20090808
2009 Sept 8
Charles Lick, MD
Mechanical CPR Devices Q and A
How Mechanical CPR Devices Are Changing EMS Protocols
- 2009 Sept 8
Q: Does the application of mechanical CPR devices delay or impact the patient's ability to receive CPR?
Dr Lick replies: We train our staff to start with manual CPR; then we change over to LUCAS while manual CPR is in progress. CPR delay can be very short (10–20 seconds) in training mode. Practically, CPR delay is 30–45 seconds in real patients.
Q: Where can I obtain the "pit crew" arrest cards Dr. Lick mentioned?
Dr Lick replies: Cards being updated. New version will be ready in a few weeks.
Q: Are there any differences in outcomes between prehospital ET patients and King/CombiTube patients?
Dr Lick replies: We are looking at that now. No definite info at this point.
Q: Are any major EMS systems using the mechanical devices?
Dr Lick replies: The following systems use LUCAS:
Anchorage Fire, Alaska;
Contra Costa County Fire, California;
Austin EMS, Texas;
Cypress Creek EMS, Houston, Texas;
County of York Virginia Fire, Virginia;
Kershaw County Medical Center;
Fairview University Hospital;
Miramar Fire, Florida;
Coon Rapids Fire;
Orangeburg County EMS;
City of La Porte EMS;
Coffee Regional Med Ctr;
Russel County Ambulance;
Abbott Northwestern;
Charleston Fire Dept;
Thompson Valley EMS; and
Port Chester Rye EMS
Q: Are you aware of any post-mortem findings that have caused medical examiners to question the use of the LUCUS like they have with the Autopulse?
Dr Lick replies: No
Q: Are these devices outfitted for obese patients? Do bigger patients require deeper compressions? Is there an adjustment that needs to be made in the field to consider the patient's size?
Dr Lick replies: AutoPulse adjusts automatically when you put the band on. LUCAS is adjusted by lowering the pressure pad to contact the sternum. Some patients are too large and some are too small, and LUCAS won’t fit. Same with AutoPulse, but our experience much more limited with AutoPulse.
Q: Are you advocating that first responders start giving non-certified classes to the general public?
Dr Lick replies: Yes. We use AHA CPR Anytime for lay people. Simple, fast, inexpensive, easy to learn -- only takes 22 minutes to learn CPR.
Q: I am an instructor. Would you say the most important thing involving CPR I can leave with students would be to minimize interruptions and allow for recoil?
Dr Lick replies: For lay people yes: per AHA- hard and fast (100BPM), minimize interruptions, and full recoil. For health care students, add No Hyperventilation also.
Q: Is the LUCAS effective coming down stairs?
Dr Lick replies: Yes. You can do effective CPR with LUCAS in a moving ambulance or a moving stretcher. Another advantage to mechanical CPR devices: crew safety--A. Don’t have to do CPR in moving ambulance, and B. Reduce back injuries??
Q: Do you expect the American Heart Association to make any significant recommendations during its next conference? Are we certain the new standards are working, and do you think the AHA will endorse a mechanical CPR device?
Dr Lick replies: Good question. I’m not aware of any pending changes. Historically, AHA has not endorsed specific products- AEDs, monitors etc.
Q: Do you bypass centers that do not continue prehospital induced hypothermia?
Dr Lick replies: All Mpls St Paul cardiac centers are cooling patients. If I was in a community where this was NOT the case, as ambulance medical director I would bypass hospitals that were not cooling patients. Take Heart America-Austin Tx did this.
Q: Do you see the hypothermia protocol extending to STEMI in the future?
Dr Lick replies: I am not aware of any research on hypothermia and STEMI. There is some work with hypothermia and stroke going on.
Q: Do you think pausing after 30 compressions to give two breaths does a better overall job than continuing compressions and fitting the breaths in between compressions?
Dr Lick replies: I don’t think we have the data at this point. This is a very hot topic, though.
Q: When your studies showed survival improvement with LUCAS versus without, was the AutoPulse used or just conventional CPR?
Dr Lick replies: LUCAS vs conventional manual CPR.
Q: In regards to securing airways during cardiac arrest resuscitation, OTI is the gold standard. What are your thoughts on the use of temporizing advanced airways to minimize any pause in compressions?
Dr Lick replies: It’s very intriguing to me to watch cardiac arrest resuscitation in real patients and in practice/simulation. When endotracheal intubation is performed, most other activities STOP (no chest compressions, no drugs, no shocks). For this reason, I’m curious to see if using alternative airways (King, Combitube, LMA, etc.) that are faster to place, will result in improved survival.
Q: Is there a difference between circumferential and piston-type devices?
Dr Lick replies: The mechanics of each device are quite different. I am not enough of an expert to describe.
Q: Have you had any experience with the LUCAS pressure pad causing trauma to the chest?
Dr Lick replies: Yes some minor trauma--bruising. No increase in rib fractures that I’m aware of.
Q: How do you feel about studies that recommend a ratio of about 50:2?
Dr Lick replies: Part of the ongoing CPR debate: continuous compressions, should we do ANY ventilations, 200:1, 50:2, 30:2.
Q: How does the ResQPOD affect capnography readings?
Dr Lick replies: We routinely get excellent capnography on cardiac arrest patients--20 to even 50s/60s. I think this is a testament to the improved circulation you get with ResQPod and LUCAS. We have even had a patient wake up with LUCAS/ResQPod/face mask on and say “turn that thing off.”
Q: I found it interesting that your EMS system is using only chemical ice packs to cool the patient. Was chilled IV NS considered? If so, what was the reason for not implementing chilled saline in addition to ice packs?
Dr Lick replies: To be honest, our performance with even the chemical ice packs has not been very good. Because of our short avg. transport times (~10 munites or so), and the fact that all Twin Cities hospitals are all cooling, raised the question whether a more aggressive approach would make any difference. The recent data from Abbott Northwestern Hospital (one Allina hospital) that showed a 29% relative increased risk of death if cooling delayed one hour is very compelling and we are reexamining this question.
Q: I understand the component that an increased tidal volume brings to the resuscitation event. What are your thoughts on decreasing Fi0?
Dr Lick replies: I have not seen any studies on this in cardiac arrest patients. With the decreased cardiac output during CPR even with these advanced devices, maximizing oxygen delivery still seems important.
Q: Who is the contact person for city officials who would like to participate in the third phase of the Take Heart America program?
Dr Lick replies: Contact Bob Niskanen--exec director Take Heart America www.takeheartamerica.org
Q: In rural sites where transport by EMS to a "cardiac arrest excellence center" is delayed or longer than 30 minutes, maybe even an hour by ground, how can EMS make a difference to the post-arrest victim?
Dr Lick replies: Cooling is probably number one. Patient probably needs to be paralyzed to prevent shivering which would raise the core temperature. Next is continuing stabilization of the patient. For these longer transports, I think you need to strongly consider helicopter if available--even from the scene. Helicopter brings advanced practice staff also.
Q: Is cooling PRIOR TO the need for CPR (i.e., cold water drowning), still beneficial, and should it be considered when performing first-responder CPR? Are you aware of any research on cooling prior to CPR in combination with cooling afterward?
Dr Lick replies: James Menagazzi, PhD at University of Pittsburgh, and his colleagues are very active in cardiac arrest research and have looked at this very question. They presented some early data @ NAEMSP a year or 2 ago that showed some survival improvement in animals in the lab with cooling during resuscitation. Stay tuned....
Q: Do you know how our volunteer rescue squad could become a participant in some of the ongoing or planned trials?
Dr Lick replies: I'm not aware that ROC or Rescue trials are adding participants at this time.
Q: In one of the hospitals where work, we provide continuous compressions (CCRs) with no ventilation interruption. Instead, an OPA is inserted and the patient is provided with 15 lpm O2 by non-rebreather mask. How can we incorporate the ITD using the CCR standard?
Dr Lick replies: Per Dr Keith Lurie--inventor of ResQPod ITD: "Without positive pressure ventilation the ITD should not be used. There are no data in support of continuous chest compressions without ventilation for patients in cardiac arrest by professionals, especially in the hospital."
Our experience and others supports current AHA recommendations: Rapid commencement of chest compressions, proper 2-handed face mask technique, along with the ITD and 30:2 with minimal time for each breath.
Davis SP, Thigpen K, Basol K, Aufderheide T, "Abstract 2687: Implementation of the 2005 American Heart Association Guidelines Together with the Impedance Threshold Device Improves Hospital Discharge Rates after In-Hospital Cardiac Arrest." Circulation. 118:S_785, 2008.
Q: Since LUCAS is now battery operated, what are your thoughts of placing the LUCAS in the public setting, such as an airport, for first responders to use with an AED? Outside of the cost, can an untrained bystander safely use one? Should they?
Dr Lick replies: Although it’s pretty easy to use, I think you would need some training for proper placement to work optimally.
Q: Some first responders keep AEDs in their vehicles. However, in the northern regions, the cold weather affects the battery life and effectiveness. Do you have any suggestions besides taking the units indoors?
Dr Lick replies: No
Q: We were provided the opportunity to field test the AutoPulse. There was an overwhelming challenge to convince the staff that this device actually improves survival. We even have a member in our community who was resuscitated in another community after 90 minutes of being on the AutoPulse. How can we work to prove the success of this device?
Dr Lick replies: What “staff?” Physician? Nursing? Paramedic? It’s hard being an early adopter. Patient survival is the best weapon we have to convince folks. Celebrate the saves and track your data well.
Q: What are the costs for ITD?
Dr Lick replies: $100 ea. $90 ea if you buy a case at a time
Q: Which mechanical devices do you recommend the most and why?
Dr Lick replies: We did a trial of 6 AutoPulse in fall 2006. I know LUCAS was coming. We trialed LUCAS also and found it superior (ease of use, size, logistics in ambulance, able to take patients to cath lab with LUCAS (you can X-ray thru it). In addition, LUCAS has a small amount of ACTIVE decompression vs. AutoPulse provides no active decompression. For these reasons, I believe (and many in my organization) that LUCAS is superior.
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Charles Lick, MD
Charles Lick, MD, is the medical director for Allina Medical Transportation, the medical director for Allina’s Buffalo Hospital Emergency Department and an emergency room physician. At AMT, Dr. Lick founded Allina’s Heart Safe Communities program, which was designed to increase the survival rate of out-of-hospital cardiac arrests by placing automated external defibrillators in public places. Throughout his career, Dr. Lick has worked with multiple community, health care and civic organizations to advance the cause of early defibrillation for sudden cardiac arrest. Dr. Lick is also medical director of Take Heart Anoka County and member of board of directors of Take Heart America- a national program to improve survival of cardiac arrest.