Art & science | cardiac arrest
Automated cardiopulmonary resuscitation: a case study Jon Spiro and colleagues describe the use of an electronic device to treat a patient who experienced cardiac arrest in an emergency department Correspondence [email protected] Jon Spiro is a cardiology specialist registrar Maria Theodosiou is a cardiology specialist registrar Sagar Doshi is a consultant cardiologist All at Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust Date of submission November 7 2013 Date of acceptance January 9 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines en.rcnpublishing.com
Abstract Rates of survival after cardiac arrest are low and correlate with the quality of cardiopulmonary resuscitation (CPR). Devices that deliver automated CPR (A-CPR) can provide sustained and effective chest compressions, which are especially useful during patient transfer and while simultaneous invasive procedures are being performed. The use of such devices can also release members of resuscitation teams for other work. This article presents a case study involving a man with acute myocardial infarction complicated by cardiogenic shock and pulmonary oedema. It describes how ED nursing and medical teams worked together to deliver A-CPR, discusses the use of A-CPR devices in a tertiary cardiac centre, and highlights the advantages of using such devices. Keywords Cardiopulmonary resuscitation, acute myocardial infarction, percutaneous coronary intervention CARDIAC ARREST complicating acute ST-segment elevation myocardial infarction (STEMI) can be difficult to manage. Primary percutaneous coronary intervention (PPCI), or primary angioplasty, may be required to help correct the causes of cardiac arrest, but can be difficult to achieve in patients who remain in cardiac arrest. Maintaining effective manual cardiopulmonary resuscitation (CPR) requires a team‑based approach, often with two or three members of a resuscitation team rotating to ensure the CPR providers do not become fatigued. However, even when such a strategy is adopted suboptimal chest-compression depth and frequency remain common problems (Abella et al 2005, Stiell et al 2012).
28 February 2014 | Volume 21 | Number 9
Devoting two or three team members to perform CPR places extra pressure on other members, who must perform important tasks such as preparing and administering drugs, arranging imaging procedures or liaising with other staff. In these circumstances, automated CPR (A-CPR) may be preferred to manual CPR. The case study opposite describes how ED nursing and medical staff delivered A-CPR to a 66-year-old man with acute myocardial infarction complicated by cardiac arrest. X-rays showing the patient’s pulmonary oedema and the results of his emergency coronary angioplasty are shown in Figures 1 and 2. Invasive blood pressure measurement during A-CPR is demonstrated in Figure 3, page 30. The A-CPR was administered during his initial treatment and assessment, and during his transfer to a cardiac catheter lab. It released several ED nurses from CPR duty so that they could liaise directly with cardiologists, intensive care unit staff and cardiac catheter lab nurses in arranging the emergency transfer and treatment of a critically ill patient.
Devices Two of the most commonly used A-CPR devices in the UK are the AutoPulse® non-invasive cardiac support pump, with which CPR is delivered by a compression band placed over the patient’s chest and attached to both sides of a mechanical backboard, and the Lucas™ chest compression system, with which CPR is delivered by a suction cup positioned over the patient’s mid sternum. Both types of device deliver effective CPR and can improve the likelihood of successful return of spontaneous circulation in patients who have experienced out-of-hospital cardiac arrest (Westfall et al 2013). EMERGENCY NURSE
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Case study An ambulance was called to the home of a 66-year-old man who was experiencing acute‑onset chest pain and shortness of breath. The crew found he was conscious but profusely sweaty, pale and clinically in pulmonary oedema. His oxygen saturation was 88% in air although his airway was clear. His pulse was rapid, irregularly irregular and weak. His blood pressure (BP) was 70/30 and a pre-hospital 12-lead electrocardiography (ECG) reading confirmed atrial fibrillation and a left-bundle branch block (LBBB) morphology. He also had a history of treated hypertension and type 2 diabetes mellitus. The crew began oxygen therapy and the patient received an intravenous (IV) 50mg bolus of furosemide. The crew alerted the nearest hospital’s primary angioplasty team, who began to prepare a cardiac catheter lab. Before the ambulance arrived, however, the patient became more hypotensive with worsening respiratory failure so the ambulance was diverted to the resuscitation area of the hospital’s emergency department (ED), where the patient was met by the ED medical and nursing teams. Despite satisfactory oxygenation, the patient experienced pulseless electrical activity (PEA) cardiac arrest, and required intubation and ventilation. After four cycles of manual cardiopulmonary resuscitation (CPR) and 2mg IV adrenaline, he achieved return of spontaneous circulation (ROSC). Non‑invasive BP measured 59/35, and repeat ECG confirmed atrial fibrillation and LBBB. His BP failed to correct with an IV bolus dose of metaraminol, a sympathomimetic vasoconstrictor. Emergency bedside echocardiography suggested severe anterior and anterolateral wall hypokinesia, and severely impaired left‑ventricular systolic function. The left ventricular ejection fraction was estimated to be 30%. A chest X-ray confirmed pulmonary oedema (Figure 1). Nurses in the ED liaised with the on-call cardiology team and a diagnosis of acute myocardial infarction, complicated by cardiogenic shock, was made. The ED team planned to transfer the patient EMERGENCY NURSE
Figure 1 Chest X-ray demonstrating gross pulmonary vascular congestion and pulmonary oedema
immediately to the cardiac catheter lab for primary percutaneous coronary intervention (PPCI) but, while he was being prepared, he experienced another PEA cardiac arrest. After two further cycles of manual CPR with no ROSC, an automated CPR (A-CPR) device, an AutoPulse®, was used. Once attached and activated the device was switched to continuous CPR mode because the patient was intubated and ventilated. Nurses in the ED could then prepare him for transfer and liaise with the catheter-lab nurses, who in turn prepared the lab for PPCI. While under continuous A-CPR the patient was transferred to the catheter lab. Once he was on the catheter lab table, the CPR device was paused and ROSC was confirmed.
The device remained in place during PPCI. Arterial access into his right femoral artery (RFA) was gained using a 6 French sheath and initial invasive BP was found to be 108/74. Emergency coronary angiography demonstrated severe coronary artery disease affecting his left main stem and proximal right coronary artery (Figure 2), and PPCI was performed to both. At the end of the procedure the patient’s BP was still low, at 85/58, and so an intra‑aortic balloon pump (IABP) was inserted through the RFA site. After successful revascularisation he was given balloon pump support and a 160mcg/mL adrenaline infusion while being transferred to the hospital’s intensive care unit (ICU), where for the next five days he was weaned off inotropes and IABP support. The patient’s recovery was complicated by aspiration pneumonia and pneumothorax, so he was treated with IV antibiotics. He also required a chest drain and a tracheostomy was inserted to aid his respiratory wean. On day 22 the patient was decannulated, and he was transferred out of the ICU two days later. On day 35 no evidence of neurological injury was found and he was discharged home. He was still well at six‑month follow up.
Figure 2 Results of emergency coronary angioplasty Right: critical left main stem lesion before (left) and after (right) coronary angioplasty
Left: proximal right coronary artery lesion before (left) and after (right) coronary angioplasty
February 2014 | Volume 21 | Number 9 29
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Art & science | cardiac arrest Figure 3 Invasive haemodynamic readings during cardiac arrest and automated cardiopulmonary resuscitation (A-CPR) Surface electrocardiogram from A-CPR
300 280 260 220 200 180 160 140 Invasive haemodynamic recording
Blood pressure (mmHg)
240 -
120 100 80 60 40 20 0-
Practitioners can use the devices effectively even after only brief training (Lapostolle et al 2009), although regular scenario‑based training may be required to maintain effective application. Automated CPR has several advantages over manual CPR. For example, A-CPR devices: ■■ Maintain depth and frequency of CPR over time. ■■ Maintain effective CPR in confined spaces, such as ambulances and helicopters, and during patient transfers. ■■ Maintain CPR without staff becoming fatigued. ■■ Release staff from performing chest compressions so that they can carry out other tasks, such as imaging procedures. ■■ Ensure a sterile field can be maintained in catheter labs. ■■ Ensure staff are not exposed to harmful radiation from X-ray devices during fluoroscopic screening in catheter labs. ■■ Provide continuous circulatory support during invasive procedures, such as coronary angiography, transoesophageal echocardiography, pericardiocentesis and insertion of transvenous endocardial pacing wires. There are also disadvantages to A-CPR. For example: ■■ Attaching A-CPR devices to patients correctly and activating them can take time, which may significantly interrupt chest compressions. ■■ Staff need initial and continuing training to use A-CPR devices. ■■ Staff must ensure that A-CPR devices and their batteries are maintained continually. 30 February 2014 | Volume 21 | Number 9
■■ In some A-CPR devices, patient movement following administration of a shock triggers a misalignment alarm and the devices must be reset. ■■ There is no single resuscitation algorithm that includes, for example, drug doses and timings to guide the use of A-CPR devices.
Conclusion Good quality CPR remains the cornerstone of successful resuscitation. In situations where patient transfer, emergency imaging or simultaneous invasive procedures are required, A-CPR can offer several advantages over manual CPR. Use of A-CPR devices can help release members of the resuscitation team so they can help arrange other resuscitation therapies or interventions. The role of A-CPR in hospitals is unclear, however, and further studies of how this technology can be integrated into resuscitation algorithms to treat in-hospital cardiac arrest are required. References Abella BS, Sandbo N, Vassilatos P et al (2005) Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest. Circulation. 111, 4, 428-434. Lapostolle F, Agostinucci JM, Bertrand P et al (2009) Use of an automated device for external chest compressions by first-aid workers unfamiliar with the device: a step toward public access? Academic Emergency Medicine. 16, 12, 1374-1377. doi: 10.1111/j.1553-2712.2009.00585.x Stiell IG, Brown SP, Chrstenson J et al (2012) What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation? Critical Care Medicine. 40, 4, 1192-1198. doi: 10.1097/CCM.0b013e31823bc8bb. Westfall M, Krantz S, Mullin C et al (2013) Mechanical versus manual chest compression in out-of-hospital cardiac arrest: a meta-analysis. Critical Care Medicine. 41, 7, 1782-1789.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
EMERGENCY NURSE
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Automated cardiopulmonary resuscitation: a case study Jon Spiro and colleagues describe the use of an electronic device to treat a patient who experienced cardiac arrest in an emergency department Correspondence [email protected] Jon Spiro is a cardiology specialist registrar Maria Theodosiou is a cardiology specialist registrar Sagar Doshi is a consultant cardiologist All at Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust Date of submission November 7 2013 Date of acceptance January 9 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines en.rcnpublishing.com
Abstract Rates of survival after cardiac arrest are low and correlate with the quality of cardiopulmonary resuscitation (CPR). Devices that deliver automated CPR (A-CPR) can provide sustained and effective chest compressions, which are especially useful during patient transfer and while simultaneous invasive procedures are being performed. The use of such devices can also release members of resuscitation teams for other work. This article presents a case study involving a man with acute myocardial infarction complicated by cardiogenic shock and pulmonary oedema. It describes how ED nursing and medical teams worked together to deliver A-CPR, discusses the use of A-CPR devices in a tertiary cardiac centre, and highlights the advantages of using such devices. Keywords Cardiopulmonary resuscitation, acute myocardial infarction, percutaneous coronary intervention CARDIAC ARREST complicating acute ST-segment elevation myocardial infarction (STEMI) can be difficult to manage. Primary percutaneous coronary intervention (PPCI), or primary angioplasty, may be required to help correct the causes of cardiac arrest, but can be difficult to achieve in patients who remain in cardiac arrest. Maintaining effective manual cardiopulmonary resuscitation (CPR) requires a team‑based approach, often with two or three members of a resuscitation team rotating to ensure the CPR providers do not become fatigued. However, even when such a strategy is adopted suboptimal chest-compression depth and frequency remain common problems (Abella et al 2005, Stiell et al 2012).
28 February 2014 | Volume 21 | Number 9
Devoting two or three team members to perform CPR places extra pressure on other members, who must perform important tasks such as preparing and administering drugs, arranging imaging procedures or liaising with other staff. In these circumstances, automated CPR (A-CPR) may be preferred to manual CPR. The case study opposite describes how ED nursing and medical staff delivered A-CPR to a 66-year-old man with acute myocardial infarction complicated by cardiac arrest. X-rays showing the patient’s pulmonary oedema and the results of his emergency coronary angioplasty are shown in Figures 1 and 2. Invasive blood pressure measurement during A-CPR is demonstrated in Figure 3, page 30. The A-CPR was administered during his initial treatment and assessment, and during his transfer to a cardiac catheter lab. It released several ED nurses from CPR duty so that they could liaise directly with cardiologists, intensive care unit staff and cardiac catheter lab nurses in arranging the emergency transfer and treatment of a critically ill patient.
Devices Two of the most commonly used A-CPR devices in the UK are the AutoPulse® non-invasive cardiac support pump, with which CPR is delivered by a compression band placed over the patient’s chest and attached to both sides of a mechanical backboard, and the Lucas™ chest compression system, with which CPR is delivered by a suction cup positioned over the patient’s mid sternum. Both types of device deliver effective CPR and can improve the likelihood of successful return of spontaneous circulation in patients who have experienced out-of-hospital cardiac arrest (Westfall et al 2013). EMERGENCY NURSE
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Case study An ambulance was called to the home of a 66-year-old man who was experiencing acute‑onset chest pain and shortness of breath. The crew found he was conscious but profusely sweaty, pale and clinically in pulmonary oedema. His oxygen saturation was 88% in air although his airway was clear. His pulse was rapid, irregularly irregular and weak. His blood pressure (BP) was 70/30 and a pre-hospital 12-lead electrocardiography (ECG) reading confirmed atrial fibrillation and a left-bundle branch block (LBBB) morphology. He also had a history of treated hypertension and type 2 diabetes mellitus. The crew began oxygen therapy and the patient received an intravenous (IV) 50mg bolus of furosemide. The crew alerted the nearest hospital’s primary angioplasty team, who began to prepare a cardiac catheter lab. Before the ambulance arrived, however, the patient became more hypotensive with worsening respiratory failure so the ambulance was diverted to the resuscitation area of the hospital’s emergency department (ED), where the patient was met by the ED medical and nursing teams. Despite satisfactory oxygenation, the patient experienced pulseless electrical activity (PEA) cardiac arrest, and required intubation and ventilation. After four cycles of manual cardiopulmonary resuscitation (CPR) and 2mg IV adrenaline, he achieved return of spontaneous circulation (ROSC). Non‑invasive BP measured 59/35, and repeat ECG confirmed atrial fibrillation and LBBB. His BP failed to correct with an IV bolus dose of metaraminol, a sympathomimetic vasoconstrictor. Emergency bedside echocardiography suggested severe anterior and anterolateral wall hypokinesia, and severely impaired left‑ventricular systolic function. The left ventricular ejection fraction was estimated to be 30%. A chest X-ray confirmed pulmonary oedema (Figure 1). Nurses in the ED liaised with the on-call cardiology team and a diagnosis of acute myocardial infarction, complicated by cardiogenic shock, was made. The ED team planned to transfer the patient EMERGENCY NURSE
Figure 1 Chest X-ray demonstrating gross pulmonary vascular congestion and pulmonary oedema
immediately to the cardiac catheter lab for primary percutaneous coronary intervention (PPCI) but, while he was being prepared, he experienced another PEA cardiac arrest. After two further cycles of manual CPR with no ROSC, an automated CPR (A-CPR) device, an AutoPulse®, was used. Once attached and activated the device was switched to continuous CPR mode because the patient was intubated and ventilated. Nurses in the ED could then prepare him for transfer and liaise with the catheter-lab nurses, who in turn prepared the lab for PPCI. While under continuous A-CPR the patient was transferred to the catheter lab. Once he was on the catheter lab table, the CPR device was paused and ROSC was confirmed.
The device remained in place during PPCI. Arterial access into his right femoral artery (RFA) was gained using a 6 French sheath and initial invasive BP was found to be 108/74. Emergency coronary angiography demonstrated severe coronary artery disease affecting his left main stem and proximal right coronary artery (Figure 2), and PPCI was performed to both. At the end of the procedure the patient’s BP was still low, at 85/58, and so an intra‑aortic balloon pump (IABP) was inserted through the RFA site. After successful revascularisation he was given balloon pump support and a 160mcg/mL adrenaline infusion while being transferred to the hospital’s intensive care unit (ICU), where for the next five days he was weaned off inotropes and IABP support. The patient’s recovery was complicated by aspiration pneumonia and pneumothorax, so he was treated with IV antibiotics. He also required a chest drain and a tracheostomy was inserted to aid his respiratory wean. On day 22 the patient was decannulated, and he was transferred out of the ICU two days later. On day 35 no evidence of neurological injury was found and he was discharged home. He was still well at six‑month follow up.
Figure 2 Results of emergency coronary angioplasty Right: critical left main stem lesion before (left) and after (right) coronary angioplasty
Left: proximal right coronary artery lesion before (left) and after (right) coronary angioplasty
February 2014 | Volume 21 | Number 9 29
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Art & science | cardiac arrest Figure 3 Invasive haemodynamic readings during cardiac arrest and automated cardiopulmonary resuscitation (A-CPR) Surface electrocardiogram from A-CPR
300 280 260 220 200 180 160 140 Invasive haemodynamic recording
Blood pressure (mmHg)
240 -
120 100 80 60 40 20 0-
Practitioners can use the devices effectively even after only brief training (Lapostolle et al 2009), although regular scenario‑based training may be required to maintain effective application. Automated CPR has several advantages over manual CPR. For example, A-CPR devices: ■■ Maintain depth and frequency of CPR over time. ■■ Maintain effective CPR in confined spaces, such as ambulances and helicopters, and during patient transfers. ■■ Maintain CPR without staff becoming fatigued. ■■ Release staff from performing chest compressions so that they can carry out other tasks, such as imaging procedures. ■■ Ensure a sterile field can be maintained in catheter labs. ■■ Ensure staff are not exposed to harmful radiation from X-ray devices during fluoroscopic screening in catheter labs. ■■ Provide continuous circulatory support during invasive procedures, such as coronary angiography, transoesophageal echocardiography, pericardiocentesis and insertion of transvenous endocardial pacing wires. There are also disadvantages to A-CPR. For example: ■■ Attaching A-CPR devices to patients correctly and activating them can take time, which may significantly interrupt chest compressions. ■■ Staff need initial and continuing training to use A-CPR devices. ■■ Staff must ensure that A-CPR devices and their batteries are maintained continually. 30 February 2014 | Volume 21 | Number 9
■■ In some A-CPR devices, patient movement following administration of a shock triggers a misalignment alarm and the devices must be reset. ■■ There is no single resuscitation algorithm that includes, for example, drug doses and timings to guide the use of A-CPR devices.
Conclusion Good quality CPR remains the cornerstone of successful resuscitation. In situations where patient transfer, emergency imaging or simultaneous invasive procedures are required, A-CPR can offer several advantages over manual CPR. Use of A-CPR devices can help release members of the resuscitation team so they can help arrange other resuscitation therapies or interventions. The role of A-CPR in hospitals is unclear, however, and further studies of how this technology can be integrated into resuscitation algorithms to treat in-hospital cardiac arrest are required. References Abella BS, Sandbo N, Vassilatos P et al (2005) Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest. Circulation. 111, 4, 428-434. Lapostolle F, Agostinucci JM, Bertrand P et al (2009) Use of an automated device for external chest compressions by first-aid workers unfamiliar with the device: a step toward public access? Academic Emergency Medicine. 16, 12, 1374-1377. doi: 10.1111/j.1553-2712.2009.00585.x Stiell IG, Brown SP, Chrstenson J et al (2012) What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation? Critical Care Medicine. 40, 4, 1192-1198. doi: 10.1097/CCM.0b013e31823bc8bb. Westfall M, Krantz S, Mullin C et al (2013) Mechanical versus manual chest compression in out-of-hospital cardiac arrest: a meta-analysis. Critical Care Medicine. 41, 7, 1782-1789.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
EMERGENCY NURSE
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