ZOLL AutoPulse

2. ZOLL AutoPulse�

3. ZOLL�s History 1952 Dr Paul Zoll first to successfully pace human 1956 Dr Paul Zoll first to successful externally defibrillate patient 1988 PD 1200 Pacemaker/Defibrillator/Monitor brought to market 1995 M Series Introduced � First fully integrated Shockable Rhythm Interpretation (Advisory) Pacemaker/Defibrillator/Monitor 1997 RescueNet � first integrated data system for EMS developed 2002 First CPR Guidance System developed with the AED Plus 2004 Revivant Corporation acquired � adding the AutoPulse Manual CPR device to the product offering

4. Automatic Portable Non-invasive Battery Operated ZOLL AutoPulse�

5. 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%.

6. 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. Norm 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. Norm 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.

7. ZOLL AutoPulse� Uninterrupted compressions Consistent rate & depth User friendly Suitable for emergency department Superior Coronary Perfusion Pressure (CPP) compared with conventional CPR during resuscitation

8. Operating Rational What is the optimal manual compression rate? A quote from the AHA Guidelines: �There is insufficient evidence from human studies to identify a single optimal chest compression rate. Animal and human studies support a chest compression rate of >80 compressions per minute to achieve optimal forward blood flow during CPR.� (IV-25) The AHA and ERC set the compression rate for manual chest compressions to 100 cpm in order to compensate for the need to achieve a 50% duty cycle (the percent of time the heart is under active compression versus relaxation). Why does the AutoPulse? run at 80 compressions/minute? Cardiac Pump Thoracic Pump Compresses mainly the heart Compresses the entire chest It is all based on optimizing blood flow and being within guidelines. The important overview is that the AutoPulse delivers circumferential chest compressions as opposed to a single point of compression. The AutoPulse technique of compressions has shown to improve blood flow with a key element being enough chest relaxation time to enhance venous return. Here are the important points on why AutoPulse improves blood flow. The references are listed below. The AutoPulse compression rate is within the guidelines of 80 � 100 per minute. The AutoPulse will automatically size the chest and deliver 20% circumferential chest compressions. Instead of the heart being compressed between the sternum and the spine, the entire chest is compressed. During thoracic compression the intrathoracic volume is reduced, increasing intrathoracic pressure therefore, compressing the heart, collapsing the thoracic arteries, veins and atria driving blood forward. With a duty cycle of 50% and 80 compressions per minute, it allows time for good venous return resulting in improved blood flow. Important studies that show improved blood flow with AutoPulse are: Halperin HR et al. JACC. 2004;44(11):2214-20 Ikeno F et al. Resuscitation. 2006;68:109-118 Timerman S et al. Resuscitation. 2004;61:273-280 What is the optimal manual compression rate? A quote from the AHA Guidelines: �There is insufficient evidence from human studies to identify a single optimal chest compression rate. Animal and human studies support a chest compression rate of >80 compressions per minute to achieve optimal forward blood flow during CPR.� (IV-25) The AHA and ERC set the compression rate for manual chest compressions to 100 cpm in order to compensate for the need to achieve a 50% duty cycle (the percent of time the heart is under active compression versus relaxation). Why does the AutoPulse? run at 80 compressions/minute? Cardiac Pump Thoracic Pump Compresses mainly the heart Compresses the entire chest It is all based on optimizing blood flow and being within guidelines. The important overview is that the AutoPulse delivers circumferential chest compressions as opposed to a single point of compression. The AutoPulse technique of compressions has shown to improve blood flow with a key element being enough chest relaxation time to enhance venous return. Here are the important points on why AutoPulse improves blood flow. The references are listed below. The AutoPulse compression rate is within the guidelines of 80 � 100 per minute. The AutoPulse will automatically size the chest and deliver 20% circumferential chest compressions. Instead of the heart being compressed between the sternum and the spine, the entire chest is compressed. During thoracic compression the intrathoracic volume is reduced, increasing intrathoracic pressure therefore, compressing the heart, collapsing the thoracic arteries, veins and atria driving blood forward. With a duty cycle of 50% and 80 compressions per minute, it allows time for good venous return resulting in improved blood flow. Important studies that show improved blood flow with AutoPulse are: Halperin HR et al. JACC. 2004;44(11):2214-20 Ikeno F et al. Resuscitation. 2006;68:109-118 Timerman S et al. Resuscitation. 2004;61:273-280

9. Operating Rational What is the optimal manual compression rate? A quote from the AHA Guidelines: �There is insufficient evidence from human studies to identify a single optimal chest compression rate. Animal and human studies support a chest compression rate of >80 compressions per minute to achieve optimal forward blood flow during CPR.� (IV-25) The AHA and ERC set the compression rate for manual chest compressions to 100 cpm in order to compensate for the need to achieve a 50% duty cycle (the percent of time the heart is under active compression versus relaxation). Why does the AutoPulse? run at 80 compressions/minute? Cardiac Pump Thoracic Pump Compresses mainly the heart Compresses the entire chest It is all based on optimizing blood flow and being within guidelines. The important overview is that the AutoPulse delivers circumferential chest compressions as opposed to a single point of compression. The AutoPulse technique of compressions has shown to improve blood flow with a key element being enough chest relaxation time to enhance venous return. Here are the important points on why AutoPulse improves blood flow. The references are listed below. The AutoPulse compression rate is within the guidelines of 80 � 100 per minute. The AutoPulse will automatically size the chest and deliver 20% circumferential chest compressions. Instead of the heart being compressed between the sternum and the spine, the entire chest is compressed. During thoracic compression the intrathoracic volume is reduced, increasing intrathoracic pressure therefore, compressing the heart, collapsing the thoracic arteries, veins and atria driving blood forward. With a duty cycle of 50% and 80 compressions per minute, it allows time for good venous return resulting in improved blood flow. Important studies that show improved blood flow with AutoPulse are: Halperin HR et al. JACC. 2004;44(11):2214-20 Ikeno F et al. Resuscitation. 2006;68:109-118 Timerman S et al. Resuscitation. 2004;61:273-280 What is the optimal manual compression rate? A quote from the AHA Guidelines: �There is insufficient evidence from human studies to identify a single optimal chest compression rate. Animal and human studies support a chest compression rate of >80 compressions per minute to achieve optimal forward blood flow during CPR.� (IV-25) The AHA and ERC set the compression rate for manual chest compressions to 100 cpm in order to compensate for the need to achieve a 50% duty cycle (the percent of time the heart is under active compression versus relaxation). Why does the AutoPulse? run at 80 compressions/minute? Cardiac Pump Thoracic Pump Compresses mainly the heart Compresses the entire chest It is all based on optimizing blood flow and being within guidelines. The important overview is that the AutoPulse delivers circumferential chest compressions as opposed to a single point of compression. The AutoPulse technique of compressions has shown to improve blood flow with a key element being enough chest relaxation time to enhance venous return. Here are the important points on why AutoPulse improves blood flow. The references are listed below. The AutoPulse compression rate is within the guidelines of 80 � 100 per minute. The AutoPulse will automatically size the chest and deliver 20% circumferential chest compressions. Instead of the heart being compressed between the sternum and the spine, the entire chest is compressed. During thoracic compression the intrathoracic volume is reduced, increasing intrathoracic pressure therefore, compressing the heart, collapsing the thoracic arteries, veins and atria driving blood forward. With a duty cycle of 50% and 80 compressions per minute, it allows time for good venous return resulting in improved blood flow. Important studies that show improved blood flow with AutoPulse are: Halperin HR et al. JACC. 2004;44(11):2214-20 Ikeno F et al. Resuscitation. 2006;68:109-118 Timerman S et al. Resuscitation. 2004;61:273-280

10. Operating Rational What is the optimal manual compression rate? A quote from the AHA Guidelines: �There is insufficient evidence from human studies to identify a single optimal chest compression rate. Animal and human studies support a chest compression rate of >80 compressions per minute to achieve optimal forward blood flow during CPR.� (IV-25) The AHA and ERC set the compression rate for manual chest compressions to 100 cpm in order to compensate for the need to achieve a 50% duty cycle (the percent of time the heart is under active compression versus relaxation). Why does the AutoPulse? run at 80 compressions/minute? Cardiac Pump Thoracic Pump Compresses mainly the heart Compresses the entire chest It is all based on optimizing blood flow and being within guidelines. The important overview is that the AutoPulse delivers circumferential chest compressions as opposed to a single point of compression. The AutoPulse technique of compressions has shown to improve blood flow with a key element being enough chest relaxation time to enhance venous return. Here are the important points on why AutoPulse improves blood flow. The references are listed below. The AutoPulse compression rate is within the guidelines of 80 � 100 per minute. The AutoPulse will automatically size the chest and deliver 20% circumferential chest compressions. Instead of the heart being compressed between the sternum and the spine, the entire chest is compressed. During thoracic compression the intrathoracic volume is reduced, increasing intrathoracic pressure therefore, compressing the heart, collapsing the thoracic arteries, veins and atria driving blood forward. With a duty cycle of 50% and 80 compressions per minute, it allows time for good venous return resulting in improved blood flow. Important studies that show improved blood flow with AutoPulse are: Halperin HR et al. JACC. 2004;44(11):2214-20 Ikeno F et al. Resuscitation. 2006;68:109-118 Timerman S et al. Resuscitation. 2004;61:273-280 What is the optimal manual compression rate? A quote from the AHA Guidelines: �There is insufficient evidence from human studies to identify a single optimal chest compression rate. Animal and human studies support a chest compression rate of >80 compressions per minute to achieve optimal forward blood flow during CPR.� (IV-25) The AHA and ERC set the compression rate for manual chest compressions to 100 cpm in order to compensate for the need to achieve a 50% duty cycle (the percent of time the heart is under active compression versus relaxation). Why does the AutoPulse? run at 80 compressions/minute? Cardiac Pump Thoracic Pump Compresses mainly the heart Compresses the entire chest It is all based on optimizing blood flow and being within guidelines. The important overview is that the AutoPulse delivers circumferential chest compressions as opposed to a single point of compression. The AutoPulse technique of compressions has shown to improve blood flow with a key element being enough chest relaxation time to enhance venous return. Here are the important points on why AutoPulse improves blood flow. The references are listed below. The AutoPulse compression rate is within the guidelines of 80 � 100 per minute. The AutoPulse will automatically size the chest and deliver 20% circumferential chest compressions. Instead of the heart being compressed between the sternum and the spine, the entire chest is compressed. During thoracic compression the intrathoracic volume is reduced, increasing intrathoracic pressure therefore, compressing the heart, collapsing the thoracic arteries, veins and atria driving blood forward. With a duty cycle of 50% and 80 compressions per minute, it allows time for good venous return resulting in improved blood flow. Important studies that show improved blood flow with AutoPulse are: Halperin HR et al. JACC. 2004;44(11):2214-20 Ikeno F et al. Resuscitation. 2006;68:109-118 Timerman S et al. Resuscitation. 2004;61:273-280













23. Presenting Cardiac Rhythms

24. Presenting Cardiac Rhythms Defibrillation is only required in less than 50% of cases. Quality CPR is required in 100% of cases!

25. Does not adequately perfuse the brain or heart Manual CPR is limited in two distinct ways, by the rescuer and by the physiology of blood flow. What would otherwise be ideal manual chest compression is frequently degraded by a number of potential sources. First, there is no feedback for the person performing manual CPR. They do not know accurately if the are performing rate, depth and duty cycle correctly. All of these are important, but duty cycle is of particular importance to generating the maximum blood flow. It has been demonstrated by several investigators that physical fatigue in the rescuer occurs as soon as one minute after starting compressions. And frequently the rescuer is unaware that fatigue has reduced their compression effectiveness. To combat the effects of fatigue, rescuers may be rotated frequently. However, this will cause some pause time during rotation which is also detrimental and increases the number of rescuers required at the scene. Because fatigue is such a large factor, there is no viable method for performing manual chest compression uninterrupted. Because the rescuer is in physical contact with the patient, defibrillation cannot be performed in rapid sequence with chest compression due to safety concerns. Similarly, manual chest compression is frequently not performed during patient transport because there is not enough space or the potential for injury of the rescuer is too great. From a physiological standpoint, manual chest compression does not produce enough blood flow to achieve regular resuscitation success. Similarly, the lack of cerebral blood flow may cause non-viable neurological status following resuscitation.Manual CPR is limited in two distinct ways, by the rescuer and by the physiology of blood flow. What would otherwise be ideal manual chest compression is frequently degraded by a number of potential sources. First, there is no feedback for the person performing manual CPR. They do not know accurately if the are performing rate, depth and duty cycle correctly. All of these are important, but duty cycle is of particular importance to generating the maximum blood flow. It has been demonstrated by several investigators that physical fatigue in the rescuer occurs as soon as one minute after starting compressions. And frequently the rescuer is unaware that fatigue has reduced their compression effectiveness. To combat the effects of fatigue, rescuers may be rotated frequently. However, this will cause some pause time during rotation which is also detrimental and increases the number of rescuers required at the scene. Because fatigue is such a large factor, there is no viable method for performing manual chest compression uninterrupted. Because the rescuer is in physical contact with the patient, defibrillation cannot be performed in rapid sequence with chest compression due to safety concerns. Similarly, manual chest compression is frequently not performed during patient transport because there is not enough space or the potential for injury of the rescuer is too great. From a physiological standpoint, manual chest compression does not produce enough blood flow to achieve regular resuscitation success. Similarly, the lack of cerebral blood flow may cause non-viable neurological status following resuscitation.

26. Does not adequately perfuse the brain or heart Manual CPR delivers Inconsistent compressions Fatigue Pausing to rotate staff Pausing to move the patient OH&S Issues Manual CPR is limited in two distinct ways, by the rescuer and by the physiology of blood flow. What would otherwise be ideal manual chest compression is frequently degraded by a number of potential sources. First, there is no feedback for the person performing manual CPR. They do not know accurately if the are performing rate, depth and duty cycle correctly. All of these are important, but duty cycle is of particular importance to generating the maximum blood flow. It has been demonstrated by several investigators that physical fatigue in the rescuer occurs as soon as one minute after starting compressions. And frequently the rescuer is unaware that fatigue has reduced their compression effectiveness. To combat the effects of fatigue, rescuers may be rotated frequently. However, this will cause some pause time during rotation which is also detrimental and increases the number of rescuers required at the scene. Because fatigue is such a large factor, there is no viable method for performing manual chest compression uninterrupted. Because the rescuer is in physical contact with the patient, defibrillation cannot be performed in rapid sequence with chest compression due to safety concerns. Similarly, manual chest compression is frequently not performed during patient transport because there is not enough space or the potential for injury of the rescuer is too great. From a physiological standpoint, manual chest compression does not produce enough blood flow to achieve regular resuscitation success. Similarly, the lack of cerebral blood flow may cause non-viable neurological status following resuscitation.Manual CPR is limited in two distinct ways, by the rescuer and by the physiology of blood flow. What would otherwise be ideal manual chest compression is frequently degraded by a number of potential sources. First, there is no feedback for the person performing manual CPR. They do not know accurately if the are performing rate, depth and duty cycle correctly. All of these are important, but duty cycle is of particular importance to generating the maximum blood flow. It has been demonstrated by several investigators that physical fatigue in the rescuer occurs as soon as one minute after starting compressions. And frequently the rescuer is unaware that fatigue has reduced their compression effectiveness. To combat the effects of fatigue, rescuers may be rotated frequently. However, this will cause some pause time during rotation which is also detrimental and increases the number of rescuers required at the scene. Because fatigue is such a large factor, there is no viable method for performing manual chest compression uninterrupted. Because the rescuer is in physical contact with the patient, defibrillation cannot be performed in rapid sequence with chest compression due to safety concerns. Similarly, manual chest compression is frequently not performed during patient transport because there is not enough space or the potential for injury of the rescuer is too great. From a physiological standpoint, manual chest compression does not produce enough blood flow to achieve regular resuscitation success. Similarly, the lack of cerebral blood flow may cause non-viable neurological status following resuscitation.

27. Manual CPR v AutoPulse Manual CPR

28. AutoPulse - Consistent Compressions

29. Clinical Evidence Summary�

30. Clinical Evidence � Manual CPR Manual CPR is variable at best, even when performed by trained professionals � Abella et al, Wik et al Effective CPR, with minimal interruptions, improves probability of successful defibrillation � Sato et al, Ikeno et al Effective CPR is more important than the timing of defibrillation in achieving ROSC � Ristagno, et al

31. Clinical Evidence - CPP CPP is the best predictor of ROSC in prolonged cardiac arrests ROSC does not occur in patients where CPP is below 15mmHg Manual CPR achieves 12.5mm Hg on average � Paradis et al CPP is improved with AutoPulse over manual CPR. � Timmerman et al

32. 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.

33. Clinical Evidence - ROSC AutoPulse provides pre arrest blood flow levels to heart and brain - Halperin et al AutoPulse provides superior levels of ROSC and survival when compared to manual CPR � Ong et al AutoPulse provides superior levels of ROSC and survival when compared to piston driven automated CPR � Ikeno et al

34. Clinical Evidence - ROSC AutoPulse provides superior levels of neurological function when compared to both manual and piston driven CPR � Ong et al, Ikeno et al

35. Clinical Review

36. Abella et al JAMA. 2005;293:305-310 University of Chicago Hospital 67 Patients Evaluated Quality of manual CPR in first 5 mins of code Found that even in highly trained professionals CPR was: too shallow, too slow ventilation occurred too frequently.

37. Wik et al JAMA. 2005;293:305-310 Multi-location Emergency Services human study (Stockholm, London, Akershus) Evaluated Quality of manual CPR in first 5 mins of arrest of 176 patients 49% of time of code, patients did not receive CPR With adjustment for defibrillation analysis, 42% time of code, patients did not receive CPR

38. Wik et al JAMA. 2005;293:305-310 59% of compressions were too shallow Found high compression rates Decreased cardiac output Not enough time for proper venous return to heart CPR performed by people is significantly different to guidelines

39. Rodent study of 25 subjects put into VF 4 minutes later defibrillation commenced animals were grouped into 0, 10, 20, 30 and 40 s delays in between defibrillation and cessation of CPR No animals that received more than 10 s delay in defibrillation survived more than 24 hours. Resuscitation and survival rates lessened as delay increased 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).

40. Porcine study of 24 subjects put into VF 5 minutes later treatment commenced 4 randomized groups Optimal CPR with early defibrillation Optimal CPR with 3 minutes of CPR first Conventional CPR* with early defibrillation Conventional CPR* with 3 minutes of CPR first * Simulated by 25% that compression required to give 15 mm Hg CPP. 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).

41. All 12 subjects that were given optimal CPR achieved ROSC Only 2 of the 12 subjects (16.6%) that were given conventional CPR achieved ROSC and those were shocked first All surviving animals achieved full neurological recovery 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).

42. Paradis NA et al. JAMA. 1990;263:1106-1113 The clearest link between CPP and the likelihood of a return of spontaneous circulation (ROSC) has been documented by Dr. Norm 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. [Paradis NA, et al. Coronary perfusion pressure and the return of spontaneous circulation. JAMA. 1990; 263:1106-1113.] The clearest link between CPP and the likelihood of a return of spontaneous circulation (ROSC) has been documented by Dr. Norm 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. [Paradis NA, et al. Coronary perfusion pressure and the return of spontaneous circulation. JAMA. 1990; 263:1106-1113.]

43. 16 terminal patients In-hospital cardiac arrest 10 minutes of failed advanced care life support Catheters were placed in the thoracic aorta and right atrium to measure CPP and peak aortic pressure AutoPulse and Manual Compressions were alternated for 90 seconds each Average time between arrest and the start of experiment was 30 (+/-5) minutes 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).

44. 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.

45. Timerman S et al. Resuscitation. 2004;61:273-280

46. Halperin et al. JAMA. 2006;295:2629-2637 Porcine Study of 20 subjects @ John Hopkins VF induced for 1 minute Treated with conventional CPR (�The Thumper�) or the AutoPulse Two arms of study �BLS� scenario � no epinephrine �ALS� scenario � with epinephrine

47. Halperin et al. JAMA. 2006;295:2629-2637

48. Ong et al. JAMA. 2006;295:2629-2637 Study conducted by Richmond Fire Department of almost 800 patients Overall improvement of ROSC (70.8%), survival to hospital admission (88%) and survival to discharge (234%).

49. Ong et al. JAMA. 2006;295:2629-2637 Improvement occurred regardless of initial cardiac rhythm VF/VT Asystole* PEA* Particularly where VF was initial rhythm or where the patient had a witnessed arrest or received bystander CPR until the AutoPulse was applied. * Small sample sizes

50. Ikeno et al. Resuscitation. 2006;68:109-118 Porcine Study with 56 subjects 22 in AutoPulse, 22 using �the thumper� at 20% compression, 12 at 30% compression VF induced for 4 minutes before treatment All subjects that achieved ROSC, survived for 72 hours Of the thumper subjects, none survived 20% compression (simulating manual CPR), even with adrenaline administered

51. Ikeno et al. Resuscitation. 2006;68:109-118 Of the 30% compression group, 4 of 12 (33%) achieved ROSC. 50% required adrenaline 2 of these 4 survivors at 72 hours had good neurological function. 2 were severely impaired 8/12 (67%) subjects suffered rib fracture and 4/12 (33%) suffered lung injury

52. Ikeno et al. Resuscitation. 2006;68:109-118 Of the AutoPulse group, 16 of 22 (73%) achieved ROSC. 50% required adrenaline All 16 survivors achieved good neurological outcomes after 72 hours No subjects in this group received rib fracture of lung injury

53. Mechanical Chest Compression During Resuscitation Academic Medical Centre, Amsterdam 2 patients being treated with the AutoPulse Primary Percutaneous Coronary Intervention. Adequately displayed the coronary system through the AutoPulse in order to complete the procedures. Conventional CPR - Intra-arterial blood pressures of up to 60mmHg AutoPulse - Intra-arterial blood pressures of up to 120mmHg Mechanical chest compression during resuscitation: Experience in hospital and use in pre-hospital care. Cardiac Monitoring Department -Academic Medical Centre, Amsterdam

54. Mechanical Chest Compression During Resuscitation Academic Medical Centre, Amsterdam 2 patients being treated with the AutoPulse Primary Percutaneous Coronary Intervention. Adequately displayed the coronary system through the AutoPulse in order to complete the procedures. Conventional CPR - Intra-arterial blood pressures of up to 60mmHg AutoPulse - Intra-arterial blood pressures of up to 120mmHg Mechanical chest compression during resuscitation: Experience in hospital and use in pre-hospital care. Cardiac Monitoring Department -Academic Medical Centre, Amsterdam

ZOLL AutoPulse

ZOLL AutoPulse

Presentation Transcript

ZOLL Medical Corporation Sales Training

ZOLL M Series

ZOLL Medical Corporation Sales Training April 2005

ZOLL M Series

ZOLL Medical Corporation Sales Training April 2005

Dr hab. Fryderyk Zoll, prof. UJ i ALK

Zoll R Series Defibrillators eLearning

ZOLL M Series

ZOLL M Series

ZOLL AutoPulse ®

Zoll Monitor Upload

ZOLL

Ventricular Assist Devices Zoll LifeVest External Defibrillator

Zoll Medical Scenario

Dr hab. Fryderyk Zoll, prof. UJ

Dr hab. Fryderyk Zoll, prof. UJ i ALK

Dr hab. Fryderyk Zoll, prof. UJ i ALK

Dr hab. Fryderyk Zoll, prof. UJ i ALK

Dr hab. Fryderyk Zoll, prof. UJ i ALK

Dr hab. Fryderyk Zoll, Professor at the Jagiellonian University

Export und Zoll KompetenzWerkstatt

Fryderyk Zoll