«LUCAS - Lund University Cardiopulmonary Assist System Liao, Qiuming Published: 01/01/2011 Link to publication Citation for published version (APA): ...»
Injuries during chest compressions It is difficult to give manual compressions consistently, many compressions are either too shallow or too deep. People are trained to give correct chest compressions on mannequins which do not get rib fractures, i.e., what is registered as adequate forceful compressions in the beginning will not take into consideration the human condition that for each rib broken, less and less force will be needed to compress the chest 5 cm (16-18). If you use the same force as needed in the beginning to compress a human thorax 5 cm, also after several ribs have been broken, then the compressions will be too deep, with the risk of creating severe injuries. This was the case with the CardioPump, in which a scale indicated the force you should use in each compression, and this force was constant throughout the CPR period, regardless of the number of broken ribs, and regardless of the flattening of the thorax. Baubin demonstrated in studies on human corpses, that the CardioPump fractured the sternum in 9 out of 17 women and in 2 out of 20 men after 1 minute of CardioPump CPR (17). The female sternum is usually thinner and broader than the male sternum (30), and thus prone to greater fragility during chest compressions.
If manual CPR has been given before the application of LUCAS, it is important to judge if the thorax is already flattened due to multiple bilateral rib fractures. If LUCAS is applied too tight on an initially flattened thorax of a normal sized or on a small patient, the compression depth of 5 cm might diminish the antero-posteroir diameter too much with the risk of causing visceral injuries.
Multiple rib fractures will diminish the elastic recoil of the thorax after each compression. The elastic recoil of an intact thorax reduces the right atrial pressure and thereby will increase the venous return. Active decompression will lower the right atrial pressure in each decompression phase, and thereby increase both coronary perfusion pressure and venous return (Fig 22).
In the manual CPR group in paper III, one pig suffered a serious liver injury. It is important to consider that one too deep compression can cause such an injury. One of the disadvantages with manual CPR is the difficulty in controlling the depth of each compression. It was not surprising that LUCAS-CPR gave significantly fewer rib fractures than manual CPR, since the compression depth with LUCAS never can be more than 5 cm.
In clinical papers studying injuries after chest compressions with LUCAS, manual CPR was given before the application of LUCAS and therefore the injuries reported could have been caused before LUCAS was applied. A prospective human study comparing manual and LUCAS-CPR showed no increased rate of injuries in the LUCAS-CPR group (31). A study (32) on 106 pigs showed fewer injuries with LUCAS-CPR (n=53) compared to manual CPR (n=53). Autopsy was done on all animals. Sternal fractures were identified in 18 animals in the manual group and only two in the LUCAS group (p=0.003). Rib fractures were present in 16 pigs in the manual group and only four pigs in the LUCAS group (p=0.001).
Nine animals in the manual group and two in the LUCAS group had liver hematomas (p=0.026), and eight animals had spleen hematomas in the manual group, whereas no such injury was identified in the LUCAS group (p=0.003) (32).
Since the first scientific paper published on LUCAS (I) in 2002, several studies and reports have shown the efficacy of LUCAS-CPR (II, III, 33-65).
1. LUCAS-CPR is significantly more effective than manual CPR regarding coronary perfusion pressure and return of spontaneous circulation in different porcine models with ventricular fibrillation.
2. LUCAS-CPR combined with surface cooling to 34°C is superior to normothermic LUCAS-CPR during one hour resuscitation of pigs with ventricular fibrillation.
3. Chest compressions before defibrillation and defibrillation during ongoing chest compressions increase return of spontaneous circulation in a porcine model with prolonged ventricular fibrillation.
4. LUCAS-CPR causes significantly fewer rib fractures during 20 minutes of CPR compared to manual CPR in pigs.
Acknowledgements my coworkers. In particular, Audrius Paskevicius, Leif Pierre and Britta KronAll borg for their skilled support on computers and medical deices.
1. The Hypothermia After Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:546 2002;346:549-556.
2. Curfman GD. Hypothermia to protect the brain. Perspective. N Engl J Med 2002;346:546.
3. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. J Am Med Assoc 1960;173:1064-1067.
4. Nationellt register för hjärtstopp utanför sjukhus. Årsrapport 2009.
5. Hightower D, Thomas SH, Stone CK, Dunn K, March JA: Decay in quality of closed-chest compressions over time. Ann Emerg Med 1995; 26:300-303.
6. Sunde L, Wik K, Steen PA: Quality of mechanical, manual standard and active compression-decompression CPR on the arrest site and during transport in a manikin model. Resuscitation 1997;34:235-242.
7. Ocha FJ, Ramalle-Gómara E, Lisa V, Saralegui I: The effect of rescuer fatigue on the quality of chest compressions. Resuscitation 1998;37:149Thorén AB, Axelsson A, Holmberg S, Herlitz J: Measurement of skills in cardiopulmonary resuscitation - do professionals follow given guidelines?
Eur J Emerg Med 2001;8:169-176.
9. Ashton A, McCluskey A, Gwinnutt CL, Keenan AM: Effect of rescuer fatigue on performance of continuous external chest compressions over 3 min. Resuscitation 2002;55:151-155.
10. Wik L, Kramer-Johansen J Myklebust H, Sørebø H, Svensson L, Fellows B, Steen PA: Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA 2005;293:299-304.
11. Heidenreich JW, Berg RA, Higdon TA, Ewy GA, Kern KB, Sanders AB:
Rescuer fatigue: standard versus continuous chest-compression cardiopulmonary resuscitation. Acad Emerg Med 2006;13:1020-1026.
12. Aufderheide TP, Pirrallo RG, Yannopoulos D, Klein JP, von C, Sparks CW, Deja KA, Kitscha DJ, Provo TA, Lurie KG: Incomplete chest wall decompression: a clinical evaluation of CPR performance by trained laypersons and an assessment of alternative manual chest compressiondecompression techniques. Resuscitation 2006;71:341-351.
13. Kim JA, Vogel D, Guimond G, Hostler D, Wang HE, Menegazzi JJ: A randomized, controlled comparison of cardiopulmonary resuscitation performed on the floor and on a moving ambulance stretcher. Prehosp Emerg Care 2006;10:68-70.
14. Olasveegen TM, Tomlison AE, Wik L, Sunde K, Steen PA, Myklbust H, Kramer-Johansen J: A failed attempt to improve quality of out-of-hospital CPR through performance evaluation. Prehosp Emerg Care 2007;11:427Plaisance P, Lurie KG, Vicaut E, Adnet F, Petit JL, Epain D, Ecollan P, Gruat R, Cavagna P, Biens J, Payen D. A comparison of standard cardiopulmonary resuscitation and active compression - decompression resuscitation for out-of-hospital cardiac arrest. N Engl J Med 1999;341:569Baubin M, Suman G, Rabl W, Eibl G, Wenzel V, Mair P. Increased frequency of thorax injuries with ACD-CPR. Resuscitation 1999;41:33-38.
17. Baubin M, Rabl W, Pfeiffer KP, Benzer A, Gilly H. Chest injuries after active compression-decompression cardiopulmonary resuscitation (ACDCPR) in cadavers. Resuscitation 1999;43:9-15.
18. Rabl W, Baubin M, Broinger G, Scheithauer R. Serious complications from active compression-decompression cardiopulmonary resuscitation. Int J Legal Med 1996;109:84-89.
19. European Resuscitation Council Guidelines 2005. Resuscitation 2005;67:53-189.
20. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circ 2005;112:1-203.
21. European Resuscitation Council Guidelines for Resuscitation 2010.
22. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. Circ 2010;122:S250-946.
23. Idris AH, Becker LB, Ornato JP, Hedges JR, Bircher NG, Chandra NC, Cummins RO, Dick W, Ebmeyer U, Halperin HR, Hazinski MF, Kerber RE, Kern K, Safar P, Steen PA, Swindle MM, Tsitlik JE, Planta v I, Planta v M, Wears RL, Weil MH. Utstein-style guidelines for uniform reporting of laboratory CPR research. Resuscitation 1996;33:69-84.
24. Paradis NA, Martin GB, Rivers EP, Goetting MG, Appleton TJ, Feingold M, Nowak RM. Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation. J Am Med Assoc 1990;263:1106-1113.
25. Kern KB, Niemann JT, Steen S. Coronary perfusion pressure during cardiopulmonary resuscitation. In: Cardiac arrest, The Science and practice of resuscitation medicine. Eds: Paradis NA, Halperin HR, Kern KB, Wenzel V, Chamberlain DA. Cambridge University Press, Cambridge, England.
26. Frenneaux M, Steen S. Hemodynamics of cardiac arrest. In: Cardiac arrest, The Science and practice of resuscitation medicine. Eds: Paradis NA, Halperin HR, Kern KB, Wenzel V, Chamberlain DA. Cambridge University Press, Cambridge, England. 2007:347-366.
27. Ghoshal NG, Nanda BS. Porcine heart and arteries. In: The anatomy of the domestic animals. Ed. Getty R. W.B. Saunders Company, Philadelphia, USA. 1975:1306-1342.
28. Wetterberg T, Steen S. Combined use of hypothermia and buffering in the treatment of critical respiratory failure. Acta Anaesthesiol Scand.
29. Wetterberg T, Sjöberg T, Steen S. Effects of hypothermia in hypercapnia and hypercapnic hypoxemia. Acta Anaesthesiol Scand. 1993;37:296-302.
30. Leopold D, Geschlechtsbestimmung durch untersuchung der einzelnen knochen des skeletts – der knöcherne thorax. In: Identifikation. Eds: Hunger H, Leopold D. Johannes Ambrosius Barth Verlag. Leipzig, Germany.
31. Smekal D, Johansson J, Huzevka T, Rubertsson S. No difference in autopsy detected injuries in cardiac arrest patients treated with manual chest compressions compared with mechanical compressions with the LUCAS device - a pilot study. Resuscitation 2009;80:1104-1107.
32. Xanthos T, Pantazopoulos I, Roumelioti H, Lelovas P, Iacovidou N, Dontas I, Demestiha T, Spiliopoulou H. A comparison of autopsy detected injuries in a porcine model of cardiac srrest treated with either manual or
mechanical chest compressions. Eur J Emerg Med 2010;00:00-00. DOI:
33. Steen S, Liao Q, Pierre L, Paskevicius A, Sjöberg T. Continuous intratracheal insufflation of oxygen improves the efficacy of mechanical chest compression-active decompression CPR. Resuscitation. 2004;62:219Steen S, Sjöberg T, Olsson P, Young M. Treatment of out-of-hospital cardiac arrest with LUCAS, a new device for automatic mechanical compressions and active decompression resuscitation. Resuscitation.
35. Rubertsson S, Karlsten R. Increased cortical cerebral blood flow with LUCAS, a new device for mechanical chest compressions compared to standard external compressions during experimental cardiopulmonary resuscitation. Resuscitation. 2005;65:357-363.
36. Holmström P, Boyd J, Sorsa M, Kuisma M. A case of hypothermic cardiac arrest treated with an external chest compression device (LUCAS) during transport to re-warming. Resuscitation. 2005;67:139-141.
37. Wik L, Kiil S. Use of an automatic chest compression device (LUCAS) as a bridge to establishing cardiopulmonary bypass for a patient with hypothermic cardiac arrest. Resuscitation. 2005;66:391-394.
38. Vatsgar TT, Ingebrigtsen O, Fjose LO, Wikstrøm B, Nilsen JE, Wik L.
Cardiac arrest and resuscitation with an automatic mechanical chest compression device (LUCAS) due to anaphylaxis of a woman receiving caesarean section because of pre-eclampsia. Resuscitation. 2006;68:155Chan LW, Wong TW, Lau CC. Mechanical cardiopulmonary resuscitation device in an accident and emergency department: a case report and literature review. Hong Kong J Emerg Med. 2008;15:49-52.
40. Olivecrona G, Bondesson P. Mechanical Chest Compressions in a Patient with Left Main Closure During PCI. www.tctmd.com, Case of the week, 24th of October 2006.