Selected topic: Prehospital care
Resuscitation, Prolonged Cardiac Arrest, and an Automated Chest Compression Device

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Abstract

Background: The European Resuscitation Council's 2005 guidelines for cardiopulmonary resuscitation (CPR) emphasize the delivery of uninterrupted chest compressions of adequate depth during cardiac arrest. Objectives: To describe how the circumstances of out-of-hospital cardiac arrest can impede the performance of CPR, and how this situation can be overcome. Case Report: The presentation of two cases of prolonged CPR (48 min and 120 min, respectively) with an automated chest compression device, the AutoPulse®, under difficult circumstances. Both patients survived without neurological sequelae. Conclusion: Prolonged chest compressions may be necessary in some cardiac arrests. These cases suggest that automated chest compression devices may increase the chance of a favorable outcome in these rare situations.

Introduction

The European Resuscitation Council (ERC) 2005 guidelines for cardiopulmonary resuscitation (CPR) emphasize the importance of continuous cardiac compression and of the minimization of hands-off time during CPR (1). However, the performance of chest compressions (CC) is exhausting. Staff who perform CC rapidly experience fatigue, and after 60 s, the efficiency of CC deteriorates (2, 3).

To optimize CPR, several mechanical devices for automated CC have been introduced, and one of these is the AutoPulse® (AP) (Figure 1). This device consists of a constrictive band driven by a battery-operated motor, and is connected to a short spine board. The patient is placed on the spine board and the band is strapped around the patient's chest. Then, the AP rhythmically squeezes the chest, with approximately a 20% reduction in the original circumference of the thorax.

Trials on pigs have shown that coronary perfusion pressures > 15 mm Hg can be achieved by using the AP. In these experiments, the AP resulted in an improved neurological outcome compared with groups treated with manual compressions (4). A study on patients with in-hospital cardiac arrest showed that the AP was superior to conventional CC in restoring sufficient coronary perfusion pressures (5). On the other hand, Hallstrom et al. demonstrated an inferior outcome for patients suffering from cardiac arrest who were treated with the AP (6). Thus, the promising findings based on surrogate measures in a highly selected population could not be confirmed in a randomized trial. At present, there is no conclusive scientific evidence for a beneficial effect of automated chest compression devices in the general treatment of cardiac arrest.

In Copenhagen, emergency medical services (EMS), which operate in a two-tiered, rendezvous fashion, consist of an ambulance staffed with emergency medical technicians who are competent to perform basic life support including defibrillations, and a Mobile Emergency Care Unit (MECU) manned with an anesthesiologist and a specially trained emergency medical technician. The MECU is currently in the process of validating the AP.

Section snippets

Case 1

A 44-year-old man collapsed with cardiac arrest while working on the eighth floor of a construction area. Bystander CPR was started immediately. Upon arrival of the first ambulance about 9 min after collapse, the patient was in ventricular fibrillation (VF) and direct current shock (360-Joule, biphasic) was administered and CPR was commenced, but with no return of spontaneous circulation (ROSC). After arrival of the MECU 4 min later, another two shocks were delivered due to VF. The heart rhythm

Discussion

In both of these cases, the patients had a significant period of apnea, followed by spontaneous respiratory efforts after commencement of mechanical CC and, in fact, this was an important reason for not discontinuing resuscitation in Case 1. This finding can be interpreted as a sign of brainstem perfusion, which suggests that the AP is capable of generating sufficient cardiac output. It is well known that respiratory efforts also are seen during effective manual CC, but ERC guidelines for 2005

Conclusion

Two patients are described who required CPR for a prolonged period of time under difficult circumstances, which was facilitated by the use of the automated chest compression device. Without this device it is highly likely that CPR would have been interrupted several times during transport. Consequently, the quality of CC would have deteriorated, possibly influencing its efficacy and potentially resulting in a poor final outcome. It is plausible that automated CC can prolong the time period of

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