ZOLL AutoPulse® ZOLL AutoPulse®
Non-invasive Cardiac Support Pump Non-invasive Cardiac Support Pump
ZOLL AutoPulse® ZOLL AutoPulse®
ZOLL’s History ZOLL’s History
1952 Dr Paul Zoll first to successfully pace human
1956 Dr Paul Zoll first to successful externally defibrillate
patient
1988 PD 1200 Pacemaker/Defibrillator/Monitor brought to
market
1995 M Series Introduced – First fully integrated Shockable
Rhythm Interpretation (Advisory)
Pacemaker/Defibrillator/Monitor
1997 RescueNet – first integrated data system for EMS
developed
2002 First CPR Guidance System developed with the AED Plus
2004 Revivant Corporation acquired – adding the AutoPulse
Manual CPR device to the product offering
• Automatic
• Portable
• Non-invasive
• Battery Operated
ZOLL AutoPulse® ZOLL AutoPulse®
30% - 40% of normal flow
10% - 20% of normal flow Kern KB Bailliere’s Clinical Anaesthesiology. 2000;14(3):591-609.
Manual CPRManual CPR
Conventional CPR provides less than optimal blood flow to the heart and brain
• A well perfused myocardium is more likely to experience ROSC• Paradis et al found that a minimum of 15 mmHg was required to achieve ROSC• Manual CPR, on average achieves 12.5 mmHg• Levels of ROSC increase with CPP in prolonged cardiac arrest.•AutoPulse provides upwards of 25 mmHg of CPP •At >25 mmHg of CPP, ROSC rates are at 79%
Solution: The AutoPulse The Solution – AutoPulse The Solution – AutoPulse
ZOLL AutoPulse®ZOLL AutoPulse®
• Uninterrupted compressions
• Consistent rate & depth
• User friendly
• Suitable for emergency department
• Superior Coronary Perfusion Pressure (CPP) compared with conventional CPR during resuscitation
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Operating RationalOperating Rational
Circumferential
AutoPulse
CPR
Uni-Directional
Manual
CPR
Presenting Cardiac RhythmsPresenting Cardiac Rhythms
Studies show that VF or VT is the initial rhythm less than 50% of the time
25%41%
75%59%
0%
20%
40%
60%
80%
100%
120%
Hospital Pre-Hospital
% o
f C
ard
iac
Arr
es
ts
VF/VT PEA/Asystole
Peberdy MA, Kaye W et al. Resuscitation 2003; 58:297-308.Kaye W et al. Journal of the American College of Cardiology. 2002:39(5), Suppl A.Cobb L et al. JAMA. 2002; 288(23):3008-3013.
Presenting Cardiac RhythmsPresenting Cardiac Rhythms
• Defibrillation is only required in less than 50% of cases.
• Quality CPR is required in 100% of cases!
• Does not adequately perfuse the brain or heart
Manual CPRManual CPR
• Does not adequately perfuse the brain or heart
Manual CPR delivers• Inconsistent compressions• Fatigue• Pausing to rotate staff• Pausing to move the patient• OH&S Issues
Manual CPRManual CPR
Manual CPR v AutoPulseManual CPR v AutoPulse
Manual CPR
AutoPulse CPR
AutoPulse - Consistent CompressionsAutoPulse - Consistent Compressions
Clinical Evidence Summary…Clinical Evidence Summary…
Clinical Evidence – Manual CPRClinical Evidence – Manual CPR
• Manual CPR is variable at best, even when performed by trained professionals – Abella et al, Wik et al
• Effective CPR, with minimal interruptions, improves probability of successful defibrillation – Sato et al, Ikeno et al
• Effective CPR is more important than the timing of defibrillation in achieving ROSC – Ristagno, et al
Clinical Evidence - CPPClinical Evidence - CPP
• CPP is the best predictor of ROSC in prolonged cardiac arrests
• ROSC does not occur in patients where CPP is below 15mmHg
• Manual CPR achieves 12.5mm Hg on average – Paradis et al
• CPP is improved with AutoPulse over manual CPR. – Timmerman et al
AutoPulse Manual CPR
CPP drops quickly when
AutoPulse compressions
stop
CPP returns after several
AutoPulse compressions
AutoPulse
Timerman S et al. Resuscitation. 2004;61:273-280
Timerman S et al. Resuscitation. 2004;61:273-280
Clinical Evidence - ROSCClinical Evidence - ROSC
• AutoPulse provides pre arrest blood flow levels to heart and brain - Halperin
et al • AutoPulse provides superior levels of
ROSC and survival when compared to manual CPR – Ong et al
• AutoPulse provides superior levels of ROSC and survival when compared to piston driven automated CPR – Ikeno et al
Clinical Evidence - ROSCClinical Evidence - ROSC
• AutoPulse provides superior levels of neurological function when compared to both manual and piston driven CPR – Ong et al, Ikeno et al
Clinical ReviewClinical Review
Abella et al JAMA. 2005;293:305-310Abella et al JAMA. 2005;293:305-310
• University of Chicago Hospital• 67 Patients• Evaluated Quality of manual CPR in
first 5 mins of code• Found that even in highly trained
professionals CPR was:– too shallow, – too slow – ventilation occurred too frequently.
Wik et al JAMA. 2005;293:305-310Wik et al JAMA. 2005;293:305-310
• Multi-location Emergency Services human study (Stockholm, London, Akershus)
• Evaluated Quality of manual CPR in first 5 mins of arrest of 176 patients
• 49% of time of code, patients did not receive CPR
• With adjustment for defibrillation analysis, 42% time of code, patients did not receive CPR
Wik et al JAMA. 2005;293:305-310Wik et al JAMA. 2005;293:305-310
• 59% of compressions were too shallow
• Found high compression rates– Decreased cardiac output – Not enough time for proper venous
return to heart
• CPR performed by people is significantly different to guidelines
• Rodent study of 25 subjects put into VF• 4 minutes later defibrillation
commenced• animals were grouped into 0, 10, 20, 30
and 40 s delays in between defibrillation and cessation of CPR
• No animals that received more than 10 s delay in defibrillation survived more than 24 hours.
• Resuscitation and survival rates lessened as delay increased
Sato et al. Critical Care Medicine. 1997;25:733-736
Sato et al. Critical Care Medicine. 1997;25:733-736
• Porcine study of 24 subjects put into VF• 5 minutes later treatment commenced• 4 randomized groups
– Optimal CPR with early defibrillation– Optimal CPR with 3 minutes of CPR first– Conventional CPR* with early defibrillation– Conventional CPR* with 3 minutes of CPR
first
* Simulated by 25% that compression required to give 15 mm Hg CPP.
Ristagno et al. Chest. 2007;132:70-75Ristagno et al. Chest. 2007;132:70-75
• All 12 subjects that were given optimal CPR achieved ROSC
• Only 2 of the 12 subjects (16.6%) that were given conventional CPR achieved ROSC and those were shocked first
• All surviving animals achieved full neurological recovery
Ristagno et al. Chest. 2007;132:70-75Ristagno et al. Chest. 2007;132:70-75
Paradis NA et al. JAMA. 1990;263:1106-1113
Paradis NA et al. JAMA. 1990;263:1106-1113
• Coronary Perfusion Pressure < 15 mmHg does not achieve Return of Spontaneous Circulation
46%
0%
79%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
<15 15-25 >25
CPP (mm Hg)
% o
f pat
ien
ts w
/ RO
SC
Conventional CPRmean CPP = 12.5 mmHg
• 16 terminal patients • In-hospital cardiac arrest• 10 minutes of failed advanced care life
support• Catheters were placed in the thoracic aorta
and right atrium to measure CPP and peak aortic pressure
• AutoPulse and Manual Compressions were alternated for 90 seconds each
• Average time between arrest and the start of experiment was 30 (+/-5) minutes
Timerman S et al. Resuscitation. 2004;61:273-280
Timerman S et al. Resuscitation. 2004;61:273-280
AutoPulse Manual CPR
CPP drops quickly when
AutoPulse compressions
stop
CPP returns after several
AutoPulse compressions
AutoPulse
Timerman S et al. Resuscitation. 2004;61:273-280
Timerman S et al. Resuscitation. 2004;61:273-280
Timerman S et al. Resuscitation. 2004;61:273-280
Timerman S et al. Resuscitation. 2004;61:273-280
15
20
0
5
10
15
20
25
Co
ron
ary
Pe
rfu
sio
n P
res
su
re (
CP
P)
mm
Hg
Manual CPR AutoPulse
Results: AutoPulse-generated Coronary Perfusion Pressure (CPP) was 33% better than manual CPR
Halperin et al. JAMA. 2006;295:2629-2637
Halperin et al. JAMA. 2006;295:2629-2637
• Porcine Study of 20 subjects @ John Hopkins
• VF induced for 1 minute• Treated with conventional CPR (“The
Thumper”) or the AutoPulse• Two arms of study
– “BLS” scenario – no epinephrine– “ALS” scenario – with epinephrine
Halperin et al. JAMA. 2006;295:2629-2637
Halperin et al. JAMA. 2006;295:2629-2637
29% 31%
127% 129%
0%
20%
40%
60%
80%
100%
120%
140%
Heart (Myocardium*) Brain (Cerebrum**)
% o
f P
re-a
rres
t B
loo
d F
low
Conventional CPR AutoPulse
Results: AutoPulse produced pre-arrest levels of blood flow to the heart and brain (ACLS protocol – with epinephrine)
Ong et al. JAMA. 2006;295:2629-2637Ong et al. JAMA. 2006;295:2629-2637
• Study conducted by Richmond Fire Department of almost 800 patients
• Overall improvement of ROSC (70.8%), survival to hospital admission (88%) and survival to discharge (234%).
Ong et al. JAMA. 2006;295:2629-2637Ong et al. JAMA. 2006;295:2629-2637
• Improvement occurred regardless of initial cardiac rhythm– VF/VT– Asystole*– PEA*
• Particularly where VF was initial rhythm or where the patient had a witnessed arrest or received bystander CPR until the AutoPulse was applied.
* Small sample sizes
Ikeno et al. Resuscitation. 2006;68:109-118
Ikeno et al. Resuscitation. 2006;68:109-118
• Porcine Study with 56 subjects• 22 in AutoPulse, 22 using “the thumper” at
20% compression, 12 at 30% compression• VF induced for 4 minutes before treatment• All subjects that achieved ROSC, survived
for 72 hours• Of the thumper subjects, none survived
20% compression (simulating manual CPR), even with adrenaline administered
Ikeno et al. Resuscitation. 2006;68:109-118
Ikeno et al. Resuscitation. 2006;68:109-118
• Of the 30% compression group, 4 of 12 (33%) achieved ROSC. 50% required adrenaline
• 2 of these 4 survivors at 72 hours had good neurological function. 2 were severely impaired
• 8/12 (67%) subjects suffered rib fracture and 4/12 (33%) suffered lung injury
Ikeno et al. Resuscitation. 2006;68:109-118
Ikeno et al. Resuscitation. 2006;68:109-118
• Of the AutoPulse group, 16 of 22 (73%) achieved ROSC. 50% required adrenaline
• All 16 survivors achieved good neurological outcomes after 72 hours
• No subjects in this group received rib fracture of lung injury
Mechanical Chest Compression During Resuscitation Academic Medical Centre, Amsterdam
Mechanical Chest Compression During Resuscitation Academic Medical Centre, Amsterdam
• 2 patients being treated with the AutoPulse• Primary Percutaneous Coronary Intervention. • Adequately displayed the coronary system
through the AutoPulse in order to complete the procedures.
• Conventional CPR - Intra-arterial blood pressures of up to 60mmHg
• AutoPulse - Intra-arterial blood pressures of up to 120mmHg
Mechanical chest compression during resuscitation: Experience in hospital and use in pre-hospital care.Cardiac Monitoring Department -Academic Medical Centre, Amsterdam
Mechanical Chest Compression During Resuscitation Academic Medical Centre, Amsterdam
Mechanical Chest Compression During Resuscitation Academic Medical Centre, Amsterdam
• 2 patients being treated with the AutoPulse• Primary Percutaneous Coronary Intervention. • Adequately displayed the coronary system
through the AutoPulse in order to complete the procedures.
• Conventional CPR - Intra-arterial blood pressures of up to 60mmHg
• AutoPulse - Intra-arterial blood pressures of up to 120mmHg
Mechanical chest compression during resuscitation: Experience in hospital and use in pre-hospital care.Cardiac Monitoring Department -Academic Medical Centre, Amsterdam