CPR Devices

[EMT19053]

JPINFV & skyemt

Thanks alot for the research info, it sure gives a person something to think about which was what I was looking for. I thought there might be some comments in support of the device though, lol. I will keep researching the device to possibly save the service a ton of money. Thanks for the help.

 

[skyemt]

ok, let's back up for a moment...

there are three phases of arrest...

Electrical, Circulatory, and Metabolic...

during the electrical phase, 0-4 minutes, early defib makes all the difference, and much more impact than CPR... this pt needs to get to the hospital PRONTO.

during the circulatory phase, 5-9 minutes, good quality CPR has the greatest effect on patient survival, and again, these patients need to be at the hospital.

it is only during the metabolic phase, post ten minutes, that the odds of ROSC diminish towards zero... perhaps they could be worked in the field, because not much matters..,

but, you're statements fly in the face of the first two stages of arrest...

i'm not sure if you are not well schooled in arrests, but your outlook on them is pretty far off... you seem to be lumping all patients who need CPR into the metabolic phase, but it just isn't that way.

between 4-10 minutes of arrest, these patients need good CPR and need to get to the hospital. Good CPR does make a difference in this time frame. this is research based, and not my opinion. maybe the medics will chime in here.

 

[JPINFV]

ok, let's back up for a moment...

there are three phases of arrest...

Electrical, Circulatory, and Metabolic...

during the electrical phase, 0-4 minutes, early defib makes all the difference, and much more impact than CPR... this pt needs to get to the hospital PRONTO.

That patient needs defibrillation. Too bad that often the time between onset and EMS patient contact is more than 4 minutes.

during the circulatory phase, 5-9 minutes, good quality CPR has the greatest effect on patient survival, and again, these patients need to be at the hospital.

Patient needs a paramedic. In and out of hospital arrests are managed similarly with paramedics present. Even then, response+assessment/on scene treatment [packaging, etc. The patient doesn't just appear in the ambulance of course]+transport is generally going to be more than 10 minutes.

it is only during the metabolic phase, post ten minutes, that the odds of ROSC diminish towards zero... perhaps they could be worked in the field, because not much matters..,

but, you're statements fly in the face of the first two stages of arrest...

That time starts at the start of the arrest, not at EMS arrival. So, unless you can teleport a patient, response+on scene treatment+transport is generally going to put you in stage 3. If you're on a paramedic unit, then the patient should be treated on scene.

i'm not sure if you are not well schooled in arrests, but your outlook on them is pretty far off... you seem to be lumping all patients who need CPR into the metabolic phase, but it just isn't that way.

between 4-10 minutes of arrest, these patients need good CPR and need to get to the hospital. Good CPR does make a difference in this time frame. this is research based, and not my opinion. maybe the medics will chime in here.

The patient needs a paramedic. If my outlook isn't so rosy on out of hospital arrests, then how come we can't get save [save being defined as minimal neuro defect upon discharge, not ROSC] rates above 5%? A paramedic does much more good for a patient with pulmonary edema circling the drain that they do trying to bring people back from the dead.

 

[skyemt]

umm... those times are from arrest to the start of treatment, not the time til packaging... most EMS arrivals occur during the second phase... defib can be done enroute to hospital...

the overall ROSC rates are significantly higher if you remove the third phase from study.

i don't mind contrary opinions... but, yours come without experience or study...you said earlier you wanted to be the devil's advocate... is it fun to take it ad finitum just to be contrary??

where are your facts or studies that say there is it is beneficial to work the code on scene in the first 9 minutes?

 

[Emtgirl21]

Okay now that everyone has said all this negative things about Zoll Auto Pulse. My company started using the autopulse about a year ago and we have seen an increase in code saves. Now factor in the part where you cant use it on kids or overly fat people and that kinda sucks. It gets your hands free for other functions such as BVM, pushing Meds and monitoring the cardiac monitor. Also if you look at the safety factor. You cant be buckled in standing up doing manual CPR. With the Autopulse you can sit down and do all your pt care of the bench or CPR seat and have someone BVM from the airway seat. We still run codes in Priority One so you really want to be restrainted.

Now its not to say that these patients walk out of the hospital. Cardiac arrest leads to MODS and some people die. Thats life sorry it happens but we have seen an increase in younger people who have walked out of the hospital and gone on to lead productives lives.

 

[JPINFV]

First off, since we are now discussing a completely different topic [cardiac arrest: Treat in the field vs immediate transport], I'm not playing devils advocate anymore. Cardiac arrests should be worked in the field until ROSC. If no ROSC is obtained, then these patients should be declared dead and not transported.


Why Are You Transporting Dead Patients? – The Final Chapter
Case in Point

By David Ross, DO

http://www.jems.com/news_and_articl...sporting_Dead_Patients_The_Final_Chapter.html

Discussion
These two cases are fairly representative of many cardiac arrest cases in the United States rapidly transported to an emergency department. Both outcomes of these cases are typical of patients likely to have received less than optimal pre-EMS arrival CPR.

Despite the vast amount of publicity, training, political posturing and dollars spent on community CPR, the survival rates are poor. In 1993, Kellerman and his colleagues 1 demonstrated a prehospital return of circulation (pulse regained) in 29% of 1,068 cardiac arrest patients treated by the Memphis Fire Department. But only 8% of the total cardiac arrest patients encountered left the hospital alive.

In the Kellerman study, 71% of the arrest victims did not regain a pulse in the field. Nevertheless, they were all transported emergently to a hospital. Of these patients, only three (0.28%) survived to hospital discharge. All three had moderate to severe neurologic deficits.

In 1993, an article by Bonin 2 suggested annual costs in the United States associated with EMS transports of non-responding patients in cardiac arrest approached $500 million.

What follows is a review of some of the literature accompanied by my editorial opinion regarding CPR initiation the field and subsequent transport to a hospital. It is by no means a fully comprehensive look at the practice but enough to make some supportable recommendations.

Once CPR has been initiated in a specific patient, the key is identification of factors that might predict at least a return of circulation. (Note that return of circulation does not in any way equal survival to hospital discharge).
Once again, the Kellerman study provides insight. In this article, the factors that appeared to be associated with a return of circulation in the field included:

1. The cardiac arrest was witnessed - either by bystanders or EMS.
2. The presenting cardiac rhythm was ventricular fibrillation (or shockable on an AED).

Many other papers have specifically noted that the absence of bystander CPR is also associated with failure to establish a return of circulation.
...
The paper by Bonin and his group suggests a time maximum of 25-30 minutes of advanced cardiac life support. A panel of experts in 2001 concluded that a time limit of 30 minutes was reasonable and that the patient should be treated on scene [emphasis not added] until either the 30 minute limit was reached or the patient demonstrated a return of circulation or developed a shockable rhythm.

BLS versus ALS
Many studies (but not all) evaluating the withholding or cessation of CPR from an ALS perspective address or require the presence of ALS providers. This is likely due to medical/legal fears that the highest level of care be available to assess a patient before a decision is made with regard to CPR. However, in large areas of the country, ALS may not be on scene in any reasonable time frame. Therefore, BLS judgment has to be a factor.

The medical literature suggests that a patient’s inability to generate a return of circulation in the absence of a shockable rhythm (after a period of good CPR, as discussed above) merits consideration of cessation of CPR – with the agreement of medical control.13, 14

A randomized, controlled comparison of cardiopulmonary resuscitation performed on the floor and on a moving ambulance stretcher.

BACKGROUND: Recent studies have demonstrated that cardiopulmonary resuscitation (CPR) of poor quality is associated with worsened outcomes.

OBJECTIVE: To compare the quality of CPR delivered on the floor with the quality of CPR delivered on a moving stretcher. The authors hypothesized that CPR performed on the floor would be superior to that performed on a moving stretcher.

METHODS: A randomized, crossover experimental design was used. Subjects included emergency medical technician students, paramedic students, and emergency medicine residents. Two-member teams were randomly assigned to perform two-rescuer CPR on a manikin either on the floor or on a moving stretcher. After a 5-minute rest, the teams performed CPR under the opposite condition. Compression and ventilation data were collected using a recording resuscitation manikin. Dependent variables were compression depth, compression rate per minute, percentage of correct chest compressions, tidal volume, and percentage of correct ventilations. Data were compared using two-tailed paired t-test.

RESULTS: Sixty-two subjects completed the study. The mean compression depth performed on the floor (39 +/- 9 mm) was greater than that on a moving stretcher (28 +/- 9 mm) (p < 0.001). The mean rates of chest compressions on the floor (110 +/- 17 beats/min) and on a moving stretcher (113 +/- 21 beats/min) were not different (p = 0.49). The percentage of correct compressions performed on the floor (54% +/- 40%) exceeded that on a moving stretcher (21% +/- 29%)(p < 0.001). The percentage of correct ventilations performed on the floor (43% +/- 26%) was greater than that on a moving stretcher (24% +/- 21%)(p < 0.04). CONCLUSIONS: Chest compression and ventilation quality of CPR performed on the floor was superior to that of CPR performed on a moving stretcher in this manikin model. The quality of CPR while moving was significantly compromised.

http://www.ncbi.nlm.nih.gov/pubmed/16418093

Dr. Bledsoe's commentary on that article:
http://merginet.com/index.cfm?pg=cardiac&fn=CPRstretcher

Termination of Resuscitation Rule Has Implications for BLS

The survival rate was 0.5% among patients whose condition met the three criteria of the termination rule. Of the 776 patients who met the criteria of the termination rule, 772 died. Of the four who survived, three were discharged with good cerebral performance and one had severe cerebral disability.

http://merginet.com/index.cfm?pg=cardiac&fn=TORrule

 

[JPINFV]

Validation of a Rule for Termination of Resuscitation in Out-of-Hospital Cardiac Arrest
Laurie J. Morrison, M.D., Laura M. Visentin, B.Sc., Alex Kiss, Ph.D., Rob Theriault, Don Eby, M.D., Marian Vermeulen, B.Sc.N., M.H.Sc., Jonathan Sherbino, M.D., P. Richard Verbeek, M.D., for the TOR Investigators

ABSTRACT

Background We prospectively evaluated a clinical prediction rule to be used by emergency medical technicians (EMTs) trained in the use of an automated external defibrillator for the termination of basic life support resuscitative efforts during out-of-hospital cardiac arrest. The rule recommends termination when there is no return of spontaneous circulation, no shocks are administered, and the arrest is not witnessed by emergency medical-services personnel. Otherwise, the rule recommends transportation to the hospital, in accordance with routine practice.

Methods The study included 24 emergency medical systems in Ontario, Canada. All patients 18 years of age or older who had an arrest of presumed cardiac cause and who were treated by EMTs trained in the use of an automated external defibrillator were included. The patients were treated according to standard guidelines. Characteristics of diagnostic tests for the prediction rule were calculated. These characteristics include sensitivity, specificity, and positive and negative predictive values.

Results Follow-up data were obtained for all 1240 patients. Of 776 patients with cardiac arrest for whom the rule recommended termination, 4 survived (0.5 percent). The rule had a specificity of 90.2 percent for recommending transport of survivors to the emergency department and had a positive predictive value for death of 99.5 percent when termination was recommended. Implementation of this rule would result in a decrease in the rate of transportation from 100 percent of patients to 37.4 percent. The addition of other criteria (a response interval greater than eight minutes or a cardiac arrest not witnessed by a bystander) would further improve both the specificity and positive predictive value of the rule but would result in the transportation of a larger proportion of patients.

Conclusions The use of a clinical prediction rule for the termination of resuscitation may help clinicians decide whether to terminate basic life support resuscitative efforts in patients having an out-of-hospital cardiac arrest.

http://content.nejm.org/cgi/content...b9d2ec6eeaafdb07182aba7c&keytype2=tf_ipsecsha

National Association of EMS Physicians Position paper

TERMINATION OF RESUSCITATION IN THE PREHOSPITAL SETTING FOR ADULT PATIENTS SUFFERING NONTRAUMATIC CARDIAC ARREST
E. David Bailey, MD, Gerald C. Wydro, MD, David C. Cone, MD, for the National Association of EMS Physicians Standards and Clinical Practice Committee
190
ABSTRACT
The National Association of EMS Physicians (NAEMSP) supports out-ofhospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of “do not resuscitate” or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm
changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the onscene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling.

 

[JPINFV]

So, now it's your turn. Show me evidence that transport improves outcomes in cardiac arrest patients. BLS or ALS [some of the articles above included articles affirming prehosptial determination of death in BLS crews as well as ALS crews]. You say with out study or experience, well, I'll take science over tradition any day of the week.

 

[BossyCow]

There is one big difference between strapping a machine on the patient and sitting back 'safely' in your seat and doing hands on CPR. One is passive and the other is active. When you are doing hands on CPR you are looking at the patient, touching the patient and subconsciously monitoring a bunch of different subtle signs and symptoms of that patient. You are involved in patient care. Sitting back, not touching the patient, secure in the knowledge that a machine is doing your job for you, I believe would cause you to feel distanced and removed from the process.

Yes we need to be safe. Yes we need to minimize risk to EMS providers, but if your driver isn't a hot-dog, and you are careful, the risk I believe is about the same as driving in my regular car. I run the risk of some other idiot on the road, doing something stupid and hitting me. I'm not willing to compromise patient care for that possibility.

Personally I believe we should be encouraging EMS providers to become more rather than less connected to the actual hands on care of their patients. We need to observe and monitor the patient, not just the machine attached to them.

 

[skyemt]

Bossy, i agree wholeheartedly...

JPINFV, i really have no idea how to respond... who was talking about terminating CPR on people who are not responding at all... I certainly wasn't!!!
don't really have any idea how you got onto that tangent...

what we were talking about, was getting to a patient within the first 10 minutes of arrest, and treating them and getting them to the hospital...

heck, even in the article you cited by Brian Bledsoe, he stated the poor outcomes were for arrests where treatment wasn't started for over 10 minutes...

sorry, you didn't post anything relating to my point... the termination rule is not for all those who can be helped, but for those who obviously can't... even i agree with that.

you are mixing and changing issues, and frankly it takes too much energy to try to follow you through your argumentative maze.

but, you want me to agree... ok, for those that are reached after 10 minutes, and do not respond to any treatments, and are obviously dead, then i will agree with the termination rule. feel better? of course, that has nothing to do with what we were talking about. LOL......

 

[JPINFV]

There should be no ambigouity. You are stating that cardiac arrest patients should be transported. I am stating that cardiac arrest patients should not be transported without ROSC. Period. The science, as seen by the poor outcomes and validation of field determination of death, side with the argument that no ROSC=no transport.

This goes back to safety and effective CPR during transit [CPR in a moving vehicle is not effective when done manually and presents a safety hazard to the crew] and my comment about the utility of a mechanical as a safety device. This facet of mechanical CPR devices was neglected. Which goes back to the argument, of which you have presented no actual evidence that transporting a patient to the hospital results in a higher ROSC.

So, do you have evidence that cardiac arrest patients, especially those in the hands of paramedics, have better outcomes when transported to the emergency department than those worked in the field till either declaration of death or ROSC? Regardless of the patients downtime [i.e. witnessed by bystanders].

 

[skyemt]

There should be no ambigouity. You are stating that cardiac arrest patients should be transported. I am stating that cardiac arrest patients should not be transported without ROSC. Period.

JPINFV, really... whatever...
you said you thought the autopulse was a good idea because it would be safer during transport... then you are talking about never transporting when they need cpr... enough already... please!


ok,, back to the original point of this thread, it does not seem like there is yet a good reason to use these devices... i totally agree with bossy, that EMS needs to be active in the standard of care delivered to the patient... i don't see how being passive and letting a device, one that has no real apparent benefit at that, deliver care to a patient does that patient any justice at all.

 

[Markhk]

The ASPIRE trial (which is quoted above) is not without its faults in the study. If you look at the data, it's a little disconcerting how different each EMS agency involved differed in their "hands off" time and the time it took them to apply the Autopulse. I'm not a sales rep for Zoll, but even I see holes in the ASPIRE study that makes me not want to discount the device just yet.

Although I do admit I am surprised the device still only compresses at 80/min. The Physio-Control LUCAS CPR device compresses at 100/min and provides active decompression, which is more in line with the science we have on the table right now on what works.

 

[JPINFV]

Just to note, the ASPIRE trial was one of the two trials that the JAMA artical the OP linked to referenced.

 

[reaper]

Does that mean that pt's should not be put on vent's? They are mech. devices and allows hands off work. Should we have someone bagging a pt round the clock, since this would be hands on pt care?

If they can design a device that works, it would be stupid not to use it. Just because you are not doing manual compressions, does not mean you are not providing pt care.

Let's just stick to the science if they work or not. I have not read a study that proved one way or the other. We don't use them, so I have no first hand basis about if they work. But, I will not put them down, until I see proof that they don't!

Just my .02 worth!

 

[skyemt]

Does that mean that pt's should not be put on vent's? They are mech. devices and allows hands off work. Should we have someone bagging a pt round the clock, since this would be hands on pt care?

If they can design a device that works, it would be stupid not to use it. Just because you are not doing manual compressions, does not mean you are not providing pt care.

Let's just stick to the science if they work or not. I have not read a study that proved one way or the other. We don't use them, so I have no first hand basis about if they work. But, I will not put them down, until I see proof that they don't!

Just my .02 worth!

Reaper, you raise a good point...

i think the issue, however, was one of intent... if a device was proven to be equal or more effective, freeing up a rescuer to do other things, i don't see anyone taking issue with that...

if one (which studies say is actually worse) is used, however, for the convenience and benefit of the EMT, having no consideration of the patient, there will be an issue... it just won't sit well with many, because it is supposed to be about patient care, not EMT care...

if there are valid uses, beneficial to the patient, for mechanical devices, of course i'd be all for it.

 

[BossyCow]

If they can design a device that works, it would be stupid not to use it. Just because you are not doing manual compressions, does not mean you are not providing pt care.

The post stated that the device was to be used while the EMT sits 'safely belted into their seat'. I don't know about you, but I can't do pt care belted into my seat. My point is that if your driver is driving safely, you have a low risk of injury. I am not going to base my pt. care decisions on what can I do while seatbelted.

 

[eggshen]

The only need I can see for this device (urban system) is carrying an arrest (that you have to work) down 3 flights of stairs in some Victorian era house. The rest (compressions) can be managed by the FD. The one save out of a thousand will never justify the cost. Boring conversation anyway.

Egg