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Automatic External DefibrillationPast, Present & Future
Prof. John McC AndersonCTO HeartSine Technologies Ltd
INTERVAL AFTER ONSET
PE
RC
EN
TA
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AL
IVE
7DAY
1DAY
0.2HR
0.1HR
0
10
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60
70
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100THE DISTRIBUTION OF ACUTE CORONARY DEATHS
Mc NEILLY (BELFAST), 1965-66, 818 DEATHS
Modern Developments in Out-of-Hospital Defibrillation
Period Defibrillator Operator Comments
1960’s Physicians Physicians staff the first mobile coronary care unit (Belfast, New York City).
Early 1970’s Paramedics Extensively trained (400-1500 hours). Defibrillation added to many advanced life support skills.
Late 1970’s EMT’s trained in defibrillation
Rhythm recognition and skills of defibrillation taught to EMT’s in 10 hour course.
The Semi-Automatic Defibrillator
Flow Diagram for Ventricular Fibrillation Detection
Energy Ratio Characteristic
Energy Ratio i.e. Yellow/Red ratio constant in Sinus Rhythm
Energy Ratio i.e. Yellow/Red ratio continuously variable in Ventricular Fibrillation
Flow Diagram for Ventricular Fibrillation Detection
Flow Diagram for Ventricular Fibrillation Detection
Defibrillators in the Home (PDU)
The development of a CPR-ICG PAD
The evolution of ‘Smart Defibrillation’
The Future Management of Sudden Cardiac Death
The Personal Defibrillation Unit – PDU 400
More than 650,000 deaths per year from cardiovascular diseases
In the US around 800,000 patients suffer an AMI annually of whom 550,000 die
Over 80% of the deaths occur in the home
PEA accounts for over 65% of cardiac arrests
In 2005 the ERC and AHA guidelines were updated to emphasize the importance of effective chest compressions with minimal interruptions
In 2008 the AHA introduced the “hands-only” protocol
Statistics
Smaller Lighter Complete Resuscitation System High IP rating Advanced Algorithm Disposable User Friendly
Design Features
The Development of a CPR-ICG PAD
Transthoracic Impedance:
“Change in thoracic impedance may be due to any change in physical shape or content of the thorax, including ventilation, cardiopulmonary blood flow ….”
Miller JC, Horvath SM. Impedance Cardiography. Psychophysiology 1978; 15: 80-91
The History of Impedance Cardiography
ECG/ICG Timing
Impedance Cardiography (ICG)
The ICG measures the cardiac impedance during the cycle and gives a waveform relating to the change in blood volume within the heart during this time. (Cardiac Output)
Example Cases from RVH Database
Patient conscious ; HR=330BPM, QRS width varies between 133ms and 189ms.
Patient required terminating shock ; HR=189BPM, QRS width 201ms.
ECG
ICG
Blood Flow in the aortaBlood Flow through the
pulmonary vesselsContracting heartChanging resistivity of blood Improved contact with electrodes
Causes of change in Cardiac Output
PEA accounts for over 65% of cardiac arrests
In 2005 the ERC and AHA guidelines were updated to emphasize the importance of effective chest compressions with minimal interruptions.
In 2008 the AHA introduced the ‘hands-only’ protocol to further minimize interruptions.
Importance of Effective CPR
ICG can offer feedback on cardiac output during chest compressions
The morphology of the ICG waveform during CPR is distinctive
HeartSine has developed an algorithm based on the RVH database of CPR cases which uses a number of parameters to enable feedback on CPR efficacy for the user
CPR Feedback Indicator
ICG Waveform During CPR
ICG Waveform During Sinus Rhythm
ICG Waveform During PEA
ICG not present due to absence of CARDIAC OUTPUT during PEA
ICG During VF
ICG not present due to absence of CARDIAC OUTPUT during VF
Noise due to motion artifact
Noise due to incorrect pad or hand placement
Initial ICG algorithm classified some cases of noise as CPR
Challenges in Algorithm Development
It was found through a number of bench tests that excessive noise could be eliminated by measuring the rate and pulse width of the signal and by focusing efforts on good CPR training to ensure the correct hand positioning and applied force
Results from initial Bench Tests
Recording of Correctly Applied CPR During Initial Bench Testing
Recording of Poor CPR (No Compressive Force Applied)
Recording of CPR on Top of Pads
Proposed CPR-ICG Algorithm
“PUSH HARDER”
“PUSH FASTER/SLOWER”
“GOOD COMPRESSIONS”
Algorithm Results to Date
CPR CriteriaICG Test
Sample SizePerformance Specifications
PerformanceResults (%)
90% One-Sided Lower Confident Limit (%)
CPR Speed Good
82377Sensitivity: > 90%Specificity: > 90%
Sensitivity: 95.38Specificity: 93.11
Sensitivity: 83.40Specificity: 82.19
CPR Force Adequate
108728Sensitivity: > 90%Specificity: > 90%
Sensitivity: 99.96Specificity: 98.47
Sensitivity: 99.54Specificity: 96.29
Animal Study Results
2cm 4cm 5cm
ICG amplitude at varying compression depths:
The ICG amplitude (in ohms) is higher for higher CPR compression depths and values of ET CO2.
ICG
Am
plitu
de in
Ohm
s
1-
0-
Thrust/depth
2cm = 20kg
4cm = 30-40kg
6cm = 60-70kg
Summary
“In order to maintain high-quality CPR, feedback to rescuers is important. The use of prompt/feedback devices during CPR will enable immediate feedback to rescuers, and the data stored in rescue equipment can be
used to monitor the quality of CPR performance and provide feedback to
professional rescuers during debriefing sessions .”
ERC Guidelines 2010 - European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators
HeartSine samaritan PAD 500P with CPR advisor was launched in August 2009 in Europe Preparations are under way for FDA 510(k) clearance in the US
The Development of a SMART Defibrillator
Optimal treatment for Sudden Cardiac Arrest (SCA)
Interactive CPR Accurate decision to defibrillate/CPRManagement of PEA
Features to be included in the SMART AED:
1. CPR-ICG Indicator
2. Pulse checker (Uses ICG to discriminate between PEA and SR)
3. Therapy Advisor (Uses DSP to extract information on frequency content of the ECG signal during cardiac arrest to determine whether CPR or defibrillation is the most appropriate therapy)
4. Using ICG to discriminate between CPR and shockable rhythms during the “hands-off” period
5. Continuous chest compressions until administration of shock
The FUTURE of Defibrillation
3-Phases of a Sudden Cardiac Arrest
Majority of customer queries result from non-adherence to the “hands-off” or analysis period of the PAD
Using ICG technology we plan to develop an algorithm to discriminate between CPR and a shockable rhythm to prevent the device from charging and then disarming following the discontinuation of CPR
The algorithm can output audio voice prompts which will advise the user to discontinue CPR
Failure to adhere to CPR prompts
CPR continued during analysis phase despite audio prompts
Shock advised due to inappropriate CPR
HeartSine Technologies currently has the basic science to build a SMART defibrillator.
A SMART defibrillator will provide the optimal treatment for Sudden Cardiac Death
SMART defibrillation will position HeartSine Technologies as a world leader in this field.
In 1775 Abilgard recorded that he
“shocked a single chicken into lifelessness and upon repeatingthe shock, the bird flew off and thus eluded further
experimentation”
Any Questions?