1. Course Objectives CPR: Ongoing Challenges. New Solutions. October 2007 © 2007 ZOLL Medical Corporation

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 AHAAmerican Heart Association A-CPRAutoPulse CPR C-CPRConventional CPR CPPCoronary Perfusion Pressure DeployTo implement and position for readiness DowntimeNumber of minutes from onset of sudden cardiac arrest to initiation of resuscitation efforts

7. Key Terms and Abbreviations Duty cycleThe time is takes to complete one cycle ECCEmergency Cardiovascular Care LDBLoad-distributing band ROSCReturn of Spontaneous Circulation SCASudden Cardiac Arrest VFVentricular 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

9. Presenting Rhythms in SCA Recent studies show that VF or VT is the initial rhythm less than 50% of the time Peberdy MA et al. Resuscitation. 2003;58:297-308. Kaye W et al. JAMA. 2002:39(5),Suppl A. Cobb L et al. JAMA. 2002;288(23):3008-3013.

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

11. Right Atrial Pressure (RAP) Aortic Pressure (AP) Coronary Perfusion Pressure CPP = AP minus RAP

12. Coronary Perfusion and ROSC A well perfused myocardium is more likely to experience return of spontaneous circulation (ROSC)

13. CPP and ROSC (Paradis et al.) Paradis NA et al. JAMA. 1990;263:1106-1113. Victims with CPP < 15 mmHg do not achieve ROSC With conventional CPR, the overall mean CPP = 12.5

14. AHA Guidelines 2005: CPR “Simply put: …push hard, push fast, allow full chest recoil, minimize interruptions in compressions…” Circulation. 2005;112:IV-206.

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: 1½ - 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

17. CPR Challenges: Quality (Abella et al.) Abella BS et al. JAMA. 2005;293:305-310. “…quality of multiple parameters of CPR was inconsistent and often did not meet published guideline recommendations….” Parameter (1 st 5 minutes)Criteria% of Time Incorrect Rate too slow< 90/min 28.1% Depth too shallow< 1.5 in 37.4% Ventilation rate too high > 20/min60.9%

18. CPR Challenges: Quality (Abella et al.) Rate too slow Depth too shallow Ventilation rate too high Abella BS et al. JAMA. 2005;293:305-310.

19. CPR Challenges: Quality (Wik et al.) “…chest compressions were not delivered half of the time, and most compressions were too shallow…” Wik L et al. JAMA. 2005;23 299-304. Flow No Flow

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.

21. Aufderheide TP et al. Circulation. 2004;109:1960-1965. Mean ventilation rate: 30/minute ± 3.2 first group: 37/minute ± 4 after retraining: 22/minute ± 3 16 seconds v v v v v CPR Challenges: Hyperventilation Hyperventilation induces hypotension

22. Future of CPR Quality Study International consortium for data collection Oslo, Norway Vienna, Austria London, UK Stockholm, Sweden Chicago, USA Phase I: Collect baseline data on CPR quality Phase II: Implement feedback system to monitor and improve CPR performance

23. CPR Challenges: Interruptions 77% decrease in ROSC when pre-shock time increased from </= 9.7 seconds to </= 22.5 seconds Edelson et al. Circulation. 2005;112(17)II-1099 Edelson DP, Abella BS et al. Circulation. 2005;112(17):II-1099. (Edelson, Abella et al.)

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 KB et al. Circulation. 2002;105:645-649. Flow No Flow

25. Berg et al, 2001 Blood pressure CPR Challenges: Interruptions (Berg et al.) Time Berg RA et al. Resuscitation. 2001;104:2465-2470. Interrupting chest compressions for rescue breathing can adversely affect hemodynamics during CPR for VF Chest compressions

26. CPR Challenges: Perfusion (Kern) Manual CPR provides minimal blood flow to the heart and brain 30% - 40% of normal flow 10% - 20% of normal flow Kern KB Bailliere’s Clinical Anaesthesiology. 2000;14(3):591-609.

27. CPR Challenges: Defibrillation Support After ~4 minutes of VF, the myocardium is nearly depleted of ATP*, a vital energy source needed for successful defibrillation *Adenosine triphosphate (ATP), which breaks down into adenosine diphosphate (ADP).

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

29. Defibrillation is most effective during the first few minutes after cardiac arrest Engdahl J et al. Resuscitation. 2002;52(3):235-245. Guidelines for CPR and ECC. Circulation. 2000;102(suppl I):I-23. Defibrillation most effective Circulation enhances outcome CPR Challenges: Defibrillation Support

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 *Load-distributing band. Circulation. 2005;112:IV-59.

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

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

34. Improved Blood flow To the brain To the coronary arteries Consistent, uninterrupted compressions Thoracic and cardiac compression

35. Dual Function Compresses only the heart Compresses the entire chest Cardiac PumpThoracic Pump Compresses only the heart Compresses much of the chest Compresses mainly the heart Compresses the entire chest

36. Functions as an “Additional Person” Clinicians are 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

38. Clinician Safety No risk of being injured while attempting to do manual compressions during chaotic codes and/or patient transport

39. 30:2 or Continuous Modes Change without stopping operation Default settings administrator-configurable

40. Battery Operated Minimum 30 minutes of continuous compressions Maximum 4¼ hours recharge time

41. Easily Transportable Transporter for HospitalsCarry Case for EMS

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.)

43. AutoPulse produced pre-arrest levels of blood flow to the heart and brain (ACLS protocol – with epinephrine) Animal Hemodynamics Study (Halperin et al.) Halperin HR et al. JACC. 2004;44(11):2214-20. *p<0.02 **p<0.003

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.)

45. 73% of subjects supported with the AutoPulse returned to normal blood flow and survived - 88% of the survivors were neurologically normal 0% of the subjects supported with only conventional CPR survived Ikeno F et al. Resuscitation. 2006;68:109-118. Animal Survival Study (Ikeno et al.) 0% *p<0.01

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.)

47. AutoPulse-generated Coronary Perfusion Pressure (CPP) was 33% better than manual CPR Human Hemodynamics Study (Timerman et al.) Timerman S et al. Resuscitation. 2004;61:273-280. *p=0.015

48. CPP drops quickly when AutoPulse compressions stop Manual CPR CPP returns after several AutoPulse compressions AutoPulse Human Hemodynamics Study Example Timerman S et al. Resuscitation. 2004;61:273-280.

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.)

50. AutoPulse improved the rate of delivery of patients in ROSC sustained to the ED by 35% Human Short-term Survival Study (Casner et al.) Casner M et al. Prehospital Emergency Care. 2005;9(1):61-67. *p=0.003

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.)

52. AutoPulse improved the rate of delivery of patients in ROSC sustained to the ED by 53% Human Short-term Survival Study (Swanson et al.) Swanson M et al. Circulation. 2005;112(17):II-106. *p=0.02

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 (Ong, Ornato et al.) Human Long-term Survival Study

54. AutoPulse improved survival to hospital discharge by 235% (Ong, Ornato et al.) Ong ME, Ornato J et al. JAMA. 2006;295(22):2629-2637. *p=0.0001 Human Long-term Survival Study

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

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.