Course Objectives
CPR: Ongoing Challenges. New Solutions.
October 2007
© 2007 ZOLL Medical Corporation
This program was made possible by
an educational grant from
ZOLL Medical Corporation.
Faculty & Planning Committee Disclosures
Benjamin S. Abella, MD, MPhil
1. Paid honorarium for participation in this program. Has also
received honoraria for other educational activities (article, speaking
engagement) performed on behalf of the sponsoring organization.
2. No product that is not labeled for the use under
discussion was discussed.
3. No preliminary research data was disclosed.
Joseph P. Ornato, MD, FACP, FACC, FACEP
1. Paid honorarium for participation in this program. Serves as a
member of the Scientific Advisory Board of the sponsoring organization.
2. No product that is not labeled for the use under discussion
was discussed.
3. No preliminary research data was disclosed.
Target Audience
• Physicians
• Nurses
• Paramedics
• EMTs
• Resuscitation Researchers
Objectives
• Upon completion of this program,
the viewer will be able to:
– Discuss the effects of chest compression on Coronary
Perfusion (CPP) and Return of Spontaneous Circulation
(ROSC)
– List at least three changes in the 2005 AHA Guidelines that
relate to CPR performance
– Discuss the outcome of at least one clinical study and one
pre-hospital study on the effects of survival with loaddistributing band CPR
– Discuss the rationale for implementing CPR prior to
defibrillation in cases with extended down time
Key Terms and Abbreviations
•
•
•
•
•
AHA
A-CPR
C-CPR
CPP
Deploy
• Downtime
American Heart Association
AutoPulse CPR
Conventional CPR
Coronary Perfusion Pressure
To implement and position for
readiness
Number of minutes from onset
of sudden cardiac arrest to
initiation of resuscitation efforts
Key Terms and Abbreviations
• Duty cycle
• ECC
• LDB
• ROSC
• SCA
• VF
The time is takes to complete
one cycle
Emergency Cardiovascular
Care
Load-distributing band
Return of Spontaneous
Circulation
Sudden Cardiac Arrest
Ventricular Fibrillation
Circulation is Critical for Survival
• Provides oxygen to preserve vital organ function
• Converts non-shockable rhythms (asystole,
PEA) to shockable ones (VF, VT)
– More than half of all arrests involve non-shockable
rhythms
Presenting Rhythms in SCA
Recent studies show that VF or VT
is the initial rhythm less than 50% of the time
120%
% of Cardiac Arrests
100%
80%
59%
60%
75%
40%
41%
20%
25%
0%
Hospital
EMS
VF/VT
Peberdy MA et al. Resuscitation. 2003;58:297-308.
Kaye W et al. JAMA. 2002:39(5),Suppl A.
Cobb L et al. JAMA. 2002;288(23):3008-3013.
PEA/Asystole
Presenting Rhythms in SCA
• Why are they non-shockable more than half the
time?
– EMS
• Long response times
– Hospital
• Some drugs (e.g., calcium channel blockers and beta blockers)
significantly shorten the time in which a person is in VF
Coronary Perfusion Pressure
Aortic
Pressure
(AP)
Right Atrial
Pressure
(RAP)
CPP = AP minus RAP
Coronary Perfusion and ROSC
A well perfused myocardium is more likely to experience
return of spontaneous circulation (ROSC)
CPP and ROSC (Paradis et al.)
Victims with CPP < 15 mmHg do not achieve ROSC
With conventional CPR, the overall mean CPP = 12.5
90%
79%
% of patients w/ ROSC
80%
70%
60%
46%
50%
40%
30%
20%
10%
0%
0%
<15
15-25
CPP (mm Hg)
Paradis NA et al. JAMA. 1990;263:1106-1113.
>25
AHA Guidelines 2005: CPR
“Simply put: …push hard, push fast,
allow full chest recoil, minimize
interruptions in compressions…”
Circulation. 2005;112:IV-206.
AHA Guidelines 2005: CPR
• High quality, consistent and uninterrupted
chest compressions
• Push hard, push fast
• Compression to ventilation ratio: 30:2
• Rate: 100 manual compressions per minute
• Depth: 1½ - 2 inches / 4 - 5 centimeters
• Duty cycle: 50% - 50%
• Ventilation: 8 -10 breaths per minute
CPR Challenges
• Poor quality
– Inconsistent rate, depth, duty cycle
• Harmful interruptions
– Required due to clinician fatigue, patient transport
• Inadequate cerebral and coronary perfusion
• Ineffective defibrillation support
CPR Challenges: Quality (Abella et al.)
• “…quality of multiple parameters of CPR was
inconsistent and often did not meet published
guideline recommendations….”
Parameter (1st 5 minutes)
Criteria
% of Time Incorrect
Rate too slow
< 90/min
28.1%
Depth too shallow
< 1.5 in
37.4%
Ventilation rate too high
> 20/min
60.9%
Abella BS et al. JAMA. 2005;293:305-310.
Parameter (1st 5 minutes)
CPR Challenges: Quality (Abella et al.)
Rate too slow 28.1%
Depth too shallow 37.4%
Ventilation rate too high
0%
60.9%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
% of Time Incorrect
Abella BS et al. JAMA. 2005;293:305-310.
CPR Challenges: Quality (Wik et al.)
“…chest compressions were not delivered half of the time,
and most compressions were too shallow…”
48%
No Flow
Wik L et al. JAMA. 2005;23 299-304.
52%
Flow
CPR Challenges: Quality
• CPR feedback to rescuers can help improve
CPR quality
– Elkadi et al.
• Pre-hospital Emergency Care. 2005;8:81-82.
– Handley et al.
• Resuscitation. 2003;57:57-62.
CPR Challenges: Hyperventilation
Hyperventilation induces hypotension
Mean ventilation rate: 30/minute ± 3.2
16 seconds
v
v
v
v
first group: 37/minute ± 4
Aufderheide TP et al. Circulation. 2004;109:1960-1965.
v
v
v
v
v
v
after retraining: 22/minute ± 3
Future of CPR Quality Study
International consortium for data collection
Oslo, Norway
Vienna, Austria
Stockholm, Sweden
London, UK
Chicago, USA
Phase I: Collect baseline data on CPR quality
Phase II: Implement feedback system to monitor and improve
CPR performance
CPR Challenges: Interruptions
(Edelson,
Abella et al.)
77% decrease in ROSC when pre-shock time increased
from </= 9.7 seconds to </= 22.5 seconds
100%
90%
87%
80%
70%
ROSC
60%
50%
40%
30%
20%
20%
10%
0%
</= 9.7 sec
Edelson et al. Circulation. 2005;112(17)II-1099
Edelson DP, Abella BS et al. Circulation. 2005;112(17):II-1099.
</= 22.5 sec
CPR Challenges: Interruptions (Kern et al.)
“…Any technique that minimizes lengthy interruptions of chest
compressions during the first 10 to 15 minutes of basic life support
should be given serious consideration in future efforts to improve
outcome results from cardiac arrest….”
38%
Flow
62%
No Flow
Kern KB et al. Circulation. 2002;105:645-649.
CPR Challenges: Interruptions (Berg et al.)
Blood pressure
Interrupting chest compressions for rescue breathing can
adversely affect hemodynamics during CPR for VF
Berg et al, 2001
Chest compressions
Berg RA et al. Resuscitation. 2001;104:2465-2470.
Time
CPR Challenges: Perfusion (Kern)
Manual CPR provides minimal blood flow
to the heart and brain
10% - 20% of normal flow
30% - 40% of normal flow
Kern KB Bailliere’s Clinical Anaesthesiology. 2000;14(3):591-609.
CPR Challenges: Defibrillation Support
After ~4 minutes of VF, the myocardium is nearly depleted of
ATP*, a vital energy source needed for successful defibrillation
*Adenosine triphosphate (ATP), which breaks down into adenosine diphosphate (ADP).
CPR Challenges: Defibrillation Support
Effective compressions help restore ATP,
increasing the likelihood of successful defibrillation
CPR Challenges: Defibrillation Support
Defibrillation is most effective during the first few
minutes after cardiac arrest
Defibrillation
most effective
Engdahl J et al. Resuscitation. 2002;52(3):235-245.
Guidelines for CPR and ECC. Circulation. 2000;102(suppl I):I-23.
Circulation
enhances outcome
AHA Guidelines 2005: LDB CPR
“LDB*-CPR may be considered for use by
properly trained personnel as an adjunct
to CPR for patients with cardiac arrest in
the out-of-hospital or in-hospital setting
(Class IIb).”
*Load-distributing band.
Circulation. 2005;112:IV-59.
AutoPulse® LDB CPR
AutoPulse LDB CPR
• What is the AutoPulse?
– The world’s only load-distributing band
chest compression device
• What does the AutoPulse do?
– Compressions that humans can’t
possibly do
• What does the AutoPulse do
for the SCA patient?
– Moves more blood, more effectively, to
the heart and brain
– Offers the promise of better outcomes
Summary of LDB CPR Benefits
• Improved blood flow
• Functions as an “additional person”
• Fast, easy and intuitive to start-up and use
• Clinician safety
Improved Blood flow
• To the brain
• To the coronary arteries
• Consistent, uninterrupted
compressions
• Thoracic and cardiac compression
Dual Function
Cardiac Pump
Thoracic Pump
Compresses only
Compresses
Compresses
the heartonly
Compresses the
Compresses
the
Compresses
entire chest much
mainly
the heart
the heart
entire
of the chest
chest
Functions as an “Additional Person”
• Clinicians are free to perform other critical tasks
• Eliminates clinician fatigue
Fast, Easy and Intuitive
• Extremely simple user interface
• Automatically “sizes the patient,” calculating…
– Size
– Shape
– Compliance/resistance
• Helps to “organize” or “calm” the code situation
Clinician Safety
• No risk of being injured while attempting to do
manual compressions during chaotic codes
and/or patient transport
30:2 or Continuous Modes
• Change without stopping operation
• Default settings administrator-configurable
Battery Operated
• Minimum 30 minutes of continuous compressions
• Maximum 4¼ hours recharge time
Easily Transportable
Carry Case for EMS
Transporter for Hospitals
Animal Hemodynamics Study (Halperin et al.)
• Conducted by Halperin et al. @ Johns Hopkins
• 20 16-kg pigs induced with VF for one minute
• Treated with conventional CPR (“The Thumper”) or the
AutoPulse
• Two arms of study
– “BLS” scenario – no epinephrine
– “ALS” scenario – with epinephrine
• Regional flow measured with neutron-activated
microspheres
Animal Hemodynamics Study (Halperin et al.)
AutoPulse produced pre-arrest levels of
blood flow to the heart and brain
(ACLS protocol – with epinephrine)
140%
129%
127%
% of Pre-arrest Blood Flow
120%
100%
80%
60%
40%
31%
29%
20%
0%
*p<0.02
**p<0.003
Heart (Myocardium*)
Conventional CPR
Halperin HR et al. JACC. 2004;44(11):2214-20.
Brain (Cerebrum**)
AutoPulse
Animal Survival Study (Ikeno et al.)
• Conducted by Ikeno et al. @ Stanford
• Objective was to evaluate the ability of AutoPulse’s
improved hemodynamics to affect survival
• Used a clinically relevant cardiac arrest model:
– 8 min down – 4 min BLS – 4 min ALS
• End-points were ROSC, 24-hour survival and
neurologic status at 24-hours
• CPR treatment was randomized to AutoPulse or
conventional CPR (“The Thumper”)
Animal Survival Study (Ikeno et al.)
• 73% of subjects supported with the AutoPulse returned to normal
blood flow and survived
- 88% of the survivors were neurologically normal
• 0% of the subjects supported with only conventional CPR survived
100%
90%
80%
73%
% Survival
70%
60%
50%
40%
30%
20%
10%
0%
0
0%
*p<0.01
Ikeno F et al. Resuscitation. 2006;68:109-118.
Conventional CPR
AutoPulse
Human Hemodynamics Study (Timerman et al.)
• Conducted by Timerman et al. in Sao Paolo, Brazil
• 16 terminally ill subjects who experienced in-hospital cardiac
arrest
• Study initiated after at least 10 minutes of failed ACLS support
• AutoPulse and manual compressions were alternated for 90
seconds each
• Catheters were placed in the thoracic aorta and right atrium to
measure CPP and peak aortic pressure
• Average time between arrest and the start of experiment was
30 (+/-5) minutes
Human Hemodynamics Study (Timerman et al.)
Coronary Perfusion Pressure (CPP) mmHg
AutoPulse-generated Coronary Perfusion Pressure (CPP)
was 33% better than manual CPR
*p=0.015
25
20
20
15
15
10
5
0
Manual CPR
Timerman S et al. Resuscitation. 2004;61:273-280.
AutoPulse
Human Hemodynamics Study Example
CPP drops quickly
when AutoPulse
compressions stop
CPP returns after
several AutoPulse
compressions
AutoPulse
Timerman S et al. Resuscitation. 2004;61:273-280.
Manual CPR
AutoPulse
Human Short-term Survival Study (Casner et al.)
• Conducted by Casner et al. in San Francisco, CA
• Compared the rate of delivery of 162 patients in ROSC
sustained to the ED
– 93 patients treated with manual CPR
– 69 patients treated with the AutoPulse
• Increased sustained ROSC rate was most pronounced
when the initial presenting rhythm was asystole or PEA
Human Short-term Survival Study (Casner et al.)
AutoPulse improved the rate of delivery of patients in ROSC
sustained to the ED by 35%
39%
40%
ROSC to ED Rate
30%
29%
20%
10%
*p=0.003
0%
Manual CPR
AutoPulse
Casner M et al. Prehospital Emergency Care. 2005;9(1):61-67.
Human Short-term Survival Study (Swanson et al.)
• Conducted by Swanson et al. in Volusia County, FL
• Compared the rate of delivery of 523 patients in ROSC
sustained to the ED
– 405 patients treated with manual CPR
– 118 patients treated with the AutoPulse
• Increased sustained ROSC rate was most pronounced
when the initial presenting rhythm was asystole or PEA
Human Short-term Survival Study (Swanson et al.)
AutoPulse improved the rate of delivery of patients in ROSC
sustained to the ED by 53%
29%
ROSC to ED Rate
30%
*p=0.02
19%
20%
10%
0%
Manual CPR
Swanson M et al. Circulation. 2005;112(17):II-106.
AutoPulse
Human Long-term Survival Study
(Ong, Ornato
et al.)
• Conducted by Ornato et al. in Richmond, VA
• Compared survival rates in 783 patients
– 499 patients treated with manual CPR
– 284 patients treated with the AutoPulse
• 235% improvement in survival to discharge
• 88% improvement in survival to hospital admission
• 71% improvement in field ROSC
Human Long-term Survival Study
(Ong, Ornato
et al.)
AutoPulse improved survival to hospital discharge by 235%
9.7%
% Survival
10%
*p=0.0001
5%
2.9%
0%
Manual CPR
Ong ME, Ornato J et al. JAMA. 2006;295(22):2629-2637.
AutoPulse
Research Synopsis
• Clinical evidence support AutoPulse benefits
– Animal study (Halperin et al.) shows blood pressure
equivalent to pre-arrest levels
– Animal study (Ikeno et al.) shows blood pressure
equivalent to normal and neurologically intact survival
– Human study (Timerman et al.) shows improved blood
pressure
– 2 human studies (Swanson et al. and Casner et al.) show
improved short-term survival
– Human study (Ong, Ornato et al.) shows improved short
and long-term survival
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It is the policy of Saint Louis University School of Medicine to insure balance,
independence, objectivity and scientific rigor in its continuing medical education
program. Faculty and planning committee participating in the planning and
presentation of these activities are required to disclose to the audiences prior to
the activity the following:
–
–
–
Existence of any significant financial or other relationship with the manufacturer of any
commercial product or provider of any commercial service discussed.
Their intention to discuss a product that is not labeled for the use under discussion.
Their intention to discuss preliminary research data.
Saint Louis University has reviewed this activity’s disclosures and resolved all
identified conflicts of interest, if applicable.
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Accreditation Council for Continuing Medical Education (ACCME)
regarding validation of clinical content for CME activities, which
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