Presenting the LUCAS 2.0, the latest and greatest in CPR technology! The LUCAS device “provides the same quality for all patients and over time, independent of transport conditions, rescuer fatigue, or variability in the experience level of the caregiver.” Or at least that is what the manufacturer, Physio-Control Inc, will have you believe.
High quality CPR and early defibrillation have been the cornerstones of cardiac arrest management since the AHA published their “Chain of Survival”. Reducing the time off the chest is of utmost importance in the current CPR mantra. So a machine that not only performs consistent high quality CPR, but delivers countershocks without interrupting compressions was sure to show benefit in patient oriented outcomes. What follows is a Paul Bunyan-like contest of man against machine. One in which the makers of the LUCAS device strived to prove modern technology’s superiority over good old fashion manpower. In a delightful twist on the original tale the fancy new mechanical CPR device was found to be no better than traditional CPR.
The trial published in JAMA in November 2013, randomized 2,589 subjects to either traditional CPR following the 2005 European Resuscitation Council guidelines or a mechanical compressions protocol. Patients in the mechanical CPR group received traditional compressions until the device could be deployed, at which point compressions were continued mechanically. Ninety seconds after deployment the device delivered a countershock regardless of the initial rhythm. After which the rhythm was checked every 3-minutes and, if appropriate, a shock was delivered after a 90-second delay.
Despite the obvious advantages the LUCAS device provides, no difference was found in survival at 4-hours, ICU discharge, 1-month, or 6-months. The authors claim victory in a single positive endpoint that reached significance. The number of patients with a CPC score of 1 at 1-month was 2.6% in the traditional CPR vs 4.2% in the mechanical CPR group (p-value of 0.04). This is, of course, just post-hoc dredging of innumerable secondary outcomes, and nothing more than statistical noise. To the authors’ credit, they do not revisit this positive finding.
Despite their claims that the LUCAS device would free up rescuers to do other life sustaining actions, patients in the manual CPR group were defibrillated sooner, intubated faster, transported earlier, and arrived at the hospital in a swifter fashion than those in the mechanical CPR group.
The authors conclude “CPR with this mechanical device using the presented algorithm can be delivered without major complications but did not result in improved outcomes compared with manual chest compressions.” Given that there were only 7 major adverse events in the mechanical CPR group vs 3 in the tradition CPR group this does seem to be the case. Though I would caution, with the low incidence of adverse events, this trial was not powered to truly assess safety of the mechanical delivered CPR.
“Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest: The LINC Randomized Trial” www.ncbi.nlm.nih.gov/pubmed/24240611
As a prehospital EMS provider, I am sold on the benefits of LUCAS over a human because Lucas doesn't stop compressions going down the stairs or out of the house. There also is a non comparible safety feature. There is nobody standing up in the back of a moving ambulance unseatbelted doing compressions while an ambulance is moving to the hospital. Lucas also doesn't become tired, need a switch or lose the depth of compression rate when distracted.
As a prehospital EMS provider, I am sold on the benefits of LUCAS over a human because Lucas doesn't stop compressions going down the stairs or out of the house. There also is a non comparible safety feature. There is nobody standing up in the back of a moving ambulance unseatbelted doing compressions while an ambulance is moving to the hospital. Lucas also doesn't become tired, need a switch or lose the depth of compression rate when distracted.
Hi Maria,
Thank you so much for your comment! Those are all fair points and why the LUCAS device provides such a theoretical advantage over traditional CPR. Unfortunately these benefits have yet to materialize into measurable patient oriented outcomes. Though there may be benefits too subtle to be detected in a study like the LINC trial, the question is do these benefits justify the immense allocation of resources needed to acquire LUCAS devices for every ambulance? Should we replace our public AEDs with LUCAS devices? Is this the wisest use of our limited resources?There will always be anecdotal evidence to support the use of any intervention but given the state of our healthcare system, we should require more than theoretical benefits before adopting a very expensive machine as "standard" practice
Thanks again, I really enjoyed your insight and appreciate your support!!
Hi Maria,
Thank you so much for your comment! Those are all fair points and why the LUCAS device provides such a theoretical advantage over traditional CPR. Unfortunately these benefits have yet to materialize into measurable patient oriented outcomes. Though there may be benefits too subtle to be detected in a study like the LINC trial, the question is do these benefits justify the immense allocation of resources needed to acquire LUCAS devices for every ambulance? Should we replace our public AEDs with LUCAS devices? Is this the wisest use of our limited resources?There will always be anecdotal evidence to support the use of any intervention but given the state of our healthcare system, we should require more than theoretical benefits before adopting a very expensive machine as "standard" practice
Thanks again, I really enjoyed your insight and appreciate your support!!
As an prehospital EMS provider you should not be moving or transporting a cardiac arrest until you have achieved ROSC. If you do, you basically assure that they do not survive your care.
As an prehospital EMS provider you should not be moving or transporting a cardiac arrest until you have achieved ROSC. If you do, you basically assure that they do not survive your care.
Our data shows that 10-15% of our cardiac arrest patients with ROSC re-arrest en route to the hospital. Right now that leaves the lead paramedic to choose between re-assembling an entire Pit Crew CPR response on the side of the road and "high flow ambulance" (usually the latter) and neither option is particularly attractive. So, we just purchased a LUCAS device for the Battalion Chief's vehicle. It will be applied prior to transport in case the patient re-arrests. That way the lead paramedic simply presses a button and gets perfect CPR. As for AEDs, data from CARES shows that they are not being used (4% of the time if memory serves). So we're also looking at PulsePoint. Whether it's a LUCAS device, the ITD, the King LTD, capnography, or defibrillator, it's not the "what" is the "how". Cardiac arrest survival is about process, not gadgets. There's no good reason that patients in the manual arm of the study were defibrillated faster. That's completely avoidable. As for when they were transported, that is completely irrelevant.
Our data shows that 10-15% of our cardiac arrest patients with ROSC re-arrest en route to the hospital. Right now that leaves the lead paramedic to choose between re-assembling an entire Pit Crew CPR response on the side of the road and "high flow ambulance" (usually the latter) and neither option is particularly attractive. So, we just purchased a LUCAS device for the Battalion Chief's vehicle. It will be applied prior to transport in case the patient re-arrests. That way the lead paramedic simply presses a button and gets perfect CPR. As for AEDs, data from CARES shows that they are not being used (4% of the time if memory serves). So we're also looking at PulsePoint. Whether it's a LUCAS device, the ITD, the King LTD, capnography, or defibrillator, it's not the "what" is the "how". Cardiac arrest survival is about process, not gadgets. There's no good reason that patients in the manual arm of the study were defibrillated faster. That's completely avoidable. As for when they were transported, that is completely irrelevant.
Maria and Rory,
We've been talking quite a bit about when to transport and when NOT to. I'm a paramedic with 15 years in the field at the ALS level, and also teach at a community college and we've revisited this topic many times in the classroom. Why are we in a hurry to transport a patient in cardiac arrest? We needn't be-our treatments are nearly identical to what the hospital will do-they may draw labs, as well, but that is not likely while a cardiac arrest is in progress. Most patients will either go into a perfusing rhythm, or asystole after being defibrillated once, twice or three times. In other words, cardiac arrest is a "stay and play" until they are either in asystole or ROSC. However, I think your points about safety and distraction are excellent. Ideally, the lead medic should be able to discern if the person on the chest is tired/distracted; I come from a world where we may be lucky to run a code with more than 2 people, so this tool would be incredibly useful. I think the best approach, both financially and otherwise, would be to consider selective purchases of the LUCAS devices for EMS use. Put them in the busiest AND most remote areas only. Busiest because those folks get ground into the dirt with calls so let's give them a "hand" and most remote because transport times can be lengthy. However, with any lengthy transport time, with a patient in continuous asystole or PEA, we should consider ceasing of resuscitative efforts. Now we're talking about the possibility of SOP changes, in some areas, getting OMDs on board, etc. Nonetheless, if we want to go to evidence based medicine, we need to make changes based on what the evidence indicates. It's great to have discussions such as these. Great info from both of you-THANKS 🙂
Maria and Rory,
We've been talking quite a bit about when to transport and when NOT to. I'm a paramedic with 15 years in the field at the ALS level, and also teach at a community college and we've revisited this topic many times in the classroom. Why are we in a hurry to transport a patient in cardiac arrest? We needn't be-our treatments are nearly identical to what the hospital will do-they may draw labs, as well, but that is not likely while a cardiac arrest is in progress. Most patients will either go into a perfusing rhythm, or asystole after being defibrillated once, twice or three times. In other words, cardiac arrest is a "stay and play" until they are either in asystole or ROSC. However, I think your points about safety and distraction are excellent. Ideally, the lead medic should be able to discern if the person on the chest is tired/distracted; I come from a world where we may be lucky to run a code with more than 2 people, so this tool would be incredibly useful. I think the best approach, both financially and otherwise, would be to consider selective purchases of the LUCAS devices for EMS use. Put them in the busiest AND most remote areas only. Busiest because those folks get ground into the dirt with calls so let's give them a "hand" and most remote because transport times can be lengthy. However, with any lengthy transport time, with a patient in continuous asystole or PEA, we should consider ceasing of resuscitative efforts. Now we're talking about the possibility of SOP changes, in some areas, getting OMDs on board, etc. Nonetheless, if we want to go to evidence based medicine, we need to make changes based on what the evidence indicates. It's great to have discussions such as these. Great info from both of you-THANKS 🙂