Use of transthoracic impedance data to evaluate intra-arrest chest compression

quality before and after placement of a mechanical chest compression system

Jonathan W. Kamrud, NREMT-P, Lori L. Boland, MPH, Carol L. Frazee, NREMT-P, Paul A. Satterlee, MD, Charles J. Lick, MD
Allina Health Emergency Medical Services, St. Paul, MN

BACKGROUND
 igh quality CPR is a key determinant of survival after
H
out-of-hospital cardiac arrest (OHCA)
Mechanical compression devices ensure high quality
chest compressions by maintaining optimal rate and
depth and minimizing interruptions.
Transthoracic impedance (TTI) recordings can be used to
assess quality of chest compressions
Allina Health EMS uses mechanical compression as
standard care, and TTI data are reviewed for all OHCA.

OBJECTIVES
 se TTI data to examine:
U
intra-arrest differences in chest compression quality
during manual versus mechanical compression
timing of mechanical compression device placement
duration of pause required for device application

METHODS
Setting & Design
Large ambulance service in Minnesota
Use of mechanical compression is standard care
Retrospective study of all OHCA events in 2013

RESULTS
 = 202 events with a manual and mechanical phase
N
(Table 1)
Mean compression rate was better aligned with the
recommended 100 compressions/min during mechanical
compression (Table 2)
Mean compression fraction was significantly higher during
mechanical versus manual compressions (Table 2)
Median pause for device application = 26 sec (Table 3)
Mean duration of pauses appears to be shorter when
defibrillator/monitor is operated in manual vs AED mode
(Table 4)

FIGURES AND TABLES

CPR Time (min:sec)

Mean
Range
Compression rate/minute (mean)
Compression fraction (%)
Mean Duration of pauses (sec)
All Pauses
Peri-Shock Pauses
Non-Shock Pauses

Mechanical
Phase

3:37
23:22
(0:05 - 19:51) (0:13 65:30)
121
102
75
89

12.6
14.8
27.2
26.3
11.0
13.9

Manual Phase

p-Valuea

<0.0001

< 0.0001
< 0.0001

<0.0001
0.715
<0.0001

p-value for paired t-test or Wilcoxon sign rank test for difference in means

Table 3: Mechanical device application timing for 184 arrests

where application time could be determined
Time from start of impedance signal to first mechanical compression (min:sec)
Mean (SD)
Median (IQR)

4:07 (2:26)
4:02 (2:10, 5:25)

Compression interruption for application of mechanical devicea (sec)

Mean (SD)
Median (IQR)

34 (27)
26 (17, 44)

Includes only main application and activation and not placement of back plate when the
steps are performed separately
a

Table 4: Comparison of characteristics of pauses by

monitor mode
Monitor Mode
Variable
N
Mean Duration (sec)
All Pauses
Peri-Shock Pauses
Non-Shock Pauses
Mean # Pauses > 10 sec/5 min of CPR

Table 1: Patient and event characteristics in 202 arrests with

mechanical compression
Variable
Age, y

N = 202
67 (16)

Male

67% (136)

Witnessed Arrest

55% (111)

Bystander CPR

32% (65)

Initial rhythm
PEA/Asystole

79% (160)

VF/VT

21% (42)

Monitor mode during arrest

Manual Mode

23% (46)

AED (Semi-automated) Mode

66% (134)

Combination

11% (22)

Results are expressed as mean (SD) or percent (n)

111024 1214 2014 ALLINA HEALTH SYSTEM. TM A TRADEMARK OF ALLINA HEALTH SYSTEM.

Variable

Figure 1. Section of an intrathoracic impedance recording

depicting the transition from manual compressions to
mechanical compressions. Single compressions are marked
with a red arrow. The interval between (A) and (B) represents
the main pause for application of the mechanical device.

Eligibility Criteria
Non-traumatic OHCA in patients 18 years of age
Mechanical compression device used
Paramedics delivered compressions for at least 5 min
TTI data available for event
Data Collection and Definitions
TTI recordings reviewed using CodeStat software
Manual and mechanical compression phases identified
(Figure 1) and CPR metrics computed for each phase
Compression rate = avg # compressions/min during
periods of active compressions
Compression fraction = proportion of time compressions
were being performed when no spontaneous circulation
was present
CPR Time = total TTI tracing time with no spontaneous
circulation
Compression Pause = interval > 2 sec with no
compressions
The pause for mechanical device application was not
considered part of the manual or mechanical phase

Table 2: Comparison of chest compression quality in the

manual and mechanical phases of 202 OHCA

AED
134

Manual
46

p-Valuea

14.6
28.0
13.5

12.0
19.6
11.5

0.003
0.130
0.006

2.11

1.16

<0.0001

p-value for independent samples t-test or Mann-Whitney-Wilcoxon rank-sum test where

applicable
a

LIMITATIONS
 anual compression occurs at the beginning of the
M
resuscitation attempt, which is typically more chaotic
Randomization of the order of manual and mechanical
phases is not feasible
Outcomes were not studied

CONCLUSIONS
In our EMS system, compression fraction and rate improve
with the introduction of mechanical compression during
the course of a resuscitation attempt, and may warrant an
emphasis on earlier device placement. Pauses for device
application are frequently longer than described by the
manufacturer and should be targeted for reduction.