The Merits of Mechanical CPR Experiences with LUCAS Mark D. Frank
Incidenz of sudden cardiac arrest - in Europe ca. 350000 humans p.a. - approx. 315000 are dying - in Germany approx. 100000 p.a. - ROSC 23.8% (10 50%) - Really only 2 10% (without neurological defizite CPC 1-2) - main cause is an acute Coronary syndrom (AMI) ca. 280000 p.a. - since 30 years no changing in survival rates Sasson C et al. Circulation 2009 (142740 Patienten)
Circulation 2009 142740 Patients Since 30 years nearly constant results
During a soccer game Miklos Feher from Benfica Lissabon was dying, because of sudden cardiac arrest. The conventional CPR was not succesful.
www.erc.edu ERC Guidelines 2010 Main intention: Reducing the No Flow Time 100 / min 5-6 cm depht
Importance of No Flow Time
All You need is flow! Editorial 81 (2010) Kjetil Sunde Cath- Lab Immediately Transport
% of patients w/ RO Coronary Perfusion Pressure < 15 mmhg does not achieve Return of Spontaneous Circulation 90% 80% n = 100 79% 70% 60% 50% 46% 40% 30% 20% 10% 0% 0% <15 15-25 >25 CPP (mm Hg) Paradis NA et al. JAMA 1990
Reducing the No Flow Time Performance in reality Implementing the guidelines into practical work Code Stat; Physio Control
Circumstances in Realitäty Time pressure less space to work less light different teams prior diseases Adipositas Aspiration Caregivers Equipment Affecting Quality of CPR
What is a good target? Reduction of stress for the medical team Focus on the patients problem Step back and realize what the patient needs
Diagnostic and Treatment of Patients with OHCA, IHCA Daily Routine?
Equipement Equipement Algorithm Algorithmus (Plan) Training Training Experience Erfahrung
Comression depht No Flow Ratio Only 50 % of the teams reached the Requirements of the guidelines
Mechanical Resuscitation: LUCAS
Mechanical Resuscitation: LUCAS LUCAS 100 Patients, no control group ROSC increased Steen S et al. Resuscitation 2005 140 Patients with manual CPR 150 Patients with LUCAS CPR ROSC significant increased Maule et al. Urgences and Accueil. 2007 Injuries according LUCAS vs manual similar (16/26 Pat. Autopsie) Smekal et al. Resuscitation 2009 Many case reports, case series, non randomised trials LINC Trial (2500 pat. until 2011)
Increased cortical cerebral blood flow with LUCAS Baseline 100% n = 14 pigs P= 0.041 P= 0.009 65% 40% LUCAS Manual Mean cerebral flow Endtidalt CO2 S. Rubertsson Resuscitation 2005
Outcomes [%] Mechanical CPR Manual CPR P-Value 4 hour survival 23.6 23.7 >.99 ROSC 35.4 34.6 0.68 Survival to discharge from ICU with CPC 1-2 Survival to Hospital discharge with CPC 1-2 6- Month Survival with CPC 1-2 7.5 6.4 0.83 8.3 7.8 0.25 8.5 7.6 0.61 CPC = Cerebral Performance Category
The LINC study protocol
n = 23 Outcomes LUCAS CPR Manual CPR P-Value Correct chest compressions During Flight [%] 100 41 < 0.001 Chest compression depth [%] 99 79 < 0.001 Pressure point [%] 100 79 < 0.001 Pressure release [%] 100 97 0.001 Time to first Defibrillation [sec] 112 49 < 0.001
Statement from the Swiss Resuscitation Council Notes for worsen neurological outcome and survival rate
No injuries: 42.1 vs 55.3
2012, 20:39
currently no evidence 2014
Innovation or Nonsense
Experience and practical Routine?? LOE 8: Grandfather- Rule
Implementation of LUCAS in Dresden, Germany Results 214.812 cases of emergency from 1/2005-12/2007 CPR in 724 cases (100 LUCAS) 67.3% male mean age females 73 Y, male 65 Y [1 Month - 100Y] mean rescue time 6.1 Min [0-24 min] 26 LUCAS 1 devices prehospital
Initial Rythm 70 60 50 40 30 Asystolie PEA VF Sonst 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 Frank MD, Andrä L, Haacke W et al. Intensivmed. 2008
First Results with regard to LUCAS 120 100 100 80 68 1 Survivor 60 51 40 20 17 0 Using LUCAS Admission to Hospital CPR during Transport ROSC at Hospital Frank et al. ICEM 2010
LUCAS Outcome?? Which Patients received LUCAS CPR? What are we calling a LUCAS CPR? Time slot to initiate LUCAS Abortion of CPR after doctor arrived on scene Pat provision was found during CPR Prior incurable disease Disability for dicision making- Transport with LUCAS
LUCAS 1
Reducing the No Flow Time Analysis every 2 Minutes? LUCAS 2
Learning curve First clinical data in Dresden miserable Increase of transports with ongoing CPR (2 x Rigor Mortis) Displacement of required decision making into the Hospital Positiv course in following years Which Patients have really a benefit? LUCAS CPR approx. 42 % in 2012
Learning curves regarding LUCAS 50 45 40 35 30 25 20 15 10 5 0 2006 2007 2008 2009 2010 2011 2012? ROSC ROSC-L Data evaluation in progress
et Carbon Dioxide during CPR 3 Carbondioxide [kpa] 2,5 n=22 2 1,5 manually Lucas 1 n=78 0,5 0 1-2 min 3-4 min 5-6 min 7-8 min 8-10 min 15 min 30 min Time [min] Data evaluation in progress
Hauptproblem Carbon Dioxide Case 1 Axelson et al. Resuscitation 2009 ( 126 Patients increasing of et CO 2 )
Transport with LUCAS we are resuscitating everyone?
An Option Pat. with acute coronary syndrome OHCA - CPR Transport with LUCAS Catheter Lab. ROSC Case 2
Case 3
Special Situations - multiple Trauma - Hypothermia - Intoxication - Thrombolysis in cardiac arrest - Transport with ongoing CPR - Others Advantage or Disadvantage???
Case 4 Car vs Bus, Pat trapped in the car, severe thoracic trauma, Cardiac arrest, CPR during transport and in ER
Fallbericht Case 5 Thoracic stab wound, CPR- ROSC, LUCAS CPR, Transport
Motorcycle accident, OHCA, Bystander CPR continuance with LUCAS Case 6
Case 7
Fall 1 Case 8
7 Accident; pat under vehicle Severe hipp injury- OHCA 1 - permissive Hypotension 2 - LUCAS 3 - ROTEM 1 5 coagulation factors 6 - Level I 7 - Team 2 6 4 5 3 Case 10
Manual CPR, Child 9 Y Case 11 OHCA cause unknown, Transport with ongoing CPR 1h to Hospital
Quality of CPR Training and CRM
Keep the overview
4 eyes will see more
Only together we can be successful
Teamwork
Presently there is no scientific evidence Conclusion LUCAS the endtidal Carbondioxide is increasing during LUCAS CPR and demonstrates good perfusion Injuries associated to LUCAS are possible like manuall CPR Transportation with ongoing CPR seems to be effective with LUCAS and is an option in several conditions LUCAS is not for relocate decisions into Hospital The use of LUCAS needs education and training to be more efficient The Quality of CPR Actions are essential (With and without mechanical Devices)
Foto: M. Frank
Afrika 2009
Point of View Marius Müller 4