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Course Objectives

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Course Objectives

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    1. Course Objectives CPR: Ongoing Challenges. New Solutions. October 2007

    2. This program was made possible by an educational grant from ZOLL Medical Corporation.

    3. Faculty & Planning Committee Disclosures Benjamin S. Abella, MD, MPhil 1. Paid honorarium for participation in this program. Has also received honoraria for other educational activities (article, speaking engagement) performed on behalf of the sponsoring organization. 2. No product that is not labeled for the use under discussion was discussed. 3. No preliminary research data was disclosed. Joseph P. Ornato, MD, FACP, FACC, FACEP 1. Paid honorarium for participation in this program. Serves as a member of the Scientific Advisory Board of the sponsoring organization. 2. No product that is not labeled for the use under discussion was discussed. 3. No preliminary research data was disclosed.

    4. Target Audience • Physicians • Nurses • Paramedics • EMTs • Resuscitation Researchers

    5. Objectives Upon completion of this program, the viewer will be able to: Discuss the effects of chest compression on Coronary Perfusion (CPP) and Return of Spontaneous Circulation (ROSC) List at least three changes in the 2005 AHA Guidelines that relate to CPR performance Discuss the outcome of at least one clinical study and one pre-hospital study on the effects of survival with load-distributing band CPR Discuss the rationale for implementing CPR prior to defibrillation in cases with extended down time

    6. Key Terms and Abbreviations AHA American Heart Association A-CPR AutoPulse CPR C-CPR Conventional CPR CPP Coronary Perfusion Pressure Deploy To implement and position for readiness Downtime Number of minutes from onset of sudden cardiac arrest to initiation of resuscitation efforts

    7. Key Terms and Abbreviations Duty cycle The time is takes to complete one cycle ECC Emergency Cardiovascular Care LDB Load-distributing band ROSC Return of Spontaneous Circulation SCA Sudden Cardiac Arrest VF Ventricular Fibrillation

    8. Circulation is Critical for Survival Provides oxygen to preserve vital organ function Converts non-shockable rhythms (asystole, PEA) to shockable ones (VF, VT) More than half of all arrests involve non-shockable rhythms Circulation is critical for survival. Not only does it provide oxygen to preserve vital organs, but it also helps to convert non-shockable rhythms such as asystole and PEA to shockable ones such as VF and VT. Further, more that half of all in-hospital codes involve non-shockable rhythms. The National Registry for Cardiopulmonary Resuscitation reports that this number is 75% for its member hospitals.Circulation is critical for survival. Not only does it provide oxygen to preserve vital organs, but it also helps to convert non-shockable rhythms such as asystole and PEA to shockable ones such as VF and VT. Further, more that half of all in-hospital codes involve non-shockable rhythms. The National Registry for Cardiopulmonary Resuscitation reports that this number is 75% for its member hospitals.

    9. Presenting Rhythms in SCA Recent studies show that VF or VT is the initial rhythm less than 50% of the time Recent studies have shown that VF and VT are the presenting rhythms in significantly less than half the cases of sudden cardiac arrest. Peberdy and Kaye reported that these shockable rhythms occurred in only 25% of hospital cases and Cobb found the incidence to be only 41% in the emergency medical service setting. Recent studies have shown that VF and VT are the presenting rhythms in significantly less than half the cases of sudden cardiac arrest. Peberdy and Kaye reported that these shockable rhythms occurred in only 25% of hospital cases and Cobb found the incidence to be only 41% in the emergency medical service setting.

    10. Why are they non-shockable more than half the time? EMS Long response times Hospital Some drugs (e.g., calcium channel blockers and beta blockers) significantly shorten the time in which a person is in VF Presenting Rhythms in SCA Presenting rhythms in sudden cardiac arrest are non-shockable more than half the time for a variety of reasons. In the EMS setting, long response times are the primary reasons. In hospitals, some drugs such as calcium channel blockers and beta blockers may significantly shorten the time in which a person is in VF.Presenting rhythms in sudden cardiac arrest are non-shockable more than half the time for a variety of reasons. In the EMS setting, long response times are the primary reasons. In hospitals, some drugs such as calcium channel blockers and beta blockers may significantly shorten the time in which a person is in VF.

    11. Coronary Perfusion Pressure According to the American Heart Association’s Guidelines 2000, “The important pressure for perfusion of the myocardium is coronary perfusion pressure…”. Coronary perfusion pressure (CPP) is an invasive research technique that is neither routinely available nor practical in the resuscitation setting. However, the desirability of increasing CPP has tremendous clinical significance. Coronary perfusion pressure is calculated by subtracting right arterial pressure (RAP) from aortic pressure (AP) during diastole. Aortic pressure is the driving force behind coronary blood flow, but blood flow to the myocardium is resisted by the pressure in the coronary venous system. Therefore, the driving force for coronary blood flow (aortic pressure) less the pressure resisting flow (right atrial pressure) yields the blood pressure gradient for that vascular bed and blood flow is directly related to this pressure gradient. Simply put, CPP is a measurement of the pressure sending blood flow into the coronary arteries minus the pressure in the coronary veins that it has to push against. According to the American Heart Association’s Guidelines 2000, “The important pressure for perfusion of the myocardium is coronary perfusion pressure…”. Coronary perfusion pressure (CPP) is an invasive research technique that is neither routinely available nor practical in the resuscitation setting. However, the desirability of increasing CPP has tremendous clinical significance. Coronary perfusion pressure is calculated by subtracting right arterial pressure (RAP) from aortic pressure (AP) during diastole. Aortic pressure is the driving force behind coronary blood flow, but blood flow to the myocardium is resisted by the pressure in the coronary venous system. Therefore, the driving force for coronary blood flow (aortic pressure) less the pressure resisting flow (right atrial pressure) yields the blood pressure gradient for that vascular bed and blood flow is directly related to this pressure gradient. Simply put, CPP is a measurement of the pressure sending blood flow into the coronary arteries minus the pressure in the coronary veins that it has to push against.

    12. Coronary Perfusion and ROSC Previous research has shown that the amount of coronary blood flow (measured as CPP) is linked to ROSC and survival. In a landmark human study published in the Journal of the American Medical Association (JAMA), Dr. Norman Paradis confirmed these results. In 100 Emergency Department patients, the minimal threshold for ROSC was found to be at 15 mmHg. No patient with a CPP under 15 mmHg was resuscitated. A CPP above 15 mmHg did not guarantee ROSC, but the higher the CPP (the more blood flow into the coronary blood vessels) the more likely the patient was going to achieve ROSC. If we are able to better supply the myocardium with blood and oxygen, it is more responsive to defibrillation. It is very difficult to achieve and sustain a CPP of 15 mmHg with conventional CPR. In more than half of the patients in this, 58%, conventional CPR never achieved the important threshold of 15 mmHg.Previous research has shown that the amount of coronary blood flow (measured as CPP) is linked to ROSC and survival. In a landmark human study published in the Journal of the American Medical Association (JAMA), Dr. Norman Paradis confirmed these results. In 100 Emergency Department patients, the minimal threshold for ROSC was found to be at 15 mmHg. No patient with a CPP under 15 mmHg was resuscitated. A CPP above 15 mmHg did not guarantee ROSC, but the higher the CPP (the more blood flow into the coronary blood vessels) the more likely the patient was going to achieve ROSC. If we are able to better supply the myocardium with blood and oxygen, it is more responsive to defibrillation. It is very difficult to achieve and sustain a CPP of 15 mmHg with conventional CPR. In more than half of the patients in this, 58%, conventional CPR never achieved the important threshold of 15 mmHg.

    13. CPP and ROSC (Paradis et al.) Victims with CPP < 15 mmHg do not achieve ROSC With conventional CPR, the overall mean CPP = 12.5 The clearest link between CPP and the likelihood of a return of spontaneous circulation (ROSC) has been documented by Dr. Norman Paradis in a study published in the Journal of the American Medical Association (JAMA) in 1990. In this study, CPPs were measured in 100 Emergency Department cardiac arrest patients during conventional CPR. A definite correlation was noted between peak CPP and ROSC. In order to eliminate the effects of fatigue and inconsistencies inherent in manual CPR, the Thumper? system (Michigan Instruments) was used as a surrogate for manual CPR. 79% of the 14 patients with a CPP greater than 25 mm Hg had ROSC, while no patient with a CPP of less than 15 mm Hg experienced ROSC. Clearly, if we can better supply the myocardium with blood and oxygen, it is more responsive to defibrillation. The problem is the difficulty in achieving and maintaining CPP above 15 mm Hg by conventional CPR. In the 100 patients studied, conventional CPR provided a mean CPP of only 12.5 mm Hg. In 58% of the patients, conventional CPR never achieved the important threshold CPP of 15 mm Hg. The clearest link between CPP and the likelihood of a return of spontaneous circulation (ROSC) has been documented by Dr. Norman Paradis in a study published in the Journal of the American Medical Association (JAMA) in 1990. In this study, CPPs were measured in 100 Emergency Department cardiac arrest patients during conventional CPR. A definite correlation was noted between peak CPP and ROSC. In order to eliminate the effects of fatigue and inconsistencies inherent in manual CPR, the Thumper? system (Michigan Instruments) was used as a surrogate for manual CPR. 79% of the 14 patients with a CPP greater than 25 mm Hg had ROSC, while no patient with a CPP of less than 15 mm Hg experienced ROSC. Clearly, if we can better supply the myocardium with blood and oxygen, it is more responsive to defibrillation. The problem is the difficulty in achieving and maintaining CPP above 15 mm Hg by conventional CPR. In the 100 patients studied, conventional CPR provided a mean CPP of only 12.5 mm Hg. In 58% of the patients, conventional CPR never achieved the important threshold CPP of 15 mm Hg.

    14. AHA Guidelines 2005: CPR “Simply put: …push hard, push fast, allow full chest recoil, minimize interruptions in compressions…” The American Heart Association’s Guidelines 2005 emphasize the importance of effective, uninterrupted chest compressions. The AutoPulse meets all of the recommendations put forth in this particular excerpt: it pushes hard, pushes fast, allows full chest recoil and minimizes interruptions.The American Heart Association’s Guidelines 2005 emphasize the importance of effective, uninterrupted chest compressions. The AutoPulse meets all of the recommendations put forth in this particular excerpt: it pushes hard, pushes fast, allows full chest recoil and minimizes interruptions.

    15. AHA Guidelines 2005: CPR High quality, consistent and uninterrupted chest compressions Push hard, push fast Compression to ventilation ratio: 30:2 Rate: 100 manual compressions per minute Depth: 1˝ - 2 inches / 4 - 5 centimeters Duty cycle: 50% - 50% Ventilation: 8 -10 breaths per minute Specific recommendations in the American Heart Association’s Guidelines 2005 include: High quality, consistent and uninterrupted chest compressions Push hard, push fast Compression to ventilation ratio: 30:2 Rate: 100 manual compressions per minute Depth: 1˝ - 2 inches / 4 - 5 centimeters Duty cycle: 50% - 50% Ventilation: 8 -10 breaths per minuteSpecific recommendations in the American Heart Association’s Guidelines 2005 include: High quality, consistent and uninterrupted chest compressions Push hard, push fast Compression to ventilation ratio: 30:2 Rate: 100 manual compressions per minute Depth: 1˝ - 2 inches / 4 - 5 centimeters Duty cycle: 50% - 50% Ventilation: 8 -10 breaths per minute

    16. CPR Challenges Poor quality Inconsistent rate, depth, duty cycle Harmful interruptions Required due to clinician fatigue, patient transport Inadequate cerebral and coronary perfusion Ineffective defibrillation support Although CPR will continue to be a frontline treatment for the sudden cardiac arrest, there are very significant challenges: The quality of human CPR is poor: we find it difficult to consistently maintain the appropriate rate, depth and duty cycle for any length of time, Interruptions due to fatigue, patient transport, etc. are extremely harmful, Cerebral and coronary perfusion are extremely inadequate, and It doesn’t provide effective support for defibrillation. More specific evidence related to each of these bullets will be covered in subsequent slides. Although CPR will continue to be a frontline treatment for the sudden cardiac arrest, there are very significant challenges: The quality of human CPR is poor: we find it difficult to consistently maintain the appropriate rate, depth and duty cycle for any length of time, Interruptions due to fatigue, patient transport, etc. are extremely harmful, Cerebral and coronary perfusion are extremely inadequate, and It doesn’t provide effective support for defibrillation. More specific evidence related to each of these bullets will be covered in subsequent slides.

    17. CPR Challenges: Quality (Abella et al.) “…quality of multiple parameters of CPR was inconsistent and often did not meet published guideline recommendations….” A very important study done by Dr. Benjamin Abella and his colleagues showed that the “…quality of multiple parameters of CPR was inconsistent and often did not meet published guideline recommendations….” This group showed that during the first five minutes of in-hospital CPR by trained professionals: The rate was too low (< 90 compressions per minute) 28.1% of the time, The depth was too shallow (< 1.5 in) 37.4% of the time, and The ventilation rate was too high (> 20 per minute) 60.9% of the time. A very important study done by Dr. Benjamin Abella and his colleagues showed that the “…quality of multiple parameters of CPR was inconsistent and often did not meet published guideline recommendations….” This group showed that during the first five minutes of in-hospital CPR by trained professionals: The rate was too low (< 90 compressions per minute) 28.1% of the time, The depth was too shallow (< 1.5 in) 37.4% of the time, and The ventilation rate was too high (> 20 per minute) 60.9% of the time.

    18. CPR Challenges: Quality (Abella et al.) This is a graphic representation of Dr. Abella’s results. As you can see, there is tremendous opportunity for improvement of in-hospital CPR.This is a graphic representation of Dr. Abella’s results. As you can see, there is tremendous opportunity for improvement of in-hospital CPR.

    19. CPR Challenges: Quality (Wik et al.) “…chest compressions were not delivered half of the time, and most compressions were too shallow…” In a study of treatment for out-of-hospital cardiac arrest, Wik and his colleagues found that chest compressions were not delivered nearly half the time, and most of the compressions delivered were too shallow.In a study of treatment for out-of-hospital cardiac arrest, Wik and his colleagues found that chest compressions were not delivered nearly half the time, and most of the compressions delivered were too shallow.

    20. CPR Challenges: Quality CPR feedback to rescuers can help improve CPR quality Elkadi et al. Pre-hospital Emergency Care. 2005;8:81-82. Handley et al. Resuscitation. 2003;57:57-62. Recent studies have shown that research provided to rescuers can help improve the quality of CPR.Recent studies have shown that research provided to rescuers can help improve the quality of CPR.

    21. CPR Challenges: Hyperventilation Aufderheide and his colleagues found that hyperventilation induces hypotension. This study showed that the mean ventilation rate by professional EMS rescuers was 30/minute ± 3.2. One group did 37/minute ± 4, then 22/minute ± 3 after some retraining. With permission - Dr.Benjamin Abella - “Rediscovering the Importance of CPR” presented at AACN National Teaching institute May 2005Aufderheide and his colleagues found that hyperventilation induces hypotension. This study showed that the mean ventilation rate by professional EMS rescuers was 30/minute ± 3.2. One group did 37/minute ± 4, then 22/minute ± 3 after some retraining. With permission - Dr.Benjamin Abella - “Rediscovering the Importance of CPR” presented at AACN National Teaching institute May 2005

    22. Future of CPR Quality Study An international consortium for CPR data collection is underway in Oslo, Norway; Vienna, Austria; London, UK; Stockholm, Sweden and Chicago, USA. Phase I of this study involves collection of baseline CPR quality data; Phase II involves implementation of a feedback system to monitor and improve CPR performance. With permission - Dr.Benjamin Abella - “Rediscovering the Importance of CPR,” presented at AACN National Teaching institute May 2005. An international consortium for CPR data collection is underway in Oslo, Norway; Vienna, Austria; London, UK; Stockholm, Sweden and Chicago, USA. Phase I of this study involves collection of baseline CPR quality data; Phase II involves implementation of a feedback system to monitor and improve CPR performance. With permission - Dr.Benjamin Abella - “Rediscovering the Importance of CPR,” presented at AACN National Teaching institute May 2005.

    23. CPR Challenges: Interruptions 77% decrease in ROSC when pre-shock time increased from </= 9.7 seconds to </= 22.5 seconds Interruptions in manual chest compressions can have a harmful effect on resuscitation efforts. Dr. Dana Edelson, Dr. Benjamin Abella and others showed that when the pre-shock time increased from </= 9.7 seconds to </= 22.5 seconds, there was a dramatic 77% decrease in return of spontaneous circulation (also know as ROSC). Interruptions in manual chest compressions can have a harmful effect on resuscitation efforts. Dr. Dana Edelson, Dr. Benjamin Abella and others showed that when the pre-shock time increased from </= 9.7 seconds to </= 22.5 seconds, there was a dramatic 77% decrease in return of spontaneous circulation (also know as ROSC).

    24. CPR Challenges: Interruptions (Kern et al.) “…Any technique that minimizes lengthy interruptions of chest compressions during the first 10 to 15 minutes of basic life support should be given serious consideration in future efforts to improve outcome results from cardiac arrest….” Kern and his colleagues also studies the negative effects of pausing. They concluded that “…Any technique that minimizes lengthy interruptions of chest compressions during the first 10 to 15 minutes of basic life support should be given serious consideration in future efforts to improve outcome results from cardiac arrest….” In this particular study, the no-flow time was a whopping 62%. Kern and his colleagues also studies the negative effects of pausing. They concluded that “…Any technique that minimizes lengthy interruptions of chest compressions during the first 10 to 15 minutes of basic life support should be given serious consideration in future efforts to improve outcome results from cardiac arrest….” In this particular study, the no-flow time was a whopping 62%.

    25. CPR Challenges: Interruptions (Berg et al.) Berg and his colleagues showed that interrupting chest compressions for rescue breathing can adversely affect hemodynamics during CPR for VF. It is very clear from looking at this graph that blood pressure drops significantly when compressions are stopped. Further, it takes several compressions for the pressure to return to its pre-pause level. With permission - Dr.Benjamin Abella - “Rediscovering the Importance of CPR,” presented at AACN National Teaching institute May 2005. Berg and his colleagues showed that interrupting chest compressions for rescue breathing can adversely affect hemodynamics during CPR for VF. It is very clear from looking at this graph that blood pressure drops significantly when compressions are stopped. Further, it takes several compressions for the pressure to return to its pre-pause level. With permission - Dr.Benjamin Abella - “Rediscovering the Importance of CPR,” presented at AACN National Teaching institute May 2005.

    26. CPR Challenges: Perfusion (Kern) Manual CPR provides less than optimal blood flow to the heart and brain. In fact, Kern et al. writes that the heart typically experiences only about 10-20% of normal blood flow, and the brain only 30-40%.Manual CPR provides less than optimal blood flow to the heart and brain. In fact, Kern et al. writes that the heart typically experiences only about 10-20% of normal blood flow, and the brain only 30-40%.

    27. CPR Challenges: Defibrillation Support After approximately 4 minutes of VF, the myocardium is nearly depleted of adenosine triphosphate (ATP), a vital energy source needed for successful defibrillation. The breakdown of ATP leads to adenosine diphosphate (ADP). After approximately 4 minutes of VF, the myocardium is nearly depleted of adenosine triphosphate (ATP), a vital energy source needed for successful defibrillation. The breakdown of ATP leads to adenosine diphosphate (ADP).

    28. CPR Challenges: Defibrillation Support Effective compressions help restore ATP, increasing the likelihood of successful defibrillation Effective compressions help restore ATP, increasing the likelihood of successful defibrillation

    29. Defibrillation is most effective during the first few minutes after cardiac arrest CPR Challenges: Defibrillation Support Electrical countershock (defibrillation) is the definitive treatment for sudden cardiac arrests resulting from ventricular fibrillation or tachycardia (VF/VT), especially early after the arrest. However, as you can see in this chart, survival from cardiac arrest caused by VF declines by approximately 7% to 10% for each minute without defibrillation. More than 12 minutes after collapse, the cardiac arrest survival rate is only 2% to 5%. [Guidelines 2000 for CPR and ECC. Circulation. 2000; 102 (suppl I): I-23.] A growing body of evidence suggests that beyond a delay of about 3 minutes, re-establishing good blood flow before defibrillation may actually improve the efficacy of the electrical countershock – in effect “priming the pump” to allow the heart to better respond. Simply stated, better circulation enhances defibrillation. Engdahl J et al. Resuscitation. 2002;52(3):235-245. Guidelines for CPR and ECC. Circulation. 2000;102(suppl I):I-23.Electrical countershock (defibrillation) is the definitive treatment for sudden cardiac arrests resulting from ventricular fibrillation or tachycardia (VF/VT), especially early after the arrest. However, as you can see in this chart, survival from cardiac arrest caused by VF declines by approximately 7% to 10% for each minute without defibrillation. More than 12 minutes after collapse, the cardiac arrest survival rate is only 2% to 5%. [Guidelines 2000 for CPR and ECC. Circulation. 2000; 102 (suppl I): I-23.] A growing body of evidence suggests that beyond a delay of about 3 minutes, re-establishing good blood flow before defibrillation may actually improve the efficacy of the electrical countershock – in effect “priming the pump” to allow the heart to better respond. Simply stated, better circulation enhances defibrillation. Engdahl J et al. Resuscitation. 2002;52(3):235-245. Guidelines for CPR and ECC. Circulation. 2000;102(suppl I):I-23.

    30. “LDB*-CPR may be considered for use by properly trained personnel as an adjunct to CPR for patients with cardiac arrest in the out-of-hospital or in-hospital setting (Class IIb).” AHA Guidelines 2005: LDB CPR The American Heart Association’s Guidelines 2005 also specifically mention the use of “LDB (load-distributing band) – CPR as an appropriate adjunct to standard CPR. The section goes on to reference some of the studies presented later in this presentation as supporting evidence.The American Heart Association’s Guidelines 2005 also specifically mention the use of “LDB (load-distributing band) – CPR as an appropriate adjunct to standard CPR. The section goes on to reference some of the studies presented later in this presentation as supporting evidence.

    31. AutoPulse® LDB CPR

    32. AutoPulse LDB CPR What is the AutoPulse? The world’s only load-distributing band chest compression device What does the AutoPulse do? Compressions that humans can’t possibly do What does the AutoPulse do for the SCA patient? Moves more blood, more effectively, to the heart and brain Offers the promise of better outcomes The AutoPulse – the world’s only LDB CPR device -- generates chest compressions humans can’t possibly do. It moves more blood, more effectively, to the heart and brain and offers the promise of better outcomes. The AutoPulse – the world’s only LDB CPR device -- generates chest compressions humans can’t possibly do. It moves more blood, more effectively, to the heart and brain and offers the promise of better outcomes.

    33. Summary of LDB CPR Benefits Improved blood flow Functions as an “additional person” Fast, easy and intuitive to start-up and use Clinician safety In keeping with the AHA’s Guidelines 2005, the AutoPulse provides “consistent compressions” with “no interruptions,” making improved blood flow during SCA possible. The primary benefits of the AutoPulse are: Improved blood flow Functions as an “additional person” Fast, easy and intuitive to start-up and use Clinician safety - No risk of being injured while attempting to do manual compressions in the back of a moving ambulance or gurneyIn keeping with the AHA’s Guidelines 2005, the AutoPulse provides “consistent compressions” with “no interruptions,” making improved blood flow during SCA possible. The primary benefits of the AutoPulse are: Improved blood flow Functions as an “additional person” Fast, easy and intuitive to start-up and use Clinician safety - No risk of being injured while attempting to do manual compressions in the back of a moving ambulance or gurney

    34. Improved Blood flow To the brain To the coronary arteries Consistent, uninterrupted compressions Thoracic and cardiac compression Research has shown that improved blood flow to the brain and coronary arteries supported by the following features: Consistent, uninterrupted chest compressions Thoracic compression, in conjunction with cardiac compressionResearch has shown that improved blood flow to the brain and coronary arteries supported by the following features: Consistent, uninterrupted chest compressions Thoracic compression, in conjunction with cardiac compression

    35. Dual Function There are two complementary mechanisms commonly sited for generating forward blood flow. One is the cardiac pump (left panel), in which the heart is compressed between the sternum and the spine. The second is thoracic pump (right panel), in which the entire chest is compressed. During thoracic compression the intrathoracic volume is reduced, increasing intrathoracic pressure and collapsing the thoracic arteries, veins and atria driving blood forward.There are two complementary mechanisms commonly sited for generating forward blood flow. One is the cardiac pump (left panel), in which the heart is compressed between the sternum and the spine. The second is thoracic pump (right panel), in which the entire chest is compressed. During thoracic compression the intrathoracic volume is reduced, increasing intrathoracic pressure and collapsing the thoracic arteries, veins and atria driving blood forward.

    36. Functions as an “Additional Person” Clinicians are free to perform other critical tasks Eliminates clinician fatigue The benefit of functioning as an “additional person” is supported by the following features: Clinician is free to perform other critical tasks Eliminates clinician fatigue The benefit of functioning as an “additional person” is supported by the following features: Clinician is free to perform other critical tasks Eliminates clinician fatigue

    37. Extremely simple user interface Automatically “sizes the patient,” calculating… Size Shape Compliance/resistance Helps to “organize” or “calm” the code situation Fast, Easy and Intuitive The benefit of the AutoPulse being fast, easy and intuitive to start-up and use is supported by the following benefits: Extremely simple user interface Automatically “sizes the patient,” calculating… - Size - Shape - Compliance/resistance It also helps to “organize” or “calm” the often chaotic code situationThe benefit of the AutoPulse being fast, easy and intuitive to start-up and use is supported by the following benefits: Extremely simple user interface Automatically “sizes the patient,” calculating… - Size - Shape - Compliance/resistance It also helps to “organize” or “calm” the often chaotic code situation

    38. Clinician Safety No risk of being injured while attempting to do manual compressions during chaotic codes and/or patient transport The benefit of clinician safety is supported by the fact that there is no risk of being injured while attempting to do manual compressions in the back of a moving ambulance or on a gurney. It may also help to minimize the possibility that a staff member could be injured while performing manual chest compressions.The benefit of clinician safety is supported by the fact that there is no risk of being injured while attempting to do manual compressions in the back of a moving ambulance or on a gurney. It may also help to minimize the possibility that a staff member could be injured while performing manual chest compressions.

    39. 30:2 or Continuous Modes AutoPulse operation can easily be switched “on the fly” from a 30:2 compression to ventilation to continuous compressions. A default setting can also be entered by an administrator.AutoPulse operation can easily be switched “on the fly” from a 30:2 compression to ventilation to continuous compressions. A default setting can also be entered by an administrator.

    40. Battery Operated Minimum 30 minutes of continuous compressions Maximum 4Ľ hours recharge time The AutoPulse is powered by a nickel metal hydride battery, which provides a minimum of 30 minutes of continuous compressions. The maximum recharge time is 4Ľ hours. The AutoPulse is powered by a nickel metal hydride battery, which provides a minimum of 30 minutes of continuous compressions. The maximum recharge time is 4Ľ hours.

    41. Easily Transportable The AutoPulse is easily transportable via a nylon carry case in EMS, and an IV-pole style Transporter in the hospital.The AutoPulse is easily transportable via a nylon carry case in EMS, and an IV-pole style Transporter in the hospital.

    42. Conducted by Halperin et al. @ Johns Hopkins 20 16-kg pigs induced with VF for one minute Treated with conventional CPR (“The Thumper”) or the AutoPulse Two arms of study “BLS” scenario – no epinephrine “ALS” scenario – with epinephrine Regional flow measured with neutron-activated microspheres Animal Hemodynamics Study (Halperin et al.) An animal study led by Dr. Henry Halperin at Johns Hopkins University, School of Medicine was performed to assess hemodynamics with the use of the AutoPulse device as compared to manual CPR. In an animal study, regional blood flow can be measured in addition to the driving forces of CPP and peak aortic pressure. The pigs utilized in the study weighed 16 kg +/- 1kg. In order to eliminate the effects of fatigue and inconsistencies inherent in manual CPR, the Thumper? system (Michigan Instruments) was used because it was found to be hemodynamically equivalent to manual CPR. Ventricular fibrillation (VF) was induced in 10 pigs and after one minute, CPR was performed. AutoPulse CPR (A-CPR) and conventional CPR (C-CPR) were performed in random order. For the “BLS” scenario, VF was induced in 10 pigs and after one minute, CPR was initiated. For the “ALS” scenario, VF was induced in 10 pigs and after one minute, a 0.5 mg bolus of epinephrine was administered followed by 0.004 mg/kg/min infusion of epinephrine. CPR was initiated simultaneously with the administration of epinephrine. Coronary Perfusion Pressure (CPP) was measured as well as regional blood flow. Regional blood flows were measured with neutron activated microspheres. An animal study led by Dr. Henry Halperin at Johns Hopkins University, School of Medicine was performed to assess hemodynamics with the use of the AutoPulse device as compared to manual CPR. In an animal study, regional blood flow can be measured in addition to the driving forces of CPP and peak aortic pressure. The pigs utilized in the study weighed 16 kg +/- 1kg. In order to eliminate the effects of fatigue and inconsistencies inherent in manual CPR, the Thumper? system (Michigan Instruments) was used because it was found to be hemodynamically equivalent to manual CPR. Ventricular fibrillation (VF) was induced in 10 pigs and after one minute, CPR was performed. AutoPulse CPR (A-CPR) and conventional CPR (C-CPR) were performed in random order. For the “BLS” scenario, VF was induced in 10 pigs and after one minute, CPR was initiated. For the “ALS” scenario, VF was induced in 10 pigs and after one minute, a 0.5 mg bolus of epinephrine was administered followed by 0.004 mg/kg/min infusion of epinephrine. CPR was initiated simultaneously with the administration of epinephrine. Coronary Perfusion Pressure (CPP) was measured as well as regional blood flow. Regional blood flows were measured with neutron activated microspheres.

    43. Animal Hemodynamics Study (Halperin et al.) The major finding of this study was that the AutoPulse produced pre-arrest levels of blood flow to the heart and brain (ACLS protocol – with epinephrine). The major finding of this study was that the AutoPulse produced pre-arrest levels of blood flow to the heart and brain (ACLS protocol – with epinephrine).

    44. Conducted by Ikeno et al. @ Stanford Objective was to evaluate the ability of AutoPulse’s improved hemodynamics to affect survival Used a clinically relevant cardiac arrest model: 8 min down – 4 min BLS – 4 min ALS End-points were ROSC, 24-hour survival and neurologic status at 24-hours CPR treatment was randomized to AutoPulse or conventional CPR (“The Thumper”) Animal Survival Study (Ikeno et al.) An animal survival study performed at Stanford University evaluated to what extent the high levels of coronary perfusion pressure and blood flow contributed to the survival of an animal from cardiac arrest. A clinically relevant model of cardiac arrest with was used: a long 8 minutes of down time, followed by 4 minutes of basic life support. If return of spontaneous circulation was not achieved, then 4 minutes of ALS was instituted. The key measurement of the study was survival 24 hours after the cardiac arrest and neurological status 24 hours after the arrest. Two different groups of animals were tested, one received AutoPulse chest compressions and the second received conventional CPR.An animal survival study performed at Stanford University evaluated to what extent the high levels of coronary perfusion pressure and blood flow contributed to the survival of an animal from cardiac arrest. A clinically relevant model of cardiac arrest with was used: a long 8 minutes of down time, followed by 4 minutes of basic life support. If return of spontaneous circulation was not achieved, then 4 minutes of ALS was instituted. The key measurement of the study was survival 24 hours after the cardiac arrest and neurological status 24 hours after the arrest. Two different groups of animals were tested, one received AutoPulse chest compressions and the second received conventional CPR.

    45. Animal Survival Study (Ikeno et al.) There were 2 very significant findings in this study: 73% of subjects supported with the AutoPulse returned to normal blood flow and survived Of these survivors, 88% were neurologically normal, i.e., they did all the “typical” things that pigs do (walk around, eat, snort, etc.) None of the subjects supported by conventional CPR (as done by the “Thumper”) survived There were 2 very significant findings in this study: 73% of subjects supported with the AutoPulse returned to normal blood flow and survived Of these survivors, 88% were neurologically normal, i.e., they did all the “typical” things that pigs do (walk around, eat, snort, etc.) None of the subjects supported by conventional CPR (as done by the “Thumper”) survived

    46. Conducted by Timerman et al. in Sao Paolo, Brazil 16 terminally ill subjects who experienced in-hospital cardiac arrest Study initiated after at least 10 minutes of failed ACLS support AutoPulse and manual compressions were alternated for 90 seconds each Catheters were placed in the thoracic aorta and right atrium to measure CPP and peak aortic pressure Average time between arrest and the start of experiment was 30 (+/-5) minutes Human Hemodynamics Study (Timerman et al.) The following are the highlights of the AutoPulse Human Hemodynamics Study: Conducted by Timmerman et al. in San Paolo, Brazil 16 terminally ill subjects who experienced in-hospital cardiac arrest Study initiated after at least 10 minutes of failed ACLS support AutoPulse and manual compressions were alternated for 90 seconds each Catheters were placed in the thoracic aorta and right atrium to measure CPP and peak aortic pressure Average time between arrest and the start of experiment was 30 (+/-5) minutes (For the more scientifically-oriented: Peak aortic pressure was also measured which is related to cerebral flow. The peak aortic pressure with the use of the AutoPulse was 153 mm Hg (+/- 4) vs. only 115 mm Hg (+/-17) for manual CPR). The following are the highlights of the AutoPulse Human Hemodynamics Study: Conducted by Timmerman et al. in San Paolo, Brazil 16 terminally ill subjects who experienced in-hospital cardiac arrest Study initiated after at least 10 minutes of failed ACLS support AutoPulse and manual compressions were alternated for 90 seconds each Catheters were placed in the thoracic aorta and right atrium to measure CPP and peak aortic pressure Average time between arrest and the start of experiment was 30 (+/-5) minutes (For the more scientifically-oriented: Peak aortic pressure was also measured which is related to cerebral flow. The peak aortic pressure with the use of the AutoPulse was 153 mm Hg (+/- 4) vs. only 115 mm Hg (+/-17) for manual CPR).

    47. Human Hemodynamics Study (Timerman et al.) The major finding of this study was that AutoPulse-generated Coronary Perfusion Pressure (CPP) was 33% better than conventional CPR. The major finding of this study was that AutoPulse-generated Coronary Perfusion Pressure (CPP) was 33% better than conventional CPR.

    48. Human Hemodynamics Study Example In this patient from the AutoPulse human hemodynamic study, we can observe significant differences in Coronary Perfusion Pressure (CPP) between AutoPulse and manual CPR. Also note how CPP drops quickly when AutoPulse compressions stop. After the period of manual CPR is completed, note that CPP returns after several AutoPulse compressions. Finally, note that for this particular patient manual CPR – even when done by residents on monitored patients – never achieved the 15 mm Hg CPP threshold that Paradis reported necessary to achieve ROSC and survive.In this patient from the AutoPulse human hemodynamic study, we can observe significant differences in Coronary Perfusion Pressure (CPP) between AutoPulse and manual CPR. Also note how CPP drops quickly when AutoPulse compressions stop. After the period of manual CPR is completed, note that CPP returns after several AutoPulse compressions. Finally, note that for this particular patient manual CPR – even when done by residents on monitored patients – never achieved the 15 mm Hg CPP threshold that Paradis reported necessary to achieve ROSC and survive.

    49. Conducted by Casner et al. in San Francisco, CA Compared the rate of delivery of 162 patients in ROSC sustained to the ED 93 patients treated with manual CPR 69 patients treated with the AutoPulse Increased sustained ROSC rate was most pronounced when the initial presenting rhythm was asystole or PEA Human Short-term Survival Study (Casner et al.) Michael Casner and his associates at the San Francisco Fire Department recently conducted a retrospective, case-matched review of the impact of the AutoPulse on survival. Specifically, the rate of delivery of 162 patients in ROSC to the emergency department (ED) was measured. The increased ROSC rate (35%) in the AutoPulse was most pronounced when the initial presenting rhythm was asystole or PEA. Michael Casner and his associates at the San Francisco Fire Department recently conducted a retrospective, case-matched review of the impact of the AutoPulse on survival. Specifically, the rate of delivery of 162 patients in ROSC to the emergency department (ED) was measured. The increased ROSC rate (35%) in the AutoPulse was most pronounced when the initial presenting rhythm was asystole or PEA.

    50. Human Short-term Survival Study (Casner et al.) The major finding of this study was that AutoPulse improved the rate of delivery of patients in ROSC to the ED by 35%.The major finding of this study was that AutoPulse improved the rate of delivery of patients in ROSC to the ED by 35%.

    51. Conducted by Swanson et al. in Volusia County, FL Compared the rate of delivery of 523 patients in ROSC sustained to the ED 405 patients treated with manual CPR 118 patients treated with the AutoPulse Increased sustained ROSC rate was most pronounced when the initial presenting rhythm was asystole or PEA Human Short-term Survival Study (Swanson et al.) Michael Casner and his associates at the San Francisco Fire Department recently conducted a retrospective, case-matched review of the impact of the AutoPulse on survival. Specifically, the rate of delivery of 162 patients in ROSC to the emergency department (ED) was measured. The increased ROSC rate (35%) in the AutoPulse was most pronounced when the initial presenting rhythm was asystole or PEA. Michael Casner and his associates at the San Francisco Fire Department recently conducted a retrospective, case-matched review of the impact of the AutoPulse on survival. Specifically, the rate of delivery of 162 patients in ROSC to the emergency department (ED) was measured. The increased ROSC rate (35%) in the AutoPulse was most pronounced when the initial presenting rhythm was asystole or PEA.

    52. The major finding in this study was that the AutoPulse improved the rate of delivery of patients in ROSC sustained to the ED by 53%.The major finding in this study was that the AutoPulse improved the rate of delivery of patients in ROSC sustained to the ED by 53%.

    53. Conducted by Ornato et al. in Richmond, VA Compared survival rates in 783 patients 499 patients treated with manual CPR 284 patients treated with the AutoPulse 235% improvement in survival to discharge 88% improvement in survival to hospital admission 71% improvement in field ROSC Human Long-term Survival Study Dr. Marcus Ong, Dr. Joseph Ornato and their associates at the Richmond Ambulance Authority in Richmond, Virginia recently survival rates in 783 patients: 499 of whom where treated with manual CPR and 284 that were treated with the AutoPulse. The results were astounding: 235% improvement in survival to discharge 88% improvement in survival to hospital admission 71% improvement in field ROSC Dr. Marcus Ong, Dr. Joseph Ornato and their associates at the Richmond Ambulance Authority in Richmond, Virginia recently survival rates in 783 patients: 499 of whom where treated with manual CPR and 284 that were treated with the AutoPulse. The results were astounding: 235% improvement in survival to discharge 88% improvement in survival to hospital admission 71% improvement in field ROSC

    54. Human Long-term Survival Study The major finding of this study is that the AutoPulse improved survival to hospital discharge by 235%.The major finding of this study is that the AutoPulse improved survival to hospital discharge by 235%.

    55. Clinical evidence support AutoPulse benefits Animal study (Halperin et al.) shows blood pressure equivalent to pre-arrest levels Animal study (Ikeno et al.) shows blood pressure equivalent to normal and neurologically intact survival Human study (Timerman et al.) shows improved blood pressure 2 human studies (Swanson et al. and Casner et al.) show improved short-term survival Human study (Ong, Ornato et al.) shows improved short and long-term survival Research Synopsis The AutoPulse has a growing body of third-party clinical evidence to support its ability to save lives that might otherwise be lost: Animal study (Halperin et al.) shows blood pressure equivalent to pre-arrest levels Animal study (Ikeno et al.) shows blood pressure equivalent to normal and neurologically intact survival Human study (Timerman et al.) shows improved blood pressure 2 human studies (Swanson et al. and Casner et al.) show improved short-term survival Human study (Ornato et al.) shows improved short and long-term survival The AutoPulse has a growing body of third-party clinical evidence to support its ability to save lives that might otherwise be lost: Animal study (Halperin et al.) shows blood pressure equivalent to pre-arrest levels Animal study (Ikeno et al.) shows blood pressure equivalent to normal and neurologically intact survival Human study (Timerman et al.) shows improved blood pressure 2 human studies (Swanson et al. and Casner et al.) show improved short-term survival Human study (Ornato et al.) shows improved short and long-term survival

    56. Disclosure Policy It is the policy of Saint Louis University School of Medicine to insure balance, independence, objectivity and scientific rigor in its continuing medical education program. Faculty and planning committee participating in the planning and presentation of these activities are required to disclose to the audiences prior to the activity the following: Existence of any significant financial or other relationship with the manufacturer of any commercial product or provider of any commercial service discussed. Their intention to discuss a product that is not labeled for the use under discussion. Their intention to discuss preliminary research data. Saint Louis University has reviewed this activity’s disclosures and resolved all identified conflicts of interest, if applicable.

    57. Validation of Content Statement Saint Louis University School of Medicine follows the policy of the Accreditation Council for Continuing Medical Education (ACCME) regarding validation of clinical content for CME activities, which requires accredited sponsors to insure that: All recommendations involving clinical medicine are based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported or used in CME in support or justification of a patient care recommendation conforms to the generally accepted standards of experimental design, data collection and analysis.

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