Auto CPR, why doesn't it work?

GMCmedic

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I did a search but didnt find what I was looking for?

I know the data doesnt support them, but theoretically it should. Does anyone have an answer or a theory as to why?

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Summit

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My reading has shown that mechanical CPR is nonsuperior to manual. Interruptions involved with placing the mechanical CPR device is probably a significant factor, although that can be addressed through practice.

The high cost of these devices combined with them being nonsuperior has prevented widespread adoption. If you have an engine company full of compressors or a bunch of medical residents and UAPs in the hospital, why buy $30K machines?

I believe they have potential in certain circumstances, particularly when manual CPR would be frequently interrupted (technical evacuation, helo) or insufficient personnel are available to keep up high quality manual compression (as before and add rural EMS). However, these applications are done by services that cannot typically afford the expensive devices or have other barriers. For example, helos don't often fly CPR in progress and they don't want to constantly haul a large heavy item that is infrequently used and of questionable superiority. Wilderness use needs motorized or really air delivery of the devices because batteries only last so long and the air powered devices would be totally impractical.
 

NomadicMedic

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The last retrospective study I saw showed that autopulse was inferior to manual CPR, and LUCAS 2 was equal in effectiveness to manual CPR, but there was no statistical difference or any measurable increase in survival to discharge.

I think the conclusion was "mechanical CPR shoukd be considered as an adjunct in special cases"
 

planetmike

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My agency now puts the Lucas on patients after we have ROSC. That way if they go back into cardiac arrest, the Lucas is in place to begin compressions. Until ROSC though, it takes too long to get the Lucas placed correctly.
 

OnceAnEMT

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Also have to consider the time that it takes to take LUCAS off. If a transport decision was made and the crew brings the patient with LUCAS on-board, the crews take LUCAS and the board after transferring to our ED bed while we continue to work the code. Also can't use LUCAS in a cath lab (at least how the ones I've been in are configured), so another reason to take it off (instead of just to get the crew back in service).
 

NomadicMedic

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I learned how to place the LUCAS in well under 30 seconds and every cath lab we transported to could perform interventions while the LUCAS was operating.

You need to practice a lot with the LUCAS to get competent with it. You can't pull it out of the bag and expect to just slap it on quickly. It's a team sport.

Our LUCAS would stay on the patient in the ED until the decision was made to d/c it.
 
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GMCmedic

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So pauses in CPR for set up seems to be the consensus?

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GMCmedic

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How do you draw that conclusion?
That seems to be the only answer so far, but maybe I could have done a better job of phrasing the question.

I know the data doesnt show any improvement over manual CPR but why? It would be assumed that the auto CPR can provide consistent depth and rate without tiring, and no required pauses to change providers. On paper it should out perform manual CPR.

The next question that comes to mind, have we reached a plateau in OHCA whereas ~10% is the best we can look forward too?

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OnceAnEMT

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I learned how to place the LUCAS in well under 30 seconds and every cath lab we transported to could perform interventions while the LUCAS was operating.
Well there you go. Was a top-down view of the chest possible, and they just elevated the xray? Or did they have to stick with side views? Whenever I see the top-down view the machine is mere inches from the chest (making compressions difficult and rather useless, if in progress). I guess if the team is good with it they could pop the device on and off between xrays, but that would be quite a show.
 

NomadicMedic

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As far as I know they were able to maneuver the gantry around the LUCAS. I hadn't been in a cath while LUCAS was on, but the interventional cardiologist was adamant about the fact that he could do it.

Of course, no LUCAS here, so it's moot.
 

MonkeyArrow

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The next question that comes to mind, have we reached a plateau in OHCA whereas ~10% is the best we can look forward too?
No, definitely not. There is some very promising research being put out about how best to treat OHCA; unfortunately, like many things, it takes a long time for research to transition to every day bedside care. Also, there is a very small group of interested researchers and physicians looking into this, somewhat limiting its applicability, as opposed to say sepsis. Aside from aiming for more public access AEDs and training the community to perform more pre-arrival bystander CPR like Seattle is doing, research is ongoing on ECMO, PCI with CPR in progress, double sequential defibrillation, new drug combos (less epi?- PARAMEDIC 2; beta blockade for VFib/VTach; steroid use intra-arrest; use of vasopressin?) and dosing (titrating epi with a drip or to A-line pressures), mechanical interventions (heads up CPR, abdominal binding), and better intra-arrest monitoring (TTE/TEE, carotid ultrasound, cerebral oximetry, A-line). The problem is many of these interventions cannot be trailed or performed in the field.

Was a top-down view of the chest possible, and they just elevated the xray? Or did they have to stick with side views? Whenever I see the top-down view the machine is mere inches from the chest (making compressions difficult and rather useless, if in progress). I guess if the team is good with it they could pop the device on and off between xrays, but that would be quite a show.
Not taking the LUCAS on and off in the lab, but not limited to lateral only. The projection source is usually not as close as you stated, more like 2 feet away from the pt.'s chest, and they can simply get a good enough picture with oblique views of different angles to subsisted for a dead on AP.
 

Bullets

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One of my agencies have Lucas 2s on 2 trucks. I love them. I think that may people are looking at these studies the wrong way. Most info shows that they are AS GOOD as a human, but has none of the draw backs. This is why they are great, 2 EMTs and a Lucas can effectively manage an arrest

We are able to apply the lucas in seconds, and if you know what your doing the only interruption that occurs is during the prescribed break for BVM ventilation. We also were able to convince the cath lab at our hospital to buy the carbon fiber backplate. it can 100% can be used during a cath, i have seen it done, and it does not interfere with the gantry being moved around.

My home agency is looking into getting them so we can finally remove the FD from EMS response all together
 

BassoonEMT

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Never had an issue with set up on the lucas. When you factor in the pauses in compressions for transporting, the ineffective compressions you get if transporting before ROSC, the extra couple seconds aren't so bad. When arrest is identified, start manual cpr. Someone can get the lucas ready, stop to put plastic underneath, maybe a 2 second roll. Start compressions while others are adjusting the back piece. Stop to attach lucas, push a couple buttons, and you're good. Even with an engine company full of compressors, you don't need to even think about the conversation of "no, I don't care that you think you're good, switch. OK new guy that's too fast, slow down a bit. OK good, now a little deeper. No don't speed up. Your hands are too high...."

The data makes sense. Lucas was designed to do compressions in place of a human. So data shows that lucas compressions are equal to proper human compressions. So when we do it right, and do it well, it's the same as lucas. Except the machine, as stated, is consistent. Always the same rate and depth. It gets tired too, but you can plug it in or swap the battery. much better than swapping people. Throw em on a backboard, carry them downstairs, into the truck, to the hospital, out of the truck, into the er. never a missed compression, unless for rhythm check (assuming advanced airway).

Maybe it's area dependent, i've never seen a pt go to cath with cpr in progess. If they don't get ROSC, they call it. Even if they did, move the patient to hospital bed, compressions still going, undo a couple clips, remove lucas, cpr monkey in the hospital takes over.

Also, i think the lucas is the only device we should be using.


tl;dr: In terms of data, yes, if we humans were perfect every time all the time, it would be the same, as it was designed to. But we're not. and there are plenty of other factors to high-quality cpr.

also, auto-pulse sucks.
 

BassoonEMT

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In my area, it all depends. SO is I can pronounce on scene after CPR if refractory asystole after 20 min, but I also need the family to be ok with that. If they want us to transport, we do.

Any other rhythm, have to call the doc, give the story. Depending on the age and hx, we may transport, may not. If the family wants us to transport we wont even call in this case.

Any arrest in a public place is automatically a transport.

Even so, if they go back into arrest while en route, it's good to have the lucas ready. (plus you can keep the arms up out of the way!) Can always pop it off while backing into the hospital bay if they maintain a pulse.
 

Jim37F

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Is it still common to transport a cardiac arrest? From reading the posts it seems to be.
I've had a couple transporting arrests recently, vs my previous dept we only transported ROSC patients. However, here they'll still work up a pt on scene until ROSC or call it, the ones we've transported working arrests are it's who got ROSC then lost pulses during the load/transport phasewhich isn't a situation I've had at my previous dept so maybe they would keep transporting a re-arrest, can't say for sure now lol

There was one case where we transported without ROSC, and that was a witnessed arrest, young patient in their 20s, <5 min away from the Cath lab and pt was in a persistent shockable rhythm (I forget exactly which one) And it was the hospital on the phone that said to transport so yeah (they called it after working him up another 20 min in the ER, was in asystole the whole time in the ER, and we were their Lucas ha, never went up to said Cath lab....)
 

Old Tracker

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Great timing on this thread. We saw a demo of the LUCAS 3 yesterday and it was pretty impressive. Being rural and 90 miles from a hospital makes this a desirable item to have, imo. Sales guy also said it is fiananceable at a pretty low interest rate for up to 5 years. Not having used one I don't really see much of a downside to have one of these available.
 

TransportJockey

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In my area, it all depends. SO is I can pronounce on scene after CPR if refractory asystole after 20 min, but I also need the family to be ok with that. If they want us to transport, we do.

Any other rhythm, have to call the doc, give the story. Depending on the age and hx, we may transport, may not. If the family wants us to transport we wont even call in this case.

Any arrest in a public place is automatically a transport.

Even so, if they go back into arrest while en route, it's good to have the lucas ready. (plus you can keep the arms up out of the way!) Can always pop it off while backing into the hospital bay if they maintain a pulse.
Unfortunately this is about our sogs too

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medicsb

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This is another in a long line of inventions, ideas, etc. that are great on paper, but do not pan out in the real world as one would expect.

I'm appreciate that the device can do as well as human CPR, but it IS cost prohibitive and i think the start up costs and the costs for ongoing maintenance is better spent on retraining and QA/QI. No one seems to want to say what its real potential is - to reduce need for additional personnel. That's all that is left from a marketing standpoint.

Also, these devices do cause injuries and I suspect that most go undiagnosed because the patient dies. But there are numerous case reports documenting these injuries and I'm willing to bet these may account for some of the poor results (relative to expectations). However, there is also plenty of documentation of serious injury after manual CPR. The questions is just how much more frequent with mechanical CPR and is it more severe? Based on some of he comparisons below, I suspect it the answer is yes and yes, but clearly better/more research needs to be done to determine if that is indeed true.

BMJ Case Rep. 2016 Feb 2;2016.
Ruptured subcapsular liver haematoma following mechanically-assisted cardiopulmonary resuscitation.

Resuscitation. 2015 Nov;96:226-31. .
Effects of mechanical chest compression device with a load-distributing band on post-resuscitation injuries identified by post-mortem computed tomography.
"Posterior rib fracture, hemoperitoneum, and retroperitoneal hemorrhage were significantly more frequent in the LDB-CPR group"

Resuscitation. 2014 Dec;85(12):1708-12.
CPR-related injuries after manual or mechanical chest compressions with the LUCAS™ device: a multicentre study of victims after unsuccessful resuscitation.
"75.9% in the manual CPR group and 91.4% in the mechanical CPR group (p=0.002) displayed CPR-related injuries"

Resuscitation. 2009 Oct;80(10):1104-7. doi: 10.1016/j.resuscitation.2009.06.010.
No difference in autopsy detected injuries in cardiac arrest patients treated with manual chest compressions compared with mechanical compressions with the LUCAS device--a pilot study.
However, I looked at the study:
For manual CPR: 0.68 injuries per use (all patients), 1.5 injuries per injured patient
For LUCAS CPR: 1.1 injuries per use (all patients), 1.9 injuries per injured pt.

Int J Legal Med. 2015 Sep;129(5):1035-42. doi: 10.1007/s00414-015-1146-x. Epub 2015 Jan 27.
Traumatic injuries after mechanical cardiopulmonary resuscitation (LUCAS2): a forensic autopsy study.
"A mean of 6.6 rib fractures per case was observed in the LUCAS2 group, but this was only 3.1 in the control group (p = 0.007)"

J Forensic Sci. 2013 Jul;58(4):904-9. doi: 10.1111/1556-4029.12146. Epub 2013 May 21.
Manual and automated cardiopulmonary resuscitation (CPR): a comparison of associated injury patterns.
"The characteristic pattern observed in manual-only CPR use included a high frequency of anterior rib fractures, sternal fractures, and midline chest abrasions along the sternum. The characteristic pattern observed in AutoPulse(®) CPR use included a high frequency of posterior rib fractures, skin abrasions located along the anterolateral chest and shoulder, vertebral fractures, and a few cases of visceral injuries including liver lacerations, splenic lacerations, and hemoperitoneum."


Citations from
Neth Heart J. 2014 Sep; 22(9): 404–407.
Complications of mechanical chest compression devices:

8. de Rooij PP, Wiendels DR, Snellen JP. Fatal complication secondary to mechanical chest compression device. Resuscitation. 2009;80:1214–5. [PubMed] [Cross Ref]

9. Hutchings AC, Darcy KJ, Cumberbatch GL. Tension pneumothorax secondary to automatic mechanical compression decompression device. Emerg Med J. 2009;26:145–6. [PubMed] [Cross Ref]

10. Wind J, Bekkers SC, van Hooren LJ, van Heurn LW. Extensive injury after use of a mechanical cardiopulmonary resuscitation device. Am J Emerg Med. 2009;27:1017–2. [PubMed] [Cross Ref]

11. Smekal D, Johansson J, Huzevka T, Rubertsson S. No difference in autopsy detected injuries in cardiac arrest patients treated with manual chest compressions compared with mechanical compressions with the LUCAS device–a pilot study. Resuscitation. 2009;80:1104–7. [PubMed] [Cross Ref]

12. Englund E, Kongstad PC. Active compression-decompression CPR necessitates follow-up post mortem. Resuscitation. 2006;68:161–2. [PubMed] [Cross Ref]

13. Spoormans I, Van HK, Balliu L, Jorens PG. Gastric perforation after cardiopulmonary resuscitation: review of the literature. Resuscitation. 2010;81:272–80. [PubMed][Cross Ref]

14. Sajith A, O’Donohue B, Roth RM, Khan RA. CT scan findings in oesophagogastric perforation after out of hospital cardiopulmonary resuscitation. Emerg Med J. 2008;25:115–6. [PubMed] [Cross Ref]

15. Luiz T, Ellinger K, Denz C. Active compression-decompression cardiopulmonary resuscitation does not improve survival in patients with prehospital cardiac arrest in a physician-manned emergency medical system. J Cardiothorac Vasc Anesth. 1996;10:178–86. [PubMed][Cross Ref]

16. Rabl W, Baubin M, Broinger G, Scheithauer R. Serious complications from active compression-decompression cardiopulmonary resuscitation. Int J Legal Med. 1996;109:84–9. [PubMed] [Cross Ref]

17. Baubin M, Sumann G, Rabl W, Eibl G, Wenzel V, Mair P. Increased frequency of thorax injuries with ACD-CPR. Resuscitation. 1999;41:33–8. [PubMed] [Cross Ref]

18. von Bary C, Hohenester S, Gaa J, Laugwitz KL. Liver laceration associated with the use of a chest compression device. Resuscitation. 2009;80:839. doi: 10.1016/j.resuscitation.2009.04.014. [PubMed][Cross Ref]

19. Camden JR, Carucci LR. Liver injury diagnosed on computed tomography after use of an automated cardiopulmonary resuscitation device. Emerg Radiol. 2011;18:429–31. doi: 10.1007/s10140-011-0949-4.[PubMed] [Cross Ref]

20. Liu N, Boyle K, Bertrand C, Bonnet F. Stomach rupture during CPR. Ann Emerg Med. 1996;27:105–6. doi: 10.1016/S0196-0644(96)70311-6. [PubMed] [Cross Ref]


 

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