1 LUCAS™ Sistema de Compresión TorácicaPresentation Title Here LUCAS Chest Compression System. Hospital Clinical presentation. LUCAS™ Sistema de Compresión Torácica

2 Datos de experimentos en cerdosP. aórtica (c. izquierdo) P. coronaria venosa (c. derecho) P. perfusión coronaria VF Inducida (Left Heart) (Right Heart) mm Hg A B C This is data of heart pressures during sudden cardiac arrest in pigs. The red line is pressure from the left side of the heart. The blue line is pressure from the right side of the heart, and the green line is the Coronary Perfusion Pressure or CPP. CPP is responsible for the perfusion and oxygenation of the heart muscle through the coronary arteries. Ventricular Fibrillation (VF) is induced at time zero. The pressure in the left side of the heart decreases immediately, but doesn't come down to zero; it stops at 20 mm/hg (Point A on the graph). Some blood is still being pushed from the left side through the body’s circulatory system and back to the right side – that’s what we see on the blue line. This pressure increases to 18mm/hg (Point B). The Coronary Perfusion Pressure or CPP is the green line. CPP doesn’t actually reach 0 as long as there continues to be a difference between the right and left-sided pressures (seen here as the yellow area). The amount of CPP decreases during the first 4 minutes of untreated VF. After 5 minutes, the pressure on the left side becomes equivalent to the pressure on the right side and the circulation to the heart muscle stops. (CPP = 0, Point C) Extra information: CPP is calculated as the difference between the left and right heart pressures during diastole or the relaxing phase of contractions. Fin de perfusión coronaria Steen S, Qiuming L, Pierre L, Paskevicius A, T S. The critical importance of miminal delay between chest compressions and subsequent defibrillation: a haemodynamic explanation. Resuscitation. 2003;58:

3 CPP y posibilidad de ROSCPresión de perfusión coronaria, mmHg It turns out CPR is not just about keeping the brain alive. In fact, our ability to perfuse the heart muscle during cardiac arrest affects the likelihood of ROSC. This study was one of the first to measure CPP in humans during a cardiac arrest. It is important because it correlated CPP, or heart muscle perfusion, with short term outcomes. If the patient had a CPP >15, they had some chance of regaining ROSC, but if the patient had a CPP of <15 then there was no chance of regaining ROSC (see the red arrow). Although there is a lot of talk about the importance of CPP, in reality it is impractical to measure in humans and it is impossible to predict what CPPs are achieved at any give time during the resuscitation attempt. Additionally, different experimental labs use a variety of methods and measuring points when they determine CPP, so it is not valid to compare CCP levels from one study to another. Extra Notes: Coronary Perfusion Pressures is defined as aortic pressure minus the pressure in the right ventricle (during diastole). Total number of patient = /58 (0%) had CPP <15. 10/23 (44%) had CPP between /7 (71%) had CPP between 21-25%). 9/12 (75%) had CPP >25. No hay ROSC en pacientes con CPP < 15mmHg Paradis N, Martin G, Rivers E, et al. Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation. JAMA. 1990;263(8):

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5 Flujo cortical durante la RCP% de la línea basal Flujo cortical durante la RCP Datos de Rubertsson et al. Resuscitation 65 (2005) 1,0 0,7 0,6 0,5 0,4 0,3 LUCAS 0,2 RCP manual 0,1 Tiempo 2 4 6 8 10 12 14 16 5

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7 Dificultad para el MCE efectivo% Given the importance of effective CPR, the burning question is: How well do we do CPR? Several studies show that proficiency in chest compressions drops rapidly, often after only 1 minute. And those studies were done with the old, easier standards! With the new recommendations regarding rate, depth, duty cycle, full chest recoil and minimal interruptions, the task is even more challenging So here’s the bottom line. It’s critical to perfuse the heart and the brain well during cardiac arrest. The guidelines for CPR have been modified for just that reason. However, most rescuers have difficulty meeting and maintaining those CPR guidelines. As a result, rescuers are looking for solutions to improve the quality of their CPR and, in doing so, hopefully improve outcomes for cardiac arrest. Minutos * MCE: Masaje cardiaco externo Ochoa F, Ramalle-Gomara E, Lisa V, Saralegui I. The effect of rescuer fatigue on the quality of chest compressions. Resuscitation. 1998;37:

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9 Lesiones dorsales al aplicar MCEEstudio sobre 205 sujetos, RCP intrahospitalaria Duración de la RCP hasta 27 minutos 86% aplicaron MCE al paciente sobre una cama: 70% con las piernas apoyadas en el borde de la cama o sin soporte adecuado 55% tenían que girar la cabeza/espalda para ver el monitor Más del 80% refirieron molestias de espalda; 56% sintieron molestias relacionadas con la duración del procedimiento 20% presentaron daños en la espalda o hernias de disco; el 40% de estos se consideraron ocasionados o agravados por la RCP Or, consider this: Results of this survey indicate a need to ensure safe administration of CPR for nurses, especially when there is considerable time before medical staff arrive. CPR could last up to 27 minutes. The most compelling piece of data is the last bullet: 20% of the nurses surveyed suffered a back injury or prolapsed disc and over 40% of these “injured” nurses considered their back injury was related to or aggravated by CPR. Extra information: Questionnaire sent to nurses at three general hospitals and 20 nursing homes. Jones A. Can cardiopulmonary resuscitation injure the back? Resuscitation. 2004;61(1):63-67.

10 Cuestiones fundamentales…Resulta crítica una buena perfusión coronaria y cerebral durante una parada cardiaca Las Recomendaciones (AHA/ERC 2005) fueron cambiadas por esta razón Los profesionales que realizan reanimaciones buscan soluciones para mejorar la calidad de la RCP Objetivo: mejorar la supervivencia (con buen estado neurológico) en las paradas cardiacas con causas reversibles So here’s the bottom line. It’s critical to perfuse the heart and the brain well during cardiac arrest. The guidelines for CPR have been modified for just this reason. However, most rescuers have difficulty meeting and maintaining those CPR guidelines. As a result, rescuers are looking for solutions to improve the quality of their CPR and, in doing so, hopefully improve outcomes for cardiac arrest.

11 Características del Sistema LUCASDiseñado para proporcionar: 100 cpm 4 a 5 cm profundidad Descompresión activa Ciclo 50/50 Here is one solution I want you to consider. LUCAS is an air driven compression device that operates according to the guidelines for CPR. It gives good quality CPR to the patient without getting exhausted. LUCAS is designed to meet the AHA guideline requirements for CPR. It provides: A rate of about 100 compressions per minute Compression depth of 2 inches for an adult Allows the chest to recoil completely after each compression Takes approximately the same amount of time for compression and relaxation (50/50 duty cycle) Minimizes interruptions in chest compressions 4 / 5 cm

12 Indicaciones El Sistema de Compresión Torácica LUCAS está concebido para proporcionar compresiones cardiacas externas a pacientes adultos que hayan sufrido una parada cardiaca aguda. LUCAS se puede utilizar en los mismos casos en los que se aplicaría masaje cardiaco manual externo.

13 Ventajas del Sistema LUCASAplicación en 20 segundos Manejo muy sencillo Permite DF sin interrumpir compresiones (o mínima interrupción) No ocupa a miembros del equipo y permite centrarse en el resto de terapias Sin consumibles LUCAS has a variety advantages A well trained individual can apply LUCAS to a patient in 20 seconds or less, interrupting compressions only minimally. The device is extremely easy to use, designed with one knob only, to simplify use LUCAS also allows for defibrillation with ongoing compressions. You do not need turn the device off to shock your patients. LUCAS allows you to free up personnel to focus on other tasks such as administering meds or ventilations and in general provide better care to your patients. Finally, there are no disposables associated with LUCAS, nothing that needs to be replaced after each use. You simply need to clean the device after each use.

14 Ventajas del Sistema LUCASSe puede transportar al paciente en el hospital sin interrumpir o empeorar las compresiones Mantiene la misma calidad del MCE para todos los pacientes todo el tiempo, ajeno a la variabilidad de circunstancias del paciente y del equipo Besides the ease of use, there are other important benefits of LUCAS. It provides continuous effective compressions during transportation throughout the hospital. You no longer have to interrupt compressions to transfer patients from one department to another. Additionally, LUCAS gives you consistency in the compressions provided to your patients. It provides the same quality compression, independent of rescuer fatigue and the variability in experience level of the care giver.

15 LUCAS en Hemodinámica Radiotransparente (excepto cabeza y pistón)Permite diversas proyecciones El procedimiento puede continuar sin interrupciones Contribuye a un ambiente seguro, calmado y focalizado en el procedimiento LUCAS can be used in the cath lab during coronary intervention procedures such as PCI and stenting. LUCAS is translucent, except for the hood and the piston, allowing views for the certain projections in monoplane. Hands-free compressions brings direct value to the cath lab operators. Cardiologists who routinely use the LUCAS CPR system clearly confirm the benefits; namely the possibility to calmly continue the intervention during prolonged CPR with sustained circulation. The rescue procedure can go on without compromising rescuer safety due to X-ray exposure or patient circulation from interrupted CPR. Ref; R Linder, Läkartidningen Nr 34, 2006

16 LUCAS en Hemodinámica This first video shows the heart being compressed with LUCAS after the patient experienced cardiac arrest. The red circle indicates where the occlusion is. The second video shows that the artery is now opened and blood flow is re-established. This was accomplished with ongoing compressions. The patient recovered without cerebral or cardiac abnormalities. Journal reference: Linder, et al. Mechanical compressions during percutaneous coronary intervention saved life. Lakartidningen. 2006;103(34). Oclusión de arteria descendente anterior izquierda (LAD) antes de PCI. Se puede ver LUCAS en proyección craneal La oclusión ahora se observa resuelta y con un stent, con buen resultado Imágenes del caso por cortesía de R Linder, St Görans Hospital. Läkartidningen (Suecia) 2006

17 Fracturas de costillas/esternón por MCEEstudio sobre 19 pacientes (edad 66,4) que recibieron MCE manual y fallecieron: 47% fracturas visibles a los rayos X 95% fracturas identificadas en la autopsia Conclusión: las fracturas son un efecto rutinario del masaje cardiaco externo manual, siendo la mayoría de ellas indetectables con rayos X. No hay evidencias de que LUCAS cause más fracturas que el MCE manual convencional The conclusion of this study is that fractures during manual CPR are common. There is no evidence that LUCAS causes more fractures than manual CPR. Lederer W, Mair D, Rabl W, Baubin M. Frequency of rib and sternum fractures associated with out-of-hospital cardiopulmonary resuscitation is underestimated by conventional chest X-ray. Resuscitation. 2004;60(2):

18 ¿Pacientes obesos? LUCAS admite un diámetro anteroposterior del tórax de 17 a 30,3 cm, y ancho máximo de 45 cm Estudio piloto con 159 sujetos en Suecia: solo 2 de ellos eran demasiado obesos Estudio sobre el terreno en EE.UU. y países nórdicos (Europa): - LUCAS fue admitido y funcionó correctamente con el 96,4 % de los pacientes a los que se intentó aplicar - El peso medio de los pacientes fue de 87,7 kg - Menos del 6% presentaban obesidad mórbida - En el 80% de los casos no se requirieron reajustes del posicionamiento de LUCAS LUCAS was able to fit even this volunteer. In a pilot study, only 2 out of 159 patients assigned to the mechanical compression group didn’t have LUCAS applied with the reason cited that the patients were “too large”. A patient is considered to be too large for LUCAS if the claw locks do not snap onto the backboard. Reference: Axelsson C, Nestin J, Svensson L, Axelsson A, Herlitz J. Clinical consequences of the introduction of mechanical chest compression in the EMS system for treatment of out-of-hospital cardiac arrest-A pilot study. Resuscitation. 2006;71:47-55. Jolife AB, datos recogidos en 2008 en países nórdicos, Alaska, California, Texas y Minnesota

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21 Period 1 2000-2002 Period 2 2003-2006 Survival 2-30 days5 1 2 12 8 3 4 Survival 2-30 days Survival >30 days Paul Olsson: Lund University Hospital, Department of Cardiothoracic Surgery, Heart Lung Division and South Sweden Ambulance Service. 2009 Supervivientes en función del lugar del suceso (tiempo de respuesta + distancia al hospital) 21

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23 Posicionamiento Encender al abrir la bolsa (autochequeo)

24 Posicionamiento Posicionar adecuadamente la ventosa – placa de compresión

25 Ventilación Vía aérea no aislada: LUCAS en 30:2 Via aérea aislada:Balón resucitador Respirador mecánico (Manejo cuidadoso para evitar riesgos de hiperventilación o barotrauma) Tubo de Boussignac If ventilating with a bag-mask, turn the knob to lock to pause and deliver breaths. Examples of ventilation of an unprotected airway include: mouth-to-mouth, mouth-to-mask, bag-valve-mask. If an advanced airway is in place, deliver ventilations without pausing for compressions. Examples of ventilation of advanced (protected) airway include: laryngeal mask airway (LMA), esophageal-tracheal combitube, or endotracheal tube (ETT).

26 Movimientos del pacientePoner la correa de estabilización Fijar las muñecas del paciente, si procede

27 Movimientos del pacienteSituar en pausa antes de movimientos bruscos o cuando el paciente no se encuentre en posición prácticamente horizontal

28 Resumen Es fundamental mantener una buena perfusión del corazón y el cerebro durante una parada cardiaca Después de la fase eléctrica de la parada cardiaca, se necesita un excelente MCE además de desfibrilación LUCAS proporciona compresiones cardiacas externas de acuerdo con las Recomendaciones, de forma constante, precisa e ininterrumpida, liberando al equipo In summary, we know it’s vital to get good perfusion of the heart and brain during a sudden cardiac arrest. And you may need more than defibrillation if you are past the electrical phase of a sudden cardiac arrest. This is where LUCAS comes in. It can provide you with compressions according to the guidelines and free up your rescuers to provide better overall patient care.

29 Preguntas y comentarios…Thank you for your attention. I’d be happy to answer your questions.

30 LUCAS™ Sistema de Compresión TorácicaPresentation Title Here LUCAS Chest Compression System. Hospital Clinical presentation. LUCAS™ Sistema de Compresión Torácica Referencias (in-hospital)

31 Verstraete S, De Knock J, Müller N, Martens P, Van den Brande F, Vandevelde K. “Does the use of LUCAS influence survival for in-hospital cardiac arrest patients?”. ERC congress 2008; Poster 240 (on file at Jolife). This is a retrospective analysis of 73 consecutive in-hospital cardiac arrest patients who got random allocation to either LUCAS CPR (N:18) or manual CPR (N:34). 22 patients were excluded from the analysis due to ROSC within 4 minutes (N:16), insufficient data records (N: 4) or too obese to fit LUCAS (N:2). There was no significant difference in ROSC (56% vs. 44%) or hospital discharge (17% vs. 14%) between LUCAS CPR and manual CPR. All patients had a good neurological outcome. There was no major complications reported on the use of LUCAS, and the authors note that the device spares a useful pair of hands during the advanced life-support efforts.

32 Bonnemeier H, Olivecrona G, Simonis G, Götberg M, Weitz G, Iblher P, Gerling I, Schunkert I. “Automated continuous chest compression for in-hospital cardiopulmonary resuscitation of patients with pulseless electrical activity: A report of five cases”. International Journal of Cardiology. 2008; Int J Cardiol Aug 6. This study reports five cases of cardiac arrest due to PEA and the benefits of having mechanical chest compression device in the in-hospital setting. In all five patients the cardiac arrest was caused either by fulminant pulmonary embolism or by coronary artery occlusion. The article contains interesting LUCAS information; pressure curves, angiographies and ECG recordings. 3 patients survived. The authors conclude that LUCAS significantly improves IHCA resuscitation management and infrastructure and may significantly improve clinical outcome.

33 Bonnemeier H, Olivecrona G KBonnemeier H, Olivecrona G K. “The decisive role of effective continuous chest compression for in-hospital resuscitation of pulseless electrical activity” Resuscitation. 2008; 77S: S7, AS-019 This is a study on prolonged in-hospital cardiac arrests patients with PEA due to fulminant pulmonary embolism (N:9), thrombotic main stem occlusion (N: 3), severe hyperkalemia (N: 1), during CRT-ICD-implantation (N:1). Of these 14 patients, all (100%) got ROSC and 10 patients (71%) survived to discharge from the hospital without significant neurological deficits. None of the patients exhibited any life-threatening, device-related complications. Especially patients with pulmonary embolism and contraindications for thrombolytic therapy seem to benefit most from effective continuous chest compression, probably due to thrombus fragmentation and increased pulmonary artery flow.

34 Wagner H, Van der Pals, Olsson H R, Gotberg M, Harnek J, Olivecrona GWagner H, Van der Pals, Olsson H R, Gotberg M, Harnek J, Olivecrona G. “Mechanical chest compression devices can save lives in the cath lab”. Resuscitation. 2008; 77S: S12, AS-031 This is an analysis of the years of 28 patients who arrived alive to the cath lab and then required prolonged CPR/mechanical chest compression at some time during the interventional cardiac procedure. 5/28 patients in the study were beyond any chance of survival due to myocardial rupture. 8/23 patients were successfully treated with PCI and seven of these patients were discharged alive. It is unlikely that any of these seven could have survived without the use of mechanical chest compressions in the cath lab, because a continued procedure with maintained circulation was crucial to their survival.

35 Durnez P, Stockman W, Wynendaele R, Germonpre P, Dobbels PDurnez P, Stockman W, Wynendaele R, Germonpre P, Dobbels P. “ROSC and neurologic outcome after in-hospital cardiac arrest and LUCAS-CPR”. Resuscitation. 2008; 77S: S49, AP-033, and ERC congress 2008; Poster 033 72 consecutive in-hospital cardiac arrest patients, of whom 24% had VF, 21% asystole and 56% PEA got treatment with LUCAS CPR. ROSC was obtained in 64% (46/72) of the patients. Early neurological outcome (GCS) was favourable in 35% (25/72). 26% (19/72) patients were alive at three and six months follow up with a good neurological outcome (18 patients had CPC1 or 2, only one had CPC 4). Three patients did not fit into LUCAS (4%).

36 Larsen AI, Hjornevik AS, Ellingsen CL, Nilsen DWTLarsen AI, Hjornevik AS, Ellingsen CL, Nilsen DWT. ”Cardiac arrest with continuous mechanical chest compression during percutaneous coronary intervention. A report on the use of the LUCAS device.” Resuscitation. 2007; 75 (3): Cardiac arrest patients (N: 13) from both out-of-hospital as well as in-hospital were transported to and treated in the cath lab during ongoing LUCAS compressions. The mean LUCAS compression time was long; 105±60 minutes (range 45—240 minutes). Angiography and eventually PCI was possible in all cases during ongoing LUCAS chest compressions. There were no practical problems with regard to LUCAS application or ventilation. The mean systolic and diastolic blood pressure obtained by LUCAS was 81±23 and 34±21 mmHg, respectively. Three patients survived the procedure, but no one was discharged alive. Autopsies were performed in 11 patients and showed no life-threatening nor unexpected injuries despite the long resuscitation attempt. Manual CPR would have been almost impossible and could not have been extended for a prolonged period. LUCAS was considered well suited for use in the cath lab and ensured an adequate systemic blood pressure in most patients without life-threatening injuries.

37 No difference in autopsy detected injuries in cardiac arrest patients treated with manual chest compressions compared with mechanical compressions with the LUCAS device-A pilot study. Smekal D, Johansson J, Huzevka T, Rubertsson S. Department of Surgical Sciences - Anaesthesiology & Intensive Care, Uppsala University, SE Uppsala, Sweden. No injuries were found in 26/47 patients in the manual group and in 16/38 patients in the LUCAS group (p=0.28). Sternal fracture was present in 10/47 in the manual group and 11/38 in the LUCAS group (p=0.46), and there were multiple rib fractures (>/=3 fractures) in 13/47 in the manual group and in 17/38 in the LUCAS group (p=0.12). Bleeding in the ventral mediastinum was noted in 2/47 and 3/38 in the manual and LUCAS groups respectively (p=0.65)… CONCLUSION: Mechanical chest compressions with the LUCAS device appear to be associated with the same variety and incidence of injuries as manual chest compressions.

38 Gracias