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CLINICAL PAPER
a
South Western Ambulance Service NHS Trust, 42 Porchester Road, Bournemouth BH8 8LE, UK
b
CardioDigital Ltd., Elvingston Science Centre, Edinburgh, Scotland, UK
c
Department of Accident and Emergency Medicine, The Royal Inrmary of Edinburgh, Scotland, UK
Received 18 September 2007; received in revised form 2 March 2008; accepted 14 March 2008
KEYWORDS Summary We report on a study designed to compare the relative efcacy of man-
Electrocardiography; ual CPR (M-CPR) and automated mechanical CPR (ACD-CPR) provided by an active
Cardiopulmonary compressiondecompression (ACD) device. The ECG signals of out-of-hospital cardiac arrest
resuscitation (CPR); patients of cardiac aetiology were analysed just prior to, and immediately after, cardiopul-
Active compression/ monary resuscitation (CPR) to assess the likelihood of successful debrillation at these time
decompression-CPR; points. The cardioversion outcome prediction (COP) measure previously developed by our group
Cardiac arrest; was used to quantify the probability of return of spontaneous circulation (ROSC) after counter-
Shock outcome shock and was used as a measure of the efcacy of CPR. An initial validation study using COP to
prediction predict shock outcome from the patient data set resulted in a performance of 60% specicity
achieved at 100% sensitivity on a blind test of the data. This is comparable with previous studies
and provided condence in the robustness of the technique across hardware platforms. Signif-
icantly, the COP marker also displayed an ability to stratify according to outcomes: asystole,
ventricular brillation (VF), pulseless electrical activity (PEA), normal sinus rhythm (NSR). We
then used the validated COP marker to analyse the ECG data record just prior to and immedi-
ately after the chest compression segments. This was initially performed for 87 CPR segments
where VF was both the pre- and post-CPR waveform. An increase in the mean COP values was
found for both CPR types. A signed rank sum test found the increase due to manual CPR not
to be signicant (p > 0.05) whereas the automated CPR was found to be signicant (p < 0.05).
This increase was larger for the automated CPR (1.26, p = 0.024) than for the manual CPR
(0.99, p = 0.124). These results indicate that the application of CPR does indeed provide ben-
ecial preparation of the heart prior to debrillation therapy whether manual or automated
CPR is applied. The COP marker shows promise as a denitive, quantitative determinant of the
A Spanish translated version of the summary of this article appears as Appendix in the nal online version at
doi:10.1016/j.resuscitation.2008.03.225.
Corresponding author. Tel.: +44 1202789317.
0300-9572/$ see front matter 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2008.03.225
266 M.S. Box et al.
immediate positive effect of both types of CPR regardless of the details of use. In work of a
more exploratory nature we then used the validated COP marker to analyse the ECG pre- and
post-CPR for all rhythm types (212 traces). We show a signicant increase in the COP measure
(p < 0.001 in both cases) as indicated by a shift in the median COP marker distribution values.
This increase was more pronounced for automated ACD-CPR than for manual CPR. However, a
detailed statistical analysis carried out between the groups adjusted for pre-CPR value showed no
signicant difference between the two methods of CPR (p = 0.20). Similarly, adjusting for length
of CPR showed no signicant difference between the groups. Secondary, subgroup analysis of the
ECG according to the length of time for which CPR was performed showed that both types of CPR
led to an increase in the likelihood of successful debrillation after increasing durations of CPR,
however results were less reliable after longer periods of continuous CPR.
2008 Elsevier Ireland Ltd. All rights reserved.
Introduction led to the early termination of the trial at the rst planned
interim monitoring point. Another recent study by Ong et
Experimental13 and clinical4 studies have indicated that al.14 showed signicant improvement in outcomes for LDB-
administering cardiopulmonary resuscitation (CPR) prior to CPR when compared with manual CPR: ROSC (34.5% for
shock therapy can increase the likelihood of successful deb- LDB-CPR versus 20.2% for manual CPR), survival to hospi-
rillation for prolonged ventricular brillation (VF). These tal admission (30.9% for LDB-CPR R versus 11.1% for manual
results are consistent with clinical studies5,6 which indi- CPR) and survival to hospital discharge (9.7% LDB-CPR for
cate that pre-shock CPR can improve the rates of return versus 2.9% for manual CPR). However, they found no sig-
of spontaneous circulation (ROSC) and survival to hospital nicant difference in cerebral performance category and
discharge when emergency medical services (EMS) response overall performance category for these patients.
times exceeded 45 min. There is recognition that, while The recent deployment of ACD-CPR devices throughout
debrillation is the only effective means of reverting the the South Western Ambulance NHS Trust provided an oppor-
heart in cardiac arrest to normal sinus rhythm (NSR), max- tunity to compare the relative effectiveness of manual and
imising the quantity and quality of CPR has a substantial automated CPR on OOH cardiac arrest patients. ECG data
bearing on the efcacy of debrillation therapy. records downloaded from the Medtronic LIFEPAK 12 debril-
CPR performed effectively improves cardiac arrest sur- lators used throughout the Trust were used in this respect.
vival. However, it is known that manual chest compressions The current non-randomised observational clinical study was
do not always achieve the recommended performance lev- designed to quantify changes in the ECG caused by episodes
els in terms of rate, depth and hands off time.7,8 In of CPR compressions. To do this a shock outcome prediction
addition, it has been shown that trained paramedics can pro- metric was computed from the ECG immediately before and
vide shallower and slower compressions over time without just after episodes of CPR compressions. The cardioversion
noticing.9,10 To this end a number of automated mechan- outcome prediction (COP) measure, previously developed
ical devices have been developed to provide consistent, by our group, was employed for this task. The COP marker
good quality CPR to the patient throughout the resuscitation pairs (pre- and post-CPR) were computed both for manual
procedure.11 These devices all provide active compression and ACD-CPR and the results compared. The COP marker was
of the chest at a set rate and compression depth. The rst validated for use on this data set using the shock seg-
LUCAS devices used in the study reported here also provide ments of ECG trace contained within the OOH data record.
active decompression of the chest.12 Such active compres- The COP marker was then used to quantify the pre and post-
sion/decompression CPR (ACD-CPR) devices are designed to CPR ECG signals, for both manual and automated mechanical
enhance the decrease in intrathoracic pressure during the ADC-CPR.
decompression phase thus improving venous blood return to
the heart. Evaluation of the cardioversion outcome
Two recent studies of another mechanical CPR device predictor (COP) marker for use in CPR study
have produced conicting results. Both studies involved the
use of a load distributed band (LDB) CPR device. These
Prior to the analysis of the CPR episodes described in the
generate active compressions through a band placed round
next section, the COP algorithm was rst tested for its
the chest. However, these machines do not produce active
efcacy as a useful predictor of shock outcome for this
decompression. In an 1838 patient randomised multicentre
particular database using the shock segments of the ECG
trial of patients experiencing out-of-hospital (OOH) cardiac
signals.
arrest, Hallstrom et al.13 found that a LDB-CPR device was
associated with worse neurological outcomes and a trend
towards worse survival than manual CPR (M-CPR). Survival The study data
to hospital discharge was 9.9% for the manual CPR group
and 5.8% for the LDB-CPR group (p = 0.06), and cerebral The study was conducted by the South Western Ambulance
performance category of 1 or 2 at hospital discharge was Service NHS Trust. ECG data was acquired over an 8-month
recorded at 7.5% of patients who underwent manual CPR period from November 2005 to June 2006 inclusive. The data
compared with 3.1% of the LDB-CPR group. These ndings was downloaded from Medtronic LIFEPAK 12 debrillators
Shock outcome prediction before and after CPR 267
CPR study
VF only
All 87 traces for which VF was the pre- and post-CPR rhythm
were analysed. COP values were computed for the VF sig-
nal immediately before and immediately after CPR. The box
plots for the results are shown in Figure 4a and b. Compar-
ing the two gures we observe a distinct increase in the
mean COP values for both CPR types. However, quantify-
ing this distributional change in the pre- and post-CPR data
is problematic due to the non-parametric nature of the dis-
tributions themselves which exhibit signicant skew directly
attributable to the logarithmic non-linearity inherent within
the COP marker (as dened by equation (2)). Hence we
report results simply in terms of median values, m, quartile-
Figure 2 ROC curve where sensitivity is a measure of the 1 and quartile-3 values q1 , q3 , and signicance, p. Boxplots
successful classication of ROSC and specicity the successful of the distributions are also shown to provide a further visual
classication of non-ROSC. overview of data distributions. Employing the median as the
Shock outcome prediction before and after CPR 269
Figure 3 Example of an ECG and associated impedance trace (patient 8 episode 5: manual CPR). The 4 s regions selected for COP
analysis are indicated schematically on the plot.
statistical index of central tendency of the distributions pro- alternative to the paired Students t-test for the case of two
vides robustness against outliers, while q1 and q3 provide related samples or repeated measurements on a single sam-
an indication of the distributional spread either side of the ple. As such it does not make assumptions concerning the
median value. The signicance of the differences in the pre- underlying distribution of the measurements.
and post-CPR COP metrics are quantied by the Wilcoxon Table 2 contains a summary of the results of the COP
signed rank sum test p values. This test is a non-parametric analysis on the CPR segments. We can see that for both CPR
types the post-CPR COP median value is greater than the
pre-CPR value indicating a general increase in the shock-
ability of the patients due to CPR. The signicance of the
differences in the pre- and post-CPR COP metrics are indi-
cated in the table by the Wilcoxon signed rank sum test p
values. Only the automated CPR shows a signicant result
(p < 0.05), although it should be noted that the data sets are
small.
Figure 4 Box plots of COP distributions according to CPR type Figure 5 The spectrum of pre-CPR COP values for the manual
for VF (a) pre-CPR and (b) post-CPR. and LUCAS CPR showing similar distributions.
270 M.S. Box et al.
0.024
p
of medians
Difference
1.26
Post-CPR COP value
105
of medians
Difference
COP results given as median values with associate q1 and q3 values (in parenthesis). These are divided by
0.99
Post-CPR COP value
CPR are 0.97 105 and 1.90 105 , respectively for manual
CPR length
0.0004
0.029
0.028
0.048
0.720
Pre-CPR COP value Post-CPR COP value Difference of mediansp
(6.2/9.9) 0.97
(6.3/10.0)1.04
(6.5/9.7) 1.31
(8.8/12.4)0.08
(4.3/7.8) 2.27
180
Figure 8 Change in COP marker values according to CPR type and CPR period. (Left to right: 01, 12, 23, and >3 min.) Note
that the plots have been cropped and some outliers now lie outwith the plotted regions.
than 2 106 . Analysis of covariance was then performed was done only for those with pre-CPR greater than 2 106
on the data adjusting for the pre-CPR value to compare the as the other data were clearly different. This gives p = 0.20
performance of the two groups. (This was performed on the showing no clear statistical evidence that manual and auto-
log scaled data as it was more normally distributed.) This mated differ in post-CPR value after adjusting for pre-CPR
value. Analysis of the length of CPR produced p = 0.22 show-
ing no signicance either.
There are 13 manual CPR data points with pre-CPR val-
ues less than 2 106 . These correspond to four separate
patients. No obvious reason for their erroneous behaviour
can be identied. However, it is interesting that the man-
ual CPR has provided this marked positive effect in so many
traces. A larger scale study would allow the signicance of
this to be probed in further detail.
Concluding remarks
CPR analysis
to an increase in the likelihood of successful debrillation. efcacy of the CPR alone is performed. The method reported
This result indicates that the application of CPR does indeed here therefore provides a denitive, quantitative determi-
provide benecial preparation of the heart prior to debril- nant of the immediate positive effect of both types of CPR
lation therapy whether manual or automated CPR is applied. regardless of the details of use.
This is in accordance with the results from the work of oth- In addition to the analysis of the pre- and post-CPR VF
ers. A signed rank sum test found the increase due to manual rhythms, our work also showed that the COP marker was
CPR not to be signicant (p > 0.05) whereas the automated able to: (1) stratify according to shock outcomes on the
CPR was found to be signicant (p < 0.05). This increase was pre-shock VF waveform and (2) demonstrate a signicant
larger for the automated CPR (1.26, p = 0.024) than for the measurable increase through the actions of both types of
manual CPR (0.99, p = 0.124), however, it is recommended CPR when all rhythm types were analysed. The marker has
that a substantially larger dataset is used to conrm these therefore shown further potential as a measure of the state
ndings with signicance. of the myocardium. If COP proves to be a useful measure
We then explored a more general the use of the COP for obtaining a metric of the myocardial state for all rhythm
marker by applying the method to all 212 CPR segments con- types considered, then it has promise in a wide range of
taining all rhythm types pre- and post-CPR. The original COP applications, specically CPR efcacy as a quality measure
distributions for both data sets (manual and automatic CPR) and feedback to user.
were very similar and the resulting levels of signicance for The work described leads directly to the main aim of the
the change in distributions due to the effect of CPR were research effort of our group to develop a suite of tools for
high (p < 0.001 in both cases). This increase is more pro- the complete analysis of the ECG signal during OOH car-
nounced for automated ACD-CPR than for manual CPR. A diac arrest including: shock outcome prediction; pre- and
further analysis of this data involving stratication of the post-CPR ECG-analysis to determine effectiveness; analy-
input data into length of CPR (<1, 12, 23, and >3 min) sis during CPR to detect the ongoing efcacy of CPR and,
all indicated that both types of CPR led to an increase in signicantly, to detect changes in the underlying rhythm dur-
the COP value. These increases were quite variable between ing CPR25 the latter leading directly to debrillation during
CPR types and for longer periods a deterioration in the sig- CPR once a shockable rhythm is realised. It is on this latter
nicance of the results (i.e. p > 0.05) occurred. The results area we now concentrate our investigations.
of the analysis within each group indicates that CPR has an
measurable effect on the waveform regardless of rhythm.
However, these increases cannot simply be equated with an
Conict of interest
increase in the shockability of the patients due to CPR as
a proportion of the pre- and post-CPR rhythms were PEA or With regards to the above research Martyn Box states he has
asystole and are hence not shockable. An analysis carried no conict of interest.
out between the groups adjusted for pre-CPR value showed
no signicant difference between the two methods of CPR Acknowledgements
(p = 0.20). Similarly, adjusting for length of CPR showed no
signicant difference between the groups (p = 0.22). How-
The authors acknowledge the support of the Wellcome Trust
ever, a number of low value pre-CPR COP measures did
(Grant number 069078/Z/02/Z) and the Joint Royal Col-
experience a dramatic increase of signicance. This is a
lage Ambulance Liaison Committee (JRCALC) in this work.
subgroup worthy of further study.
The authors also acknowledge the assistance of Dr. Rob
Elton in the statistical analysis. CardioDigital Ltd. is a Well-
come Trust supported University Spin Off Company set up to
Discussion
research biomedical signal processing applications, includ-
ing the analysis of ventricular brillation. James Watson and
Lewis and Niemann11 have suggested the details of use
Paul Addison are co-founders and company directors of Car-
for the apparently contradictory results of the Hallstrom13
dioDigital. Gareth Clegg and Colin Robertson are members
and Ong14 studies of (load distributed) ADC-CPR devices.
of the CardioDigital Medical Advisory Panel.
Including almost certainly the time to deployment and
inuence of deployment on time to debrillation when
appropriate. Axelsson et al.24 cite the delay between References
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