Based on PICO from RT 2-WK 2
Clinical Question: As in the past, please briefly outline the scenario and state your clinical question as concisely and specifically as possible
65 year old male patient with a past medical history of HTN has an acute cardiac arrest at home, and EMS is called by the wife. In the ambulance the patient becomes nonresponsive and his vitals begin to drop. The EMS team start with manual chest compressions but then switch over to the mechanical LUCAS compression machine, which consistent compressions in a continuous manner. The team then arrives to the hospital and transfers the patient with the LUCAS machine still strapped on. The wife wants to know why this method is better then manual compressions.
PICO Question:
In the case of a patient having an acute cardiac arrest, what is the benefit of using mechanical compression machine like LUCAS vs doing manual compressions for resuscitation in order to decrease patient morbidity and mortality
| P | I | C | O |
| Patients having cardiac arrest | Mechanical compression machine | Manual chest compressions | Decreased morbidity and mortality |
| Patients who are unresponsive | LUCAS | Compressions done by EMS and hospital staff | Increased patient survival |
| Patients needing cardiac resuscitation | Autopulse | Standard protocol for resuscitation | Positive patient outcome |
| Automated compressions | |||
Search Strategy:
Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on.
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| Search terms used | Search terms used | Search terms used | Search terms used |
| a. Benefits of using LUCAS for chest compressions: 40
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a. Benefits of using LUCAS for compression in the ER: 653
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a. mechanical compressions vs manual compressions in CPR: 18,540
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a. Benefits of Lucas for chest compressions: 147
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| b. Benefits of using LUCAS for chest compressions + past 10 years: 23
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b. Benefits of using LUCAS for compression vs manual compressions: 602
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b. mechanical compressions vs manual compressions in CPR + increased survival: 4,230 | b. Benefits of Lucas for chest compressions + last 10 years: 91
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| c. Benefits of using LUCAS for compression vs manual compressions + past 10 years: 304 | |||
| Selection criteria | Selection criteria | Selection criteria | Selection criteria |
| Cochrane review produced a pretty narrow search initially. However I still wanted to narrow this even farther by looking at articles within the past 10 years for added relevancy.
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Science Direct is a great source to use. However with a broad search, it can produce a lot of articles to sift through. I Narrowed my search by only looking at articles that were published in the last 10 years. I also wanted to specify in the search criteria “vs manual compressions” so I could clearly see how mechanical acts in comparison. I also looked for research articles rather then textbook content or just journals.
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Google scholar I always a great resource to use, and a great first step in starting a research. Whenever I am stuck on which PICO topic to choose, I come here first and start looking up interesting facts. However, it can be overwhelming at times since it can produce a lot of searches from various sources. I narrowed my selection criteria by looking for articles published in the last 5 years, as well as articles that were published in familiar science journals such as NIH, pubMed, wiley, cochrane, etc, in order to see if they fit my PICO question. | Similar to the last few search sources I mentioned above, I first narrowed my search by looking at articles published in the last 10 years. I also looked to see if the articles focused on the question at hand of benefits on mechanical compressions using the LUCAS. Finally I would check to see if the articles were either meta-analysis or comparative studies like RCTs as they offer higher level of evidence.
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Articles Chosen (4 or more) for Inclusion (please copy and paste the abstract with link):
- Mechanical versus manual chest compressions for cardiac arrest
Wang, Peter L, and Steven C Brooks. “Mechanical versus manual chest compressions for cardiac arrest.” The Cochrane database of systematic reviews vol. 8,8 CD007260. 20 Aug. 2018, doi:10.1002/14651858.CD007260.pub4
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6953326/
Abstract:
Background
Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR).
Objectives
To assess the effectiveness of resuscitation strategies using mechanical chest compressions versus resuscitation strategies using standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest.
Search methods
On 19 August 2017 we searched the Cochrane Central Register of Controlled Studies (CENTRAL), MEDLINE, Embase, Science Citation Index‐Expanded (SCI‐EXPANDED) and Conference Proceedings Citation Index–Science databases. Biotechnology and Bioengineering Abstracts and Science Citation abstracts had been searched up to November 2009 for prior versions of this review. We also searched two clinical trials registries for any ongoing trials not captured by our search of databases containing published works: Clinicaltrials.gov (August 2017) and the World Health Organization International Clinical Trials Registry Platform portal (January 2018). We applied no language restrictions. We contacted experts in the field of mechanical chest compression devices and manufacturers.
Selection criteria
We included randomised controlled trials (RCTs), cluster‐RCTs and quasi‐randomised studies comparing mechanical chest compressions versus manual chest compressions during CPR for patients with cardiac arrest.
Data collection and analysis
We used standard methodological procedures expected by Cochrane.
Main results
We included five new studies in this update. In total, we included 11 trials in the review, including data from 12,944 adult participants, who suffered either out‐of‐hospital cardiac arrest (OHCA) or in‐hospital cardiac arrest (IHCA). We excluded studies explicitly including patients with cardiac arrest caused by trauma, drowning, hypothermia and toxic substances. These conditions are routinely excluded from cardiac arrest intervention studies because they have a different underlying pathophysiology, require a variety of interventions specific to the underlying condition and are known to have a prognosis different from that of cardiac arrest with no obvious cause. The exclusions were meant to reduce heterogeneity in the population while maintaining generalisability to most patients with sudden cardiac death.
The overall quality of evidence for the outcomes of included studies was moderate to low due to considerable risk of bias. Three studies (N = 7587) reported on the designated primary outcome of survival to hospital discharge with good neurologic function (defined as a Cerebral Performance Category (CPC) score of one or two), which had moderate quality evidence. One study showed no difference with mechanical chest compressions (risk ratio (RR) 1.07, 95% confidence interval (CI) 0.82 to 1.39), one study demonstrated equivalence (RR 0.79, 95% CI 0.60 to 1.04), and one study demonstrated reduced survival (RR 0.41, CI 0.21 to 0.79). Two other secondary outcomes, survival to hospital admission (N = 7224) and survival to hospital discharge (N = 8067), also had moderate quality level of evidence. No studies reported a difference in survival to hospital admission. For survival to hospital discharge, two studies showed benefit, four studies showed no difference, and one study showed harm associated with mechanical compressions. No studies demonstrated a difference in adverse events or injury patterns between comparison groups but the quality of data was low. Marked clinical and statistical heterogeneity between studies precluded any pooled estimates of effect.
Authors’ conclusions
The evidence does not suggest that CPR protocols involving mechanical chest compression devices are superior to conventional therapy involving manual chest compressions only. We conclude on the balance of evidence that mechanical chest compression devices used by trained individuals are a reasonable alternative to manual chest compressions in settings where consistent, high‐quality manual chest compressions are not possible or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, during preparation for extracorporeal CPR [ECPR], etc.). Systems choosing to incorporate mechanical chest compression devices should be closely monitored because some data identified in this review suggested harm. Special attention should be paid to minimising time without compressions and delays to defibrillation during device deployment.
- The Efficacy of LUCAS in Prehospital Cardiac Arrest Scenarios: A Crossover Mannequin Study
Gyory, Robert A et al. “The Efficacy of LUCAS in Prehospital Cardiac Arrest Scenarios: A Crossover Mannequin Study.” The western journal of emergency medicine vol. 18,3 (2017): 437- 445. doi:10.5811/westjem.2017.1.32575
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5391893/
Abstract:
Introduction
High-quality cardiopulmonary resuscitation (CPR) is critical for successful cardiac arrest outcomes. Mechanical devices may improve CPR quality. We simulated a prehospital cardiac arrest, including patient transport, and compared the performance of the LUCAS™ device, a mechanical chest compression-decompression system, to manual CPR. We hypothesized that because of the movement involved in transporting the patient, LUCAS would provide chest compressions more consistent with high-quality CPR guidelines.
Methods
We performed a crossover-controlled study in which a recording mannequin was placed on the second floor of a building. An emergency medical services (EMS) crew responded, defibrillated, and provided either manual or LUCAS CPR. The team transported the mannequin through hallways and down stairs to an ambulance and drove to the hospital with CPR in progress. Critical events were manually timed while the mannequin recorded data on compressions.
Results
Twenty-three EMS providers participated. Median time to defibrillation was not different for LUCAS compared to manual CPR (p=0.97). LUCAS had a lower median number of compressions per minute (112/min vs. 125/min; IQR = 102–128 and 102–126 respectively; p<0.002), which was more consistent with current American Heart Association CPR guidelines, and percent adequate compression rate (71% vs. 40%; IQR = 21–93 and 12–88 respectively; p<0.002). In addition, LUCAS had a higher percent adequate depth (52% vs. 36%; IQR = 25–64 and 29–39 respectively; p<0.007) and lower percent total hands-off time (15% vs. 20%; IQR = 10–22 and 15–27 respectively; p<0.005). LUCAS performed no differently than manual CPR in median compression release depth, percent fully released compressions, median time hands off, or percent correct hand position.
Conclusion
In our simulation, LUCAS had a higher rate of adequate compressions and decreased total hands-off time as compared to manual CPR. Chest compression quality may be better when using a mechanical device during patient movement in prehospital cardiac arrest patient.
3.. LUCAS compared to manual cardiopulmonary resuscitation is more effective during helicopter rescue—a prospective, randomized, cross-over manikin study
Gabriel Putzer, Patrick Braun, Andrea Zimmermann, Florian Pedross, Giacomo Strapazzon, Hermann Brugger, Peter Paal, LUCAS compared to manual cardiopulmonary resuscitation is more effective during helicopter rescue—a prospective, randomized, cross-over manikin study, The American Journal of Emergency Medicine,Volume 31, Issue 2,2013,Pages 384-389, ISSN 0735-6757,
https://www-sciencedirect-com.york.ezproxy.cuny.edu/science/article/pii/S0735675712003774
Abstract:
Objective
High-quality chest-compressions are of paramount importance for survival and good neurological outcome after cardiac arrest. However, even healthcare professionals have difficulty performing effective chest-compressions, and quality may be further reduced during transport. We compared a mechanical chest-compression device (Lund University Cardiac Assist System [LUCAS]; Jolife, Lund, Sweden) and manual chest-compressions in a simulated cardiopulmonary resuscitation scenario during helicopter rescue.
Methods
Twenty-five advanced life support–certified paramedics were enrolled for this prospective, randomized, crossover study. A modified Resusci Anne manikin was employed. Thirty minutes of training was allotted to both LUCAS and manual cardiopulmonary resuscitation (CPR). Thereafter, every candidate performed the same scenario twice, once with LUCAS and once with manual CPR. The primary outcome measure was the percentage of correct chest-compressions relative to total chest-compressions.
Results
LUCAS compared to manual chest-compressions were more frequently correct (99% vs 59%, P < .001) and were more often performed correctly regarding depth (99% vs 79%, P < .001), pressure point (100% vs 79%, P < .001) and pressure release (100% vs 97%, P = .001). Hands-off time was shorter in the LUCAS than in the manual group (46 vs 130 seconds, P < .001). Time until first defibrillation was longer in the LUCAS group (112 vs 49 seconds, P < .001).
Conclusions
During this simulated cardiac arrest scenario in helicopter rescue LUCAS compared to manual chest-compressions increased CPR quality and reduced hands-off time, but prolonged the time interval to the first defibrillation. Further clinical trials are warranted to confirm potential benefits of LUCAS CPR in helicopter rescue.
- Manual versus Mechanical Chest Compressions on Surfaces of Varying Softness with or without Backboards: A Randomized, Crossover Manikin Study
Gabriel Putzer, Anna Fiala, Patrick Braun, Sabrina Neururer, Karin Biechl, Bernhard Keilig, Werner Ploner, Ernst Fop, Peter Paal, Manual versus Mechanical Chest Compressions on Surfaces of Varying Softness with or without Backboards: A Randomized, Crossover Manikin Study, The Journal of Emergency Medicine, Volume 50, Issue 4,2016, Pages 594-600.e1,
https://www-sciencedirect-com.york.ezproxy.cuny.edu/science/article/pii/S0736467915010501
Abstract
Background
Chest compression quality is decisive for overall outcome after cardiac arrest. Chest compression depth may decrease when cardiopulmonary resuscitation (CPR) is performed on a mattress, and the use of a backboard does not necessarily improve compression depth. Mechanical chest compression devices may overcome this problem.
Objectives
We sought to investigate the effectiveness of manual chest compressions both with and without a backboard compared to mechanical CPR performed on surfaces of different softness.
Methods
Twenty-four advanced life support (ALS)–certified rescuers were enrolled. LUCAS2 (Physio-Control, Redmond, WA) delivers 52 ± 2 mm deep chest compressions and active decompressions back to the neutral position (frequency 102 min−1; duty cycle, 50%). This simulated CPR scenario was performed on a Resusci-Anne manikin (Laerdal, Stavanger, Norway) that was lying on 3 different surfaces: 1) a concrete floor, 2) a firm standard mattress, and 3) a pressure-relieving mattress. Data were recorded by the Laerdal Skill Reporting System.
Results
Manual chest compression with or without a backboard were performed correctly less often than mechanical chest compressions (floor: 33% [interquartile range {IQR}, 27–48%] vs. 90% [IQR, 86–94%], p < 0.001; standard mattress: 32% [IQR, 20–45%] vs. 27% [IQR, 14–46%] vs. 91% [IQR, 51–94%], p < 0.001; and pressure-relieving mattress 29% [IQR, 17–49%] vs. 30% [IQR, 17–52%] vs. 91% [IQR, 87–95%], p < 0.001). The mean compression depth on both mattresses was deeper with mechanical chest compressions (floor: 53 mm [range, 47–57 mm] vs. 56 mm [range, 54–57 mm], p = 0.003; standard mattress: 50 mm [range, 44–55 mm] vs. 51 mm [range, 47–55 mm] vs. 55 mm [range, 54–58 mm], p < 0.001; and pressure-relieving mattress: 49 mm [range, 44–55 mm] vs. 50 mm [range, 44–53 mm] vs. 55 mm [range, 55–56 mm], p < 0.001). In this ∼6-min scenario, the mean hands-off time was ∼15 to 20 s shorter in the manual CPR scenarios.
Conclusions
In this experimental study, only ∼30% of manual chest compressions were performed correctly compared to ∼90% of mechanical chest compressions, regardless of the underlying surface. Backboard use did not influence the mean compression depth during manual CPR. Chest compressions were deeper with mechanical CPR. The mean hands-off time was shorter with manual CPR.
- Efficacy and safety of mechanical versus manual compression in cardiac arrest – A Bayesian network meta-analysis
Safi U. Khan, Ahmad N. Lone, Swapna Talluri, Muhammad Z. Khan, Muhammad U. Khan, Edo Kaluski, Efficacy and safety of mechanical versus manual compression in cardiac arrest – A Bayesian network meta-analysis, Resuscitation, Volume 130, 2018
Abstract:
Aim
To compare relative efficacy and safety of mechanical compression devices (AutoPulse and LUCAS) with manual compression in patients with cardiac arrest undergoing cardiopulmonary resuscitation (CPR).
Methods
For this Bayesian network meta-analysis, seven randomized controlled trials (RCTs) were selected using PubMed/Medline, EMBASE, and CENTRAL (Inception- 31 October 2017). For all the outcomes, median estimate of odds ratio (OR) from the posterior distribution with corresponding 95% credible interval (Cr I) was calculated. Markov chain Monte Carlo (MCMC) modeling was used to estimate the relative ranking probability of each intervention based on surface under the cumulative ranking curve (SUCRA).
Results
In analysis of 12, 908 patients with cardiac arrest [AutoPulse (2, 608 patients); LUCAS (3, 308 patients) and manual compression (6, 992 patients)], manual compression improved survival at 30 days or hospital discharge (OR, 1.40, 95% Cr I, 1.09–1.94), and neurological recovery (OR, 1.51, 95% Cr I, 1.06–2.39) compared to AutoPulse. There were no differences between LUCAS and AutoPulse with regards to survival to hospital admission, neurological recovery or return of spontaneous circulation (ROSC). Manual compression reduced the risk of pneumothorax (OR, 0.56, 95% Cr I, 0.33–0.97); while, both manual compression (OR, 0.15, 95% Cr I, 0.01–0.73) and LUCAS (OR, 0.07, 95% Cr I, 0.00–0.43) reduced the risk of hematoma formation compared to AutoPulse. Probability analysis ranked manual compression as the most effective treatment for improving survival at 30 days or hospital discharge (SUCRA, 84%).
Conclusions
Manual compression is more effective than AutoPulse and comparable to LUCAS in improving survival at 30 days or hospital discharge and neurological recovery. Manual compression had lesser risk of pneumothorax or hematoma formation compared to AutoPulse.
Summary of the Evidence:
| Author (Date) | Level of Evidence | Sample/Setting
(# of subjects/ studies, cohort definition etc. ) |
Outcome(s) studied | Key Findings | Limitations and Biases |
| 1. Mechanical versus manual chest compressions for cardiac arrest
Wang, Peter L, and Steven C Brooks 2018 |
Systematic review | -they looked at 11 trails in this review.
-data was calculated from 12,944 adult participants, who had either a in-hospital or out of hospital cardiac arrest. -some of the studies looked at the survival to hospital discharge with good neurological function. -In this paper, they mainly looked at studies that were RCTs and quasi-random, and excluded any cross over studies.
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The three major outcomes that were looked at in this systematic review were:
1.the survival to hospital discharge with the maintenance of good neurological functioning. 2.The second outcome is the survival to hospital admission. 3. the final outcome that was looked at was the overall survival to hospital discharge. -other minor outcomes included return of blood circulation, and adverse effects sch as abdominal injuries and rib fractures. |
– CPR is usually done with someone using their hands to manually push on the patients breast bone in a rhythmic fashion.
– This can tire and exhaust the person doing the CPR, and weaken their compressions. Hence, machines have been introduced to take over this pumping action in order to provide consistent compressions with equal depth and pressure each time, without the fear of over exhaustion – In this study they looked at 11 studies (mainly RCTs) with about 12,944 patients who suffered a cardiac arrest. The results of these studies varied as they looked at different mechanical compression tools and different CPR protocols they followed – They found that there was no real statistical survival difference in those using mechanical vs manual compressions. However mechanical compressions were the most useful in situations where they were being used by trained professionals in a setting where continuous compressions was not possible |
-One limitation is that since this was a systematic review, there was some bias in some of the trails that were looked at, leading to overall moderate quality of evidence.
-I also believe that another limitation is that they included patients who had both out of hospital and in hospital cardiac arrests. This could skew the results of the type of compression, since there is more life-saving equipment, and professionals present at the hospital that could also influence the patients survival rates.
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2. The Efficacy of LUCAS in Prehospital Cardiac Arrest Scenarios: A Crossover Mannequin Study
Gyory, Robert 2017 |
Cross over study | -in this study there was a total of 23 EMS providers that participated.
-They had 10 teams, with 2 subjects in each team (one paramedic and one EMS), totaling up to 20 subjects -each subject was then randomly asked to do either manual or mechanical compressions using the LUCAS.
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-Primary outcomes that were assessed included time to defibrillation and overall CPR characteristics, such as better depth, rate and consistency.
-improved blood flow and return to baseline neurological functioning was also assessed. |
Each participant was asked to do a questionnaire in order to better understand their certification level, training with CPR and experience with LUCAS.
– Each subject then got 15 min training to properly use the LCUAS. – They study was then performed on a mannequin which was programmed to have a v-fib attack, and everyone was asked to perform 2 cycles of manual CPR prior to anything else. They were then asked to use the LUCAS, this order was randomized – It was found that the LUCAS lead to less hands off time, and decreased time in resuscitation with a defibrillator. It also had more consistent chest compression rate and depth
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-One major limitation of this study was that it was done on mannequins, and not real patients/subjects.
-This is of course for ethical reasons, and saftey reasons. However, it is difficult to assess the overall quality of this technique when it is not done on people. -Another limitation was that there were only 23 EMS providers that participated. This limits the data results, as there can be more room for error with less people. |
| 3. LUCAS compared to manual cardiopulmonary resuscitation is more effective during helicopter rescue—a prospective, randomized, cross-over manikin study
Gabriel Putzer, Patrick Braun, Andrea Zimmermann, Florian Pedross, Giacomo Strapazzon, Hermann Brugger, Peter Paal 2013 |
Prospective Randomized cross over study
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-Total of 25 trained paramedics were enrolled in this study.
-They were each given 30 minutes training on how to properly do both manual and mechanical compressions using LUCAS. They were then asked to perform these in a random order in the setting of a helicopter rescue.
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-The primary outcome hat was looked at was the percentage of correct chest compressions that were done (based on accurate depth, rate and consistency) compared to the total number of compressions done. This was then compared between the two types manual and mechanical to see which had the higher percentage.
-secondary outcomes include compression depth, pressure point, pressure release, hands off time and time until the first defibrillation. |
-During helicopter EMS transport this is even worse due to the excessive movement of the vehicle and limited space
– Each member was then given a 30 minute lesson, and then were tasked to perform each on a mannequin in a randomized order. This was divided into 3 scenarios, preflight, in flight, and after flight; and 2 cycles of compressions which each mechanical and manual technique was done. -they found that the rate and quality of compressions using the LUCAS was better and more consistent, there was also less hands off time, but there was longer time to first defibrillation (mainly because of time needed to take off the device and put on the defibrillator – Over all, the LUCAS was more successful then manual compressions in a helicopter EMS scenario |
-The limitations of this study was similar to the one above, in that the research was done on mannequins instead of real people. This will not give the most accurate results, as there are factors such as tissue density and quality of bone and excess fat that a human has and a mannequin does not.
-Another limitation was that there were only 25 paramedics that were used in this study, which is a fairly small sample size, hence there is more room for error and bias. -Finally the study should have specified the years of experience each paramedic has, since those with more experience will be better at overall CPR then new paramedics. |
| 4. Manual versus Mechanical Chest Compressions on Surfaces of Varying Softness with or without Backboards: A Randomized, Crossover Manikin Study
Gabriel Putzer, Anna Fiala, Patrick Braun, Sabrina Neururer, Karin Biechl, Bernhard Keilig,Werner Ploner, Ernst Fop, Peter Paal 2016 |
Randomized cross over study | -24 ALS certified rescuers were enrolled in this study.
-These providers were split into teams of two and were tasked to perform the same CPR scenario on different surfaces (such as backboard) in a randomized order with manual and mechanical chest compressions-they were then asked to assess the efficacy of chest compressions and their level of fatigue after each scenario. |
-the primary outcome was similar to the study above, in that they looked at the amount of correct chest compressions in comparison with total amount of compressions when using the manual or mechanical technique.
-they also looked at depth, pressure point, pressure release, hands off time, time to defibrillation, as well as provider fatigue and exhaustion. |
-Each rescuer was asked to perform CPR using manual and mechanical techniques in mannequins with or without backboards.
In the manual compression scenario each rescuer was asked to switch every 2 minutes, where as the LUCAS machine went on continuously. -Compressions were only interrupted to check for return of cardiac rhythm. They found that compression rate was deeper with the LUCAS and shallower with manual compressions. They also found that hands off time was shorter with manual CPR. There was no difference in the quality of compressions when comparing between the mattress and backboard, however rescuers reported more exhaustion without the backboard. Overall they found that 30% of manual compressions were performed correctly vs 90% of mechanical compressions regardless of surface |
-limitations of this study as are those articles above. The use of a mannequin limits the correct accuracy of the results, even though they used varying softness with an without backboards to emulate a more realistic scenario. Also there were only 24 ALS providers that were used which is a small sample size. |
| 5. Efficacy and safety of mechanical versus manual compression in cardiac arrest – A Bayesian network meta-analysis
Safi U. Khan, Ahmad N. Lone, Swapna Talluri, Muhammad Z. Khan, Muhammad U. Khan, Edo Kaluski 2018 |
Meta-analysis | -7 RCTs were selected from databases like Pubmed, medline, etc.
-there were a total of 12,908 patients enrolled, who suffered a cardiac arrest. -3,308 patients had compressions via the LUCAS done -2,608 patients used mechanical compression machine called the autopulse. -6,992 patients had manual compressions done. |
-primary outcome was survival at 30 days after the attack or until hospital discharge
-secondary outcomes included hospital admission, return of spontaneous circulation, neurological recovery, rib fracture, pneumothorax, and hematoma formation. |
-when compared to the autopulse, manual compression improved the 30 day survival better.
-There was no difference seen between the LUCAS and Autopulse in regards to survival to hospital admission, neuro recovery or recovery of circulation. -Manual compressions reduced the risk of hematoma formation when compared to mechanical. -Overall, manual compressions are more effective then the Autopulse and comparable to the LUCAS in regards to surviving to hospital discharge. |
-some limitations of this study included that since this is a meta-analysis, it is difficult to know the specific characteristics of each participant, such as the co-morbidities, exclusion criteria, and follow up duration.
-Also there is a variation in the timing of the device application, quality of CPR< lack of feed back and lack of post-resuscitation follow up. |
Conclusion(s):
Article 1: This articles concludes that there is not enough evidence to suggest that mechanical CPR devices are superior to conventional manual compressions. It was shown that chest compressions done mechanically using the LUCAS done by trained professionals are a reasonable alternative to manual chest compressions in a setting where consistent manual compressions are not possible or are dangerous or risky to the provider. This includes settings where there are not enough to help, increasing chances of exhaustion, helicopter transfers, moving ambulance, hypothermic event, etc). As long as providers are adequately trained in using this technology, it can be helpful, however there is still chance of computer error and more research needs to be done.
Article 2: This study was a cross over study comparing the use of mechanical and manual compressions in prehospital cardiac arrest events. The finds of this study concluded that the use of LUCAS is highly effective in these pre hospital events, and the patient outcome is successful. It also shows that the use of this machine does not lead to increased patient injury. However since this was a mannequin study, the results are inconclusive since it was not done on humans. The compressions were however consistent with AHA standards, and didn’t create any delays to tasks such as defibrillation. The hands off time was also reduced using the LUCAS, allowing for better overall outcome. However the effect of patient movement should be considered when progressing these studies to human studies.
Article 3: This article was a cross over study that looked at the difference in survival rates when using mechanical vs manual compressions in a setting of a helicopter rescue. EMS providers were trained in how to properly do compressions with both techniques, and were then asked to randomly perform them on the mannequin. The time to perfusion, defibrillation, rate, consistency and the level of exhaustion of the rescuer were all assessed. They found that overall, the LUCAS out performed the manual compressions in that it allowed for less hands off time, had better rate and depth of compressions. However they found that time to defibrillation was increased with the LUCAS, which could be due to the time it takes to take off the machine and apply the defibrillator.
Article 4: This study is a randomized cross over study in which they assessed the difference in manual and mechanical compressions when looking at if the patient was on a backboard or not. They found that around 30% of manual compressions were done correctly, compared to the 90% of the mechanical ones that were done correctly. This was regardless of the backboard use. They found that the backboard did not effect the compression depth and rate of the compressions. Over all in this mannequin study it was found that mechanical compressions left to deeper compressions with a shorter mean hands off time.
Article 5: Over all CPR done with manual compressions showed a better long term survival or survival till hospital discharge and neurological outcome then with using the autopulse compression machine. However, the outcomes were similar when compared to the LUCAS machine. This could be because of poor fit of the machine, computer error, and risk of hematoma or pneumothorax formation. These findings show that these machines may be more successful when used by providers who have proper training.
Overall conclusion: Acute cardiac arrest is one of the main reasons that a patient may need cardiopulmonary resuscitation; and the patients survival and neurocognitive functioning depends on the rate and quality of the compressions. With manual compressions there were often inconsistencies with the depth, time and rate of the compressions; leading to delayed cardiac functioning. There was also a increased hands off period with manual compressions which leads to poor return in rhythm function. For this reason, mechanical compression devices such as the LUCAS have been introduced. These studies compared how the LUCAS compressions measured up to the manual ones and their findings were very consistent. It was found that the LUCAS allows for more consistent compressions of equal quality and depth along with decreased hands off time and decreased rescuer fatigue and exhaustion. However, a lot of these studies were done on mannequins in order to test their efficacy, and thus before making a confident statement about which method of compressions is better, more clinical studies and patient trails are warranted.
Clinical Bottom Line:
Article 1: The clinical bottom line of this article is that overall manual compressions is always preferred. However in situations where there is risk or danger to the patient by doing manual compressions, the mechanical route is preferred, however only if it is used by trained professionals. Situations that warrant the use of the machine like LUCAS, include helicopter transfer, situations where there are limited providers available, etc.
Article 2: The clinical bottom line of this article is that over all based on a mannequin cross over study, the use of the mechanical compression technique with the LUCAS proved to be overall better in quality, efficiency and consistency in pre hospital cardiac events. The LUCAS allowed for decreased hands off time, which allowed for increased profusion of blood, allowed for faster time to defibrillation, consistent rate and depth. However, since this study was done on a mannequin, more research on humans is needed before a conclusive argument can be made,
Article 3: This article is a cross over study for the use of mechanical vs manual compressions in helicopter rescue settings. In this simulated cardiac arrest scenario in helicopter rescue setting LUCAS mechanical compressions compared to manual chest-compressions lead to increased CPR quality and reduced hands-off time, however prolonged the time interval to the first defibrillation. Further clinical trials are warranted to confirm potential benefits of LUCAS-CPR in helicopter rescue
Article 4: This clinical bottom line of this randomized cross over study is that mechanical compressions out perform manual compressions regardless of backboard use. They found that the compressions were deeper and there was a shorter hands off time when compared to the manual. The manual performed better with the backboard since it limited the patients rebound on a soft surface. But overall the mechanical allowed for a better success rate.
Article 5: The clinical bottom line of this article is that manual compressions are better then the Autopulse machine and are of equal success to the LUCAS mechanical compression tool. However they found that mechanical compressions can lead to more damage due to computer error and fit issues and can also cause pneumothorax and hematomas. Unless the provider is properly trained in its use, CPR done with manual compressions allows for a better overall outcome.
Magnitude of any effects
I believe that the magnitude of effect was significant enough to allow for the discussion of the use of mechanical compression tools such as the LUCAS compared to doing manual compressions. Articles 2, 3 and 4 were done on mannequins, in which a setting of a emergent cardiac arrest was staged. They compared the use of mechanical vs manual in situations that involved the ambulance, helicopter and backboards, and all had similar findings. They found that mechanical compressions allow for better consistency and less hands off time. The last article showed that there was increased time in perfusion using the mechanical technique, however there were more chances of hematoma formation when compared with the manual technique. However the magnitude of effect overall is not too clearly discernable from these studies since they were done on mannequins, and not human, thus further clinical trails and studies are needed.
Clinical significance
I believe that this PICO search shows great clinical significance in life saving scenarios in which patients are suffering cardiac arrests and require chest compressions prior to defibrillation. A lot of these patients require emergent CPR either in the hospital or during transport in ambulances or hospitals. In a lot of these situations, there is a limited number of people available to help, plus the motions of the vehicles make it difficult to give consistent effective compressions. Hence, the idea of mechanical compressions is under question, since it can be automated to always provide the correct consistent, depth and rate of compression with minimum hands off time.
Any other considerations
I think that this PICO question was very interesting, as there is so much controversy and conversation going on about mechanical compressions. As we progress into a more technologically advanced medical practice the use of a machine to do this life saving technique is a strong consideration. The only thing about the studies that I found is that most of them have been done on mannequins, since they are not approved to be used on humans, especially in life saving scenarios, since any mistake or time delay can lead to the patient risking their life. More research and clinical studies are needed on patients before this can be securely recommended.
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