Advances in Automated CPR

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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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  • 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. Chain of Survival Courtesy of Life Support Training Centre, Singapore General Hospital
  • 3. 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
  • 4. Aortic diastolic (red) and right atrial (yellow) pressures during CPR (2 ventilations in 4-second period)
  • 5. Chest Compressions and Coronary Perfusion Pressure CPP at 5:1 Ratio CPP at 15:2 Ratio
  • 6. 2006 ACLS Guidelines
    • Chest compressions 30:2
    • 100 per minute
  • 7. Thumper Model 1007 Mechanical CPR System
  • 8. X-CPR (automatic simultaneous sternothoracic CPR, SST-CPR, device)
  • 9. Lund University Cardiopulmonary Assist System (LUCAS)
  • 10. 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
  • 11.  
  • 12. 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.
  • 13.
    • 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
  • 14.
    • 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.
  • 15. 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
  • 16. 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
  • 17.
      • 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
  • 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
  • 19. 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)
  • 20. 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%
  • 21. 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%
  • 22. ROSC (%) by phases
    • OR 2.08, 95%CI [1.49, 2.89]
  • 23. 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]
  • 24. Survival to Admission (%) by Phases
    • OR 2.11, 95%CI [1.41, 3.17]
  • 25. 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]
  • 26. Survival to Discharge (%) by Phases
    • OR 3.63, 95% CI [1.90, 7.23]
  • 27. 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]
  • 28. 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)
  • 29. 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
  • 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
  • 31. Survival to hospital discharge for manual and A-CPR stratified by 3 month periods
  • 32.
    • 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.
  • 33.  
  • 34. 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?
  • 35.
      • 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
  • 36. Interruptions to CPR during device deployment
  • 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)
  • 38. Resuscitation Protocol - AutoPulse TM Incorporated
  • 39. 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
  • 40. Deployment Sequence
  • 41. Deployment Sequence
  • 42. Deployment Sequence
  • 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
  • 44. 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.
  • 45.  
  • 46. Organised by:
  • 47. Conference Secretariat: Tel: (65) 6 379 5261/ 6 379 5259 Fax: (65) 6 475 2077 Email: admin@ icem2010.org
  • 48. Visit our website :
  • 49. See You in Singapore!