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Advances in Automated CPR

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Advances in Automated CPR

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

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    Advances in Automated CPR Advances in Automated CPR Presentation Transcript

    • 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
    • Chain of Survival Courtesy of Life Support Training Centre, Singapore General Hospital
    • Introduction
      • 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)
    • Chest Compressions and Coronary Perfusion Pressure CPP at 5:1 Ratio CPP at 15:2 Ratio
    • 2006 ACLS Guidelines
      • Chest compressions 30:2
      • 100 per minute
    • Thumper Model 1007 Mechanical CPR System
    • X-CPR (automatic simultaneous sternothoracic CPR, SST-CPR, device)
    • Lund University Cardiopulmonary Assist System (LUCAS)
    • AutoPulse
      • 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
    •  
    • Introduction
      • 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).
      Introduction
      • 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.
    • Methods
      • 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
    • Methods
        • 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
      Methods
    • 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
    • Study 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)
      • STD-CPR LDB-CPR P value
      • (n=499) (n=284)
      • Age (mean) (S.D) 68.1 (15.6) 67.3 (16.2) 0.49
      • Male gender 53.9% 56.7% 0.45
      • At Residence 81.6% 78.2% 0.26
      • Bystander witnessed 34.5% 33.5% 0.77
      • EMS witnessed 12.6% 18.7% 0.03
      • Bystander CPR 31.7% 30.5 % 0.73
      • VF 20.4% 23.3% 0.80
      • VT 0.6% 0.7%
      • Asystole 54.5% 51.9%
      • PEA 24.5% 24.1%
    • Patient Demographics (N=908)
      • STD-CPR LDB-CPR P value
      • (n=499) (n=284)
      • Defibrillated 10.2% 8.3 0.38
      • Response time (s) (SD) 393 (171) 367 (144) 0.03
      • Hypothermia 0 (0%) 10 (3.5%) <0.01
      • AutoPulse TM 0% 74.2%
    • ROSC (%) by phases
      • OR 2.08, 95%CI [1.49, 2.89]
    • Comparison 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]
    • Survival to Admission (%) by Phases
      • OR 2.11, 95%CI [1.41, 3.17]
    • Comparison of Survival to Admission by Phases
      • Logistic regression model adjusting for response time and whether EMS witnessed
      • Adjusted OR : 1.88, 95%CI [1.23, 2.86]
    • Survival to Discharge (%) by Phases
      • OR 3.63, 95% CI [1.90, 7.23]
    • Comparison of Survival to 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 Phases
      • STD-CPR LDB-CPR P value
      • (n=101) (n=96)
      • CPC 1 (%) 5 (5.6) 13 (15.1) 0.36
      • CPC 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) 0.40
      • OPC 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 Treat for outcome ‘survival to discharge’
      • Risk Lower 95% Upper 95%
      • RR of death 0.93 0.89 0.97
      • LDB-CPR vs STD-CPR
      • Absolute 0.07 0.03 0.11
      • Risk Reduction
      • NNT to save a life 15 9 33
    • 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
    • Survival to hospital discharge for manual and 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 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 AutoPulse TM 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 results
    • Interruptions to CPR during device deployment
    • 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)
    • Resuscitation Protocol - AutoPulse TM Incorporated
    • Pit Crew Philosophy to Integration of AutoPulse TM into Resuscitation Protocol
      • Efficient method of utilizing all available resources
      • Each crew member has a defined role and position relative to patient.
      • AutoPulse TM readied for application while manual compressions are being performed.
      • DO NOT STOP AutoPulse TM during the defibrillation shock
    • Deployment Sequence
    • Deployment Sequence
    • Deployment Sequence
    • 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
    • Summary
      • Using this concept, and following this guide, deployment of the AutoPulse TM will only in very rare circumstances take more than 60 seconds
      • Hands-off time will not be longer than approximately 20 seconds.
    •  
    • Organised by:
    • Conference Secretariat: Tel: (65) 6 379 5261/ 6 379 5259 Fax: (65) 6 475 2077 Email: admin@ icem2010.org
    • Visit our website :
    • See You in Singapore!