284 STD-CPR phase N= 499 STD-CPR phase Absence of signs of circulation and/or considered for resuscitation (age  18) N= 1475 LDB-CPR phase Absence of signs of circulation and/or considered for resuscitation (age  18) N= 819 Resuscitation attempted N = 657 Presumed cardiac etiology N = 499 Device applied N= 210 Device not applied N= 74 (Reason missing =2) Not indicated N= 50 Not available N= 14 Mechanical failure N= 4 Inability to fit N= 4 Cease resuscitation N= 22 ROSC N= 20 En route N= 8
  18. 19. Study patients by phases <ul><li>1 Jan 2001 to 31 Mar 2003 499 </li></ul><ul><li>(STD-CPR) </li></ul><ul><li>1 Apr 2003- 19 Dec 2003 160 </li></ul><ul><li>(Phase-in) </li></ul><ul><li>20 Dec 2003 to 31 Mar 2005 284 </li></ul><ul><li>(LDB-CPR) </li></ul>
  19. 20. Patient Demographics (N=908) <ul><li>STD-CPR LDB-CPR P value </li></ul><ul><li> (n=499) (n=284) </li></ul><ul><li>Age (mean) (S.D) 68.1 (15.6) 67.3 (16.2) 0.49 </li></ul><ul><li>Male gender 53.9% 56.7% 0.45 </li></ul><ul><li>At Residence 81.6% 78.2% 0.26 </li></ul><ul><li>Bystander witnessed 34.5% 33.5% 0.77 </li></ul><ul><li>EMS witnessed 12.6% 18.7% 0.03 </li></ul><ul><li>Bystander CPR 31.7% 30.5 % 0.73 </li></ul><ul><li>VF 20.4% 23.3% 0.80 </li></ul><ul><li>VT 0.6% 0.7% </li></ul><ul><li>Asystole 54.5% 51.9% </li></ul><ul><li>PEA 24.5% 24.1% </li></ul>
  20. 21. Patient Demographics (N=908) <ul><li> STD-CPR LDB-CPR P value </li></ul><ul><li> (n=499) (n=284) </li></ul><ul><li>Defibrillated 10.2% 8.3 0.38 </li></ul><ul><li>Response time (s) (SD) 393 (171) 367 (144) 0.03 </li></ul><ul><li>Hypothermia 0 (0%) 10 (3.5%) <0.01 </li></ul><ul><li>AutoPulse TM 0% 74.2% </li></ul>
  21. 22. ROSC (%) by phases <ul><li>OR 2.08, 95%CI [1.49, 2.89] </li></ul>
  22. 23. Comparison of ROSC by Phases <ul><li>Logistic regression model adjusting for response time and whether EMS witnessed </li></ul><ul><li>Adjusted OR : 1.94, 95%CI [1.38, 2.72] </li></ul>
  23. 24. Survival to Admission (%) by Phases <ul><li>OR 2.11, 95%CI [1.41, 3.17] </li></ul>
  24. 25. Comparison of Survival to Admission by Phases <ul><li>Logistic regression model adjusting for response time and whether EMS witnessed </li></ul><ul><li>Adjusted OR : 1.88, 95%CI [1.23, 2.86] </li></ul>
  25. 26. Survival to Discharge (%) by Phases <ul><li>OR 3.63, 95% CI [1.90, 7.23] </li></ul>
  26. 27. Comparison of Survival to Discharge by Phases <ul><li>Logistic regression model adjusting for response time, EMS witnessed and whether post-resuscitation hypothermia was used </li></ul><ul><li>Adjusted OR: 2.32, 95%CI [2.23, 2.40] </li></ul><ul><li>OR for survival with post-resuscitation hypothermia: 3.58, 95% CI [3.43, 3.73] </li></ul>
  27. 28. CPC/OPC by Phases <ul><li> STD-CPR LDB-CPR P value </li></ul><ul><li> (n=101) (n=96) </li></ul><ul><li>CPC 1 (%) 5 (5.6) 13 (15.1) 0.36 </li></ul><ul><li>CPC 2 (%) 3 (3.4) 3 (3.5) </li></ul><ul><li>CPC 3 (%) 2 (2.3) 2 (2.3) </li></ul><ul><li>CPC 4 (%) 3 (3.4) 3 (3.5) </li></ul><ul><li>CPC 5 (%) 76 (85.4) </li></ul><ul><li> </li></ul><ul><li>OPC 1 (%) 2 (2.3) 4 (4.7) 0.40 </li></ul><ul><li>OPC 2 (%) 4 (4.5) 10 (11.6) </li></ul><ul><li>OPC 3 (%) 4 (4.5) 4 (4.7) </li></ul><ul><li>OPC 4 (%) 3 (3.4) 3 (3.5) </li></ul><ul><li>OPC 5 (%) 76 (85.4) 65 (75.6) </li></ul>
  28. 29. Number Needed to Treat for outcome ‘survival to discharge’ <ul><li> Risk Lower 95% Upper 95% </li></ul><ul><li>RR of death 0.93 0.89 0.97 </li></ul><ul><li>LDB-CPR vs STD-CPR </li></ul><ul><li> </li></ul><ul><li>Absolute 0.07 0.03 0.11 </li></ul><ul><li>Risk Reduction </li></ul><ul><li>NNT to save a life 15 9 33 </li></ul>
  29. 30. Relationship between response time and survival to hospital discharge by phases for patients not witnessed by EMS 1/37 (2.7, 0.5 – 13.8) 3/103 (2.9, 1.0 - 8.2) > 8 15/185 (8.1, 5.0 – 13.0) 6/323 (1.9, 0.9 - 4.0) <8 Survival N (%, 95% CI) Survival N (%, 95% CI) Ambulance response time interval [min] LDB-CPR STD-CPR
  30. 31. Survival to hospital discharge for manual and A-CPR stratified by 3 month periods
  31. 32. <ul><li>Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial. </li></ul><ul><li>Jama. Jun 14 2006;295(22):2620-2628. </li></ul><ul><li>Hallstrom A, Rea TD, Sayre MR, et al. </li></ul>
  32. 34. Reconciling the results <ul><ul><li>Different EMS systems and study populations? </li></ul></ul><ul><ul><li>Different study methodologies? </li></ul></ul><ul><ul><li>Response time? </li></ul></ul><ul><ul><li>Different protocols and application of the device? </li></ul></ul><ul><ul><li>Is mechanical CPR better than manual CPR? </li></ul></ul>
  33. 35. <ul><ul><li>Device should not be seen as the ‘miracle’ solution to cardiac arrest </li></ul></ul><ul><ul><li>Multiple factors will affect cardiac arrest outcomes </li></ul></ul><ul><ul><li>The AutoPulse TM should be seen as a possible new component of an overall resuscitation strategy </li></ul></ul><ul><ul><li>Challenge is to incorporate this in current treatment protocols seamlessly </li></ul></ul>Reconciling the results
  34. 36. Interruptions to CPR during device deployment
  35. 37. QCPR variables (1 st 5 mins) after Autopulse Implementation 0.50 (0.28) 0.25 (0.13) NFR 150.82 (83.89) 76.29 (39.92) NFT 34.76 (23.98) 39.78 (24.26) Compression/min 102.93 (28.00) 128.00 (14.19) Compression rate/min 34.86 (21.49) 33.26 (20.19) Compression ratio AutoPulse (n=29) Manual CPR (n=23) Variables (n=52)
  36. 38. Resuscitation Protocol - AutoPulse TM Incorporated
  37. 39. Pit Crew Philosophy to Integration of AutoPulse TM into Resuscitation Protocol <ul><li>Efficient method of utilizing all available resources </li></ul><ul><li>Each crew member has a defined role and position relative to patient. </li></ul><ul><li>AutoPulse TM readied for application while manual compressions are being performed. </li></ul><ul><li>DO NOT STOP AutoPulse TM during the defibrillation shock </li></ul>
  38. 40. Deployment Sequence
  39. 41. Deployment Sequence
  40. 42. Deployment Sequence
  41. 43. IS IT VF/ PULSELESS VT? NO (ASYSTOLE/PEA) YES * Restart AutoPulse TM * Follow asystole/PEA Protocol * Give 2nd dose of adrenaline * Restart AutoPulse TM * 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 AutoPulse TM  Check BP  S tart inotropes NO PULSE Deployment Sequence
  42. 44. Summary <ul><li>Using this concept, and following this guide, deployment of the AutoPulse TM will only in very rare circumstances take more than 60 seconds </li></ul><ul><li>Hands-off time will not be longer than approximately 20 seconds. </li></ul>
  43. 46. Organised by:
  44. 47. Conference Secretariat: Tel: (65) 6 379 5261/ 6 379 5259 Fax: (65) 6 475 2077 Email: admin@ icem2010.org
  45. 48. Visit our website :
  46. 49. See You in Singapore!

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