How to Implement New Resuscitation Guidelines Enhancing 4 th chain: Mechanical chest compression during transportation 한림대의료원강동성심병원응급의학과조영석
Contents The Present of Mechanical CPR Device Barriers of High Quality CPR during transportation Experience of Mechanical CPR Device in local community
Present 2015 AHA CPR Guidelines Mechanical CPR devices : No demonstrable benefit Considered in specific settings where the delivery of high-quality manual compressions may be challenging or dangerous - Limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance in the angiography suite, during preparation for extracorporeal CPR (Class IIb, LOE C-EO). Use by properly trained personnel - limit interruptions in CPR during deployment and removal of the devices
Mechanical CPR Devices? Impedance Threshold Device (ITD) Active Compression-Decompression CPR/ITD Mechanical Piston Devices Load-Distributing Band CPR Devices Extracorporeal Techniques and Invasive Perfusion Devices : E-CPR
Mechanical Piston Device The Lund University Cardiac Arrest System (LUCAS 2) Chest compressions Sternal compressions Depth: 53±2 mm Rate : 102 strokes per minute Suction cup for full chest recoil Patient fit Sternum height of 17.0-30.3 cm Maximum chest width of 44.9 cm Lightweight and small Weight (with battery) 7.8kg Dimensions (in bag) : 65x33x25cm(H x W x D) Battery operated Light weight(0.6 kg)/lipo battery Battery operation time : 45 min External power supply(100-240v)
Cluster-randomized open-label clinical trial : EMS-treated non-traumatic OHCA, LUCAS 2, England Perkins GD. et al Lancet 2015
2 ambulances with a digital-video-recording system : EMS-treated OHCA, Thumper, Taipei Wang HC. et al Resuscitation 2007
Load-Distributing Band CPR Device (LDB-CPR) AutoPulse Non-invasive Cardiac Support Pump
Randomized open-label clinical trial, 2009-2011 : EMS-treated cardiac-origin OHCA, AutoPulse,USA/Europe Wik L. et al Resuscitation 2014
Secondary Analysis of the CIRC trial : Control of the quality factor of CPR (chest compression duration) Olsen JA. et al Acta Anaesthesiol Scand 2016
Needs for Mechanical CPR Device Consistent depth/rate Easy transport Ensure chest recoil Decrease rescuer s stress No interruption Pre-hospital high-quality CPR
Barrier Chain of Survival : OHCAs Funeral ER High-Quality Basic Life Support ICU Pre-hospital EMS resuscitation Advanced Life Support
Rapid Defibrillation & High Quality CPR Compression fraction: 60~80% Compression rate: 100~120/min Rapid Defibrillation + High Quality CPR Compression depth: 5cm Full chest recoil Optimal Ventilation
Pre-hospital chest compression rate in OHCAs Resuscitation Outcome Consortium 2007-9, EMS treated adult OHCAs (N=6,399) Observational cohort study with monitoring devices 54.2% low quality compression rate Idris AH. et al CCM 2015
Pre-hospital Compression depth in OHCAs Resuscitation Outcome Consortium (N=9,136) 2007-10, EMS treated adult OHCAs (10min data) Mean compression depth 41.9mm, 18% > 51mm 41.5%, Compression depth < 40mm Stiell IG. et al Circulation 2014
Pre-hospital Chest Compression Fraction in OHCAs Resuscitation Outcome Consortium 2005-7, EMS treated adult OHCAs (confirmed 506 VF/VT cases) 291/506 cases (57.5%), CCF < 61% Christenson J. et al Circulation 2009
Barriers of Pre-hospital HQCPR ER Pre-hospital BLS /ACLS More than 70% people : live in apartment house Home - most common place of OHCAs (57.1% from Korean CDC 2013) Level of collapse (non-ground floor) : possible barrier of HQCPR
Experience Kangdong Province EMS System Population : 470,000 persons 1 Fire station / 3 Regional EMS centers Annual OHCA events : 272 events/2005 yr 2-tiered ambulance system - 6 Ambulances, 1 Fire truck, 1 Motorcycle - 55 EMTs (paramedic, nurses, EMS personnel) -3 EMTs for a OHCA event Introduction of 6 mechanical CPR 25 Provinces of Seoul devices(autopulse ) to 6 ambulances (2015. 09)
Mechanical CPR Protocol at KD 1 st arrival ambulance : Scene arrival/recognize cardiac arrest Manual CPR (30:2 ratio with Bag-valve mask device) Apply a AED & Defibrillation 2 nd arrival ambulance : Apply a manual defibrillator Mechanical CPR (AutoPulse, LDB-CPR) Airway management (LMA/intubation) Continuous chest compression with BVM High-quality CPR/defibrillation & Transfer to hospital
Protocol : BLS + ALS Airway(leader) Drug Defibrillation Breathing Compression Equipement BLS team only BLS1 (1 급 ) BLS1 (1 급 ) BLS1 (1 급 ) 0:00 ~ 0:20 * 반응및호흡확인 * 기도확보 * 간단한병력청취 ---------- 선발대도착 ---------- BLS2 (2 급 ) BLS3 (driver) * 가슴압박시작 BLS3 (driver) * 주차및물품가지고현장이동 0:20~0:40 * 간단한병력청취및보호자설명 * 해당없음 * AED 부착및적응증시제세동 * BVM 통한호흡보조 (30:2 에맞춰서 * ( 분당 100 회이상 5cm 이상, 30:2) * 현장도착 0:40 ~ 2:00 0:40 ~ 2:00 * 맥박확인 가능한가슴압박장치적용 장치미적용시 30:2 가슴압박시행 2:00 * 2분간격으로리듬확인 ~ 후발대도착시까 장치적용시 * 매 2분마다맥박확인및적응증일시제세동지속적가슴압박지 ---------- 후발대도착 ---------- ALS2 (2급), BLS2 (2급), BLS team ALS1 (1급) ALS1 (1급) BLS1 (1급) BLS1 (1급) BLS3 (driver), ALS3 ALS3 (driver) + ALS team (driver) * 환자및현장처치상황 * 주차및물품후발대도착 ~ 0:20 인계받음 * 가슴압박장치가지고현장이동 * LMA 삽관미적용시적용 0:20 ~ 2:00 * BVM 통한호흡보조 * 현장도착 ( 기관삽관시도 ) 2:00 * 맥박확인및리듬확인 * 적응증일시제세동 2:00 ~ 4:00 정맥로확보 ( 필요시 ) * 지속적가슴압박 4:00 * 맥박확인및리듬확인 * 적응증일시제세동 4:00 ~ 6:00 * 적절한간격에맞춰 6:00 * 맥박확인및리듬확인 약물투여 * 적응증일시제세동 6:00 ~ * 모니터링장비유지하며이송지시 * 앱뷰백을통하여 8 회 / 분의호흡보조 - 기관삽관실패시, 30:2 에맞춰서 ) * 이송보조
Team CPR + Mechanical CPR BVM + LMA/I-gel AED & Defibrillation AutoPulse Manual CPR
Simulation Education in Kangdong EMS
Pre-hospital mechanical CPR device apply at Kangdong province, Seoul 2015.10-2016.3 (6 months) Non-randomized retrospective medical record review EMS-treated OHCA events, adult, non-traumatic origin Primary end-result : ROSC : Manual CPR only versus Manual CPR + AutoPulse apply Preliminary unpublished data
Univariate & multivariate analyses for ROSC Variables Preliminary unpublished data Yes (n=31) ROSC (%) No (n=64) OR(95% CI) Univariate analyses Gender Male 22(36.1) 39(63.9) 1.0 Female 9(26.5) 25(73.5) 0.64(0.25-1.61) 0.339 Age < 65 years 10(38.5) 16(61.5) 1.0 65 years 21(30.4) 48(69.6) 0.70(0.27-1.80) 0.457 Level of collapse Ground floor 20(42.6) 27(57.4) 1.0 Non-ground floor 11(22.9) 37(77.1) 0.40(0.17-0.98) 0.041 Prehospital CPR methods Manual CPR 15(38.5) 24(61.5) 1.0 Mechanical CPR 16(28.6) 40(71.4) 0.64(0.27-1.52) 0.312 Prehospital advanced airway Bag valve mask 2(16.7) 10(83.3) 1.0 Advanced airway 29(34.9) 54(65.1) 2.69(0.55-13.09) 0.207 Call 119 to arrival time 4 minutes 4(30.8) 9(69.2) 1.0 > 4 minute, 8 minutes 23(37.1) 39(62.9) 1.68(0.40-6.98) 0.475 > 8 minutes 4(20.0) 16(80.0) 0.77(0.14-4.29) 0.761 Bystander CPR No 6(27.3) 16(72.7) 1.0 Yes 25(34.2) 48(65.8) 1.39(0.48-3.99) 0.541 ECG rhythm on scene Non-shockable 25(30.9) 56(69.1) 1.0 Shockable 6(42.9) 8(57.1) 1.68(0.53-5.35) 0.377 Multivariate analyses Level of collapse Ground floor 1.0 Non-ground floor 0.40(0.17-0.98) 0.044 P
A retrospective cohort study in Singapore, 2001-2004 EMS-treated OHCA events, all causes of cardiac arrest Goh ES et al. Ann Acad Med Singapore 2007
A retrospective observational study in Toroto, Canada, 2007-2012 EMS-treated OHCA events, all causes of cardiac arrest < Floor 3(n=7842) versus Floor 3(n=1844) Drennan IR et al. CMAJ 2016
Survey of EMS personnel who used the mechanical CPR device in OHCA patients at Kangdong fire-station (n=54) Variables Category n(%) Gender, male 41(75.9) Age, year 35.0(31.0-41.0) Working career, month 49.50(19.5-119.8) Numbers of activation for OHCA in recent 6 months 12.0(8.8-18.3) Numbers of mechanical CPR device apply in recent 6 months 9.0(6.0-10.5) Locations of CPR interruption * Scene 4(7.4) Scene to ambulance 33(61.1) Ambulance 7(13.0) Ambulance to ER 26(48.1) Others 3(5.6) High floors interrupt HQCPR Yes 46(85.2) Usefulness of mechanical CPR device for HQCPR Useful 53(93.1) Barrier to use mechanical CPR device * Bulky and heavy device 34(63.0) Difficulty of taking over in ED 11(20.4) Difficult transport with device 9(16.7) Time-consuming for apply 4(7.4) Preliminary unpublished data OHCA, oust-of hospital cardiac arrest; CPR, cardiopulmonary resuscitation; HQCPR, high quality CPR *It allowed multiple responses.
Summary Vertical level of collapse : Possible barrier to high-quality EMS-CPR Pre-hospital use of mechanical CPR device : Until now, insufficient evidence to routine use BUT, May useful in specific setting (high-floored house/building, prolonged CPR duration, limited rescuers) Need more light & simple mechanical device A Well-designed RCT in these specific settings (like as Seoul)