Journal Reading

Mechanical CPR: Who? When? How?

Oleh:

Syifa Nurrohmah, S.Ked

23360080

Pembimbing:
dr. Yusnita Debora, Sp.An

KEPANITERAAN KLINIK ILMU ANASTESIOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS MALAHAYATI
RSUD JENDRAL AHMAD YANI KOTA METRO
TAHUN 2023
 LEMBAR PENGESAHAN

Telah Dipresentasikan Tugas Journal Reading Berjudul:

“Mechanical CPR: Who? When? How?”

Dipresentasikan pada Juni 2023

Pembimbing Penyaji

dr. Yusnita Debora, Sp.An Syifa Nurrohmah

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 KATA PENGANTAR

Dengan menyebut nama Allah SWT yang Maha Pengasih lagi Maha Penyayang,
Kami panjatkan syukur atas kehadirat-Nya, yang telah melimpahkan rahmat dan
hidayah-Nya kepada kami, sehingga kami dapat menyelesaikan telaahkritis jurnal ini
dengan baik.
Penulis mengucapkan terimakasih kepada dr. Yusnita Debora, Sp.An selaku
pembimbing yang telah memberikan bimbingan selama penyusunan telaah kritis jurnal
ini, serta semua pihak yang telah membantu hingga selesainya telaah kritis jurnal ini.
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masa yang akan datang. Semoga telaah kritis jurnal ini dapat memberi manfaat bagi
yang membacanya.

Metro, 20 Juni 2023

Penulis

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 PENELITIAN ASLI

Mechanical CPR: Who? When? How?

Kurtis Poole1,2, Keith Couper1,3, Michael A. Smyth1,4, Joyce Yeung1,3 and Gavin D. Perkins1,3*

Department of Anesthesiology and Pain Medicine, Gwangju Christian Hospital, Gwangju, Korea

Abstract
In cardiac arrest, high quality cardiopulmonary resuscitation (CPR) is a key determinant
of patient survival. However, delivery of effective chest compressions is often
inconsistent, subject to fatigue and practically challenging. Mechanical CPR devices
provide an automated way to deliver high-quality CPR. However, large randomised
controlled trials of the routine use of mechanical devices in the out-of-hospital setting
have found no evidence of improved patient outcome in patients treated with
mechanical CPR, compared with manual CPR. The limited data on use during in-
hospital cardiac arrest provides preliminary data supporting use of mechanical devices,
but this needs to be robustly tested in randomised controlled trials.
In situations where high-quality manual chest compressions cannot be safely delivered,
the use of a mechanical device may be a reasonable clinical approach. Examples of such
situations include ambulance transportation, primary percutaneous coronary
intervention, as a bridge to extracorporeal CPR and to facilitate uncontrolled organ
donation after circulatory death.
The precise time point during a cardiac arrest at which to deploy a mechanical device is
uncertain, particularly in patients presenting in a shockable rhythm. The deployment
process requires interruptions in chest compression, which may be harmful if the pause
is prolonged. It is recommended that use of mechanical devices should occur only in
systems where quality assurance mechanisms are in place to monitor and manage
pauses associated with deployment. In summary, mechanical CPR devices may provide
a useful adjunct to standard treatment in specific situations, but current evidence does
not support their routine use

Keywords: Cardiac arrest, Cardiopulmonary resuscitation, Mechanical CPR, Review

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Background
High-quality chest compressions are a critical component in the cardiac arrest chain
of survival [1]. Despite its importance, the sustained delivery of high-quality
cardiopulmonary resuscitation (CPR) is infrequently achieved in clinical practice [2, 3].
Mechanical chest compression devices deliver high-quality external chest
compressions, in place of a human rescuer. A number of devices are currently marketed,
but devices can be broadly categorised as load distributing band or piston devices, based
on the mechanism that is used to deliver compressions. The Autopulse (Zoll Medical,
Chelmsford, MA, USA) is a load distributing band device, which consists of a large
backplate that is positioned behind the patient and a band that encircles the patient’s
chest to deliver compressions at a rate of 80 per minute and a depth of 20% of the
anterior-posterior chest height. The LUCAS (Physio-Control Inc./Jolife AB, Lund,
Sweden) is an example of a piston device, which also incorporates a mechanism for
active chest recoil. It consists of two parts (a backplate and the piston mechanism),
which link together to encircle the patient. The device consistently delivers
compressions at a rate of 102 per minute and a depth of 5.3 cm in patients with a sternal
height greater than 18.5 cm. The key theoretical benefit to the use of such devices is
their ability to consistently deliver high-quality chest compressions, which has been
associated with improved intra-arrest haemodynamic profiles [4, 5].
The purpose of this review is to provide an update on mechanical device use for
both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA), an
overview on device use in special circumstances, and guidance on deployment in the
clinical setting.

The Importance of High Quality CPR

International guidelines highlight the importance of high-quality chest
compressions, which are defined as compressions at a depth of 5–6 cm and a rate of
100– 120 per minute, allowing full chest recoil between compressions, and
minimisation of interruptions [6, 7].
Despite consistent observational data showing the association between CPR quality
and patient outcome [8, 9], the delivery of high-quality manual chest compressions is
challenging in both the out-of-hospital and in-hospital settings [2, 3]. Specific barriers

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include provider fatigue [10, 11], physical effort to overcome stiffness of the patient’s
thoracic cage [12], and compressible underlying surfaces, such as mattresses, which can
lead to shallow chest compressions [13, 14]. For example, in an analysis of 9136 OHCA
patients, only 45% received the recommended guideline chest compression depth [15].
In contrast to manual chest compressions, mechanical devices are not subject to the
physical limitations of the rescuer and are able to consistently deliver high-quality chest
compressions
Current treatment recommendations
In 2015, the International Liaison Committee on Resuscitation’s (ILCOR)
consensus on science and treatment recommendation process evaluated the use of
mechanical chest compression devices in clinical practice [16]. The evidence evaluation
process made a single treatment recommendation to cover all settings and all
mechanical device types.
Based on the expert review of the available data, ILCOR made a weak
recommendation (moderate quality evidence) against the routine use of mechanical
devices in clinical practice. However, the review acknowledged situations where the
delivery of high quality manual chest compressions may be impractical or dangerous to
rescuers. In such circumstances, ILCOR made a weak recommendation based on low-
quality evidence supporting the use of mechanical devices. The commentary
accompanying the treatment recommendation highlighted concerns that the deployment
of mechanical devices without appropriate training might cause patient harm through an
increase in no-flow time during the early part of the cardiac arrest and delay
defibrillation in patients with a shockable rhythm.

Out-of-hospital cardiac arrest

Routine deployment in OHCA
The routine deployment of mechanical devices has been robustly tested in the pre-
hospital setting in large high-quality randomised controlled trials. In 2014–2015, the
CIRC (Circulation Improving Resuscitation Care) [17], LINC (LUCAS in Cardiac
Arrest) [18], and PARAMEDIC (Prehospital Randomised Assessment of a Mechanical
Chest Compression Device in Cardiac Arrest) [19] trials were published. These studies,
alongside two earlier small randomised studies [20, 21], are summarised in Table 1.

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 The CIRC trial was an industry sponsored trial, designed to determine equivalence,
superiority, or inferiority in survival to hospital discharge for OHCA patients who were
randomised in a 1:1 ratio to receive either manual CPR or Autopulse CPR [17]. The
study was terminated early, in accordance with pre-defined stopping rules, after 4753
randomised patients were enrolled. Of those randomised, 4231 were included in the
intention-to-treat analysis. Overall, manual CPR showed a numeric increase in survival
to hospital discharge compared to Autopulse CPR (11.0 versus 9.4%). The adjusted
odds ratio (OR) was 1.06 (95% confidence interval (CI) 0.83, 1.37) after adjustment for
covariates and interim analyses. This fell within the pre-defined equivalence region (OR
0.69–1.44), although the width of the equivalence margin incorporates the potential for
both significant harm and benefit [22]. Overall hospital survival rate was higher than
that reported in similar studies (PARAMEDIC 30 day survival 6.6%; LINC hospital
survival 8.0%). This may reflect the stringent study inclusion criteria and intensive
training and oversight by the study team which emphasised the importance of high-
quality CPR.
The LINC trial was also an industry-sponsored efficacy trial, in which OHCA
patients were randomised in a 1:1 ratio to receive either LUCAS or manual CPR [18].
The trial used a modified treatment algorithm for the LUCAS arm that incorporated
defibrillation without rhythm assessment and 3-minute periods between rhythm
assessments. The study randomised 2593 patients, of which 1589 were included in the
intention-to-treat analysis. In relation to the primary outcome of 4-h survival, LUCAS
was not superior to manual chest compressions (treatment difference 0.05%, 95% CI −
3.3, 3.2).
The PARAMEDIC study was an academic pragmatic cluster randomised trial, in
which ambulance vehicles were randomised in a 2:1 ratio to receive either manual CPR
or LUCAS CPR. The treatment allocation of the individual patient was determined by
the first vehicle to arrive on scene. The study included 4471 patients, of which 4470
were included in the primary analysis. In relation to the primary outcome of 30-day
survival, LUCAS was not superior to manual compressions (adjusted OR 0.86, 95% CI
0.64, 1.15). The study experienced a high incidence of non-compliance in the LUCAS
CPR arm, such that only 60% received mechanical CPR. A CACE (compiler average
causal effect) analysis, which accounts for non-compliance, generated similar findings

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to the main analysis [23].
The PARAMEDIC study also collected cost-effectiveness and quality of life data
following hospital discharge [24–26]. The long-term (up to 12 months) outcome
analysis found

Table 1 Summary of randomized controlled trials comparing routine use of mechanical CPR with manual
CPR in OHCA
Load-distributing band trials Piston-device trials
Hallstrom et al. CIRC [17] Smekal et LINC [18] PARAMEDIC
[20] a al. [21] [19]
Design Efficacy Efficacy Pilot Efficacy Effectiveness
superiortity equivalence multicentre superiority superiority
multicentre multicentre RCT multicentre multicentre RCT
RCT RCT RCT
Randomisation Cluster- EMS Patient (ratio Patient Patient (ratio Cluster-
station(s) (ratio 1:1) (ratio 1:1) 1:1) ambulance (ratio 2
1:1) manual:1
mechanical)
Inclusion Adult non- OHCA Adult Adult non- Adult Adult non-
criteria traumatic OHCA of traumatic unexpected traumatic OHCA
cardiac OHCA non-traumatic where a trial
aetiology. OHCA where vehicle was first
EMS arrival resuscitation ambulance on
time ≤ 16 was scene
min appropriate
Number of 1071 (1071 4231 (4753 149 2589 (2593 4470 (4471
cases analysed randomised) randomised) randomised) randomised)

Setting US/Canada US /Europe Sweden Europe UK

Sponsor Industry Industry Academicb Industry Academic
Device used Autopulse Autopulse LUCAS LUCAS LUCAS
Primary 4-h survival: STD Manual Not 4-h survival 30-day survival
outcome Manual 29.5% 11.0% vs specified Manual 23.7% Manual 7% vs
vs mechanical mechanical vs mechanical mechanical 6%,
28.5%, p = 0.74 9.4%, adj. 23.6%, adj. OR 0.86 (95%
OR 1.06 treatment CI 0.64, 1.15)
(95% CI difference −
0.83, 1.37)c 0.05 (95% CI
− 3.3, 3.2)
Key secondary Cardiac Sustained ROSC: STD: Manual ROSC: Manual
aetiology group ROSC: Manual 9.2% vs 31% vs
(n = 767): STD: Manual 32% vs mechanical mechanical 32%,
Manual 9.9% 32.3% vs mechanical 9.0%, adj. OR 0.99 (95%
vs mechanical mechanical 41%, p = treatment CI 0.86, 1.14)
5.8%, p = 0.06 28.6%, adj. 0.30 STD: difference − Good neurological
(adjusted) Good OR 0.84 Manual 0.15 (95% CI outcome: Manual
neurological (95% CI 10% vs − 2.4, 2.1) 6% vs mechanical
outcome: 0.73, 0.96) mechanical Good 5%, adj. OR 0.72

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 Manual 7.5% Good 8%, p = neurological (95% CI 0.52,
vs mechanical neurological 0.78 outcome: 0.99)
3.1%, p = 0.006 outcome in Manual 7.3%
survivors: vs mechanical
Manual 8.1%,
48.1% vs treatment
mechanical difference
44.4%, adj. 0.78 (95% CI
OR 0.80 − 1.3, 2.8)
(95% CI
0.47, 1.37)
a
Trial stopped early by data monitoring board
b
One author received consulting fee from device manufacturer
c
Primary outcome result within pre-specified boundary of equivalence. Trial stopped early in accordance
with pre-specified stopping rule EMS Emerency Medical Service, OHCA out-of-hospital cardiac arrest,
RCT randomised controlled trial, STD survival to discharge, adj OR adjusted odds ratio

no clinically important differences between groups in relation to outcomes such as

survival, neurological outcome, and quality of life at 3 months and 12 months, although
the analysis was subject to a high risk of attrition bias [24]. The cost-effectiveness
analysis found that routine use of mechanical CPR devices in the out-of-hospital setting
was not cost-effective [25].
A systematic review and meta-analysis by Gates et al. [22] incorporated all five
randomised controlled trials, as summarised in Table 1, with a total patient population
of 12,206. The random-effects meta-analysis found that mechanical CPR was not
superior to manual CPR, in relation to key outcomes such as return of spontaneous
circulation (OR 0.96, 95% CI 0.85, 1.10), survival at hospital discharge/30 days (OR
0.89, 95% CI 0.77, 1.02), or good neurological outcome (OR 0.76, 95% CI 0.53, 1.11).
In summary, these data do not support the routine use of mechanical CPR in
OHCA.
Use during transfer to hospital
The Universal Termination of Resuscitation rule guides clinical teams when to
consider transport from scene of the cardiac arrest to hospital with on-going CPR [27].
Other indications for transport include situations where potentially lifesaving treatments
cannot be delivered outside a hospital, such as extra-corporeal CPR, re-warming after
hypothermic cardiac arrest, and invasive procedures (e.g. primary percutaneous
coronary intervention (pPCI)) [28]. The process of intra-arrest transport typically
requires two phases: extrication of the patient to the ambulance and vehicular transfer to

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the hospital. In each of these phases, a key challenge for the EMS crew is the safe
ongoing delivery of high-quality CPR.
The majority of OHCAs occur in the patient’s home [29]. As such, a key challenge
in the extrication stage is manoeuvring past obstacles and downstairs whilst continuing
to deliver CPR. In an observational study, researchers analysed the pauses associated
with this process prior to and following the introduction of mechanical CPR to facilitate
the extrication process [30]. In the first period where manual CPR was provided, the
median chest compression pause during extrication was 270 s (interquartile range (IQR)
201, 387), with some pauses recorded as being in excess of 10 min. In contrast, after
introduction of mechanical CPR, chest compressions were delivered continuously
during extrication, except for the pause required to deploy the mechanical device
(median 39 s (IQR 29, 47).
For the vehicular transfer to hospital stage, there are three main concerns. Firstly,
delivery of manual CPR in a moving vehicle is inherently unsafe, and exposes both the
patient and EMS provider to risk of injury or death [31, 32]. Secondly, there is a risk of
suboptimal CPR delivery due to acceleration forces during ambulance transport [33].
However, evidence from clinical studies has been mixed with some reporting a similar
quality of manual chest compressions prior to and during transfer, whilst other studies
have reported either a transfer related deterioration or increased variability in quality
[30, 34–36]. Finally space consideration, such as in the context of transport by
helicopter, may render delivery of manual CPR difficult or impossible. In this setting,
mechanical chest compression devices have been used to effectively deliver ongoing
CPR during transport [37].
Based on these data, in particular the safety concerns associated with the delivery
of manual CPR during transport, it would seem reasonable to consider the use of
mechanical CPR during transport to hospital.

Use in the emergency department

The emergency department (ED) cardiac arrest population comprises both OHCA
patients that did have a pre-hospital ROSC and patients that arrest in the emergency
department. In view of limited personnel and a case-mix that likely includes prolonged

7
cardiac arrests, mechanical device use in the ED may appear an attractive solution. A
recent multi-centre Japanese observational study analysed the outcome of 6537 cardiac
arrest patients (5619 manual CPR, 918 mechanical CPR) treated in the ED [38]. The use
of a device was associated with reduced likelihood of ROSC (unadjusted OR 0.90, 95%
CI 0.77, 1.06; adjusted 0.71, 95% CI 0.53, 0.94) and hospital survival (unadjusted OR
0.97, 95% CI 0.62, 1.51; adjusted 0.40, 95% CI 0.20, 0.78). However, the decision as to
whether or not to use a mechanical device was made on a patient by patient basis, such
that there is a high risk that selective enrolment introduced unmeasured confounding
variables which may have biased the results.
In a before–after study in two Singaporean hospitals, researchers compared patient
outcomes prior to and following the implementation of the Autopulse device as part of
the treatment for ED cardiac arrests [39]. In total, 1011 (459 manual CPR period; 552
mechanical CPR period) patients were studied. Unadjusted ORs show an association
between treatment in the mechanical CPR period and improved ROSC (OR 1.89, 95%
CI 1.43, 2.50), hospital survival (OR 2.55, 95% CI 1.00, 6.47), and good neurological
outcome (OR 8.7, 95% CI 1.1, 71.6), but the interpretation of these findings is
complicated by marked differences in baseline patient characteristics (e.g. initial
rhythm, arrest location). Adjusted analyses showed an association between treatment in
the mechanical CPR period and ROSC (OR 1.60, 95% 1.16, 2.22), but no association
was observed in relation to any other outcome. The reason for the apparent contrast in
findings may reflect differences in patient population, study risk of bias (selection bias,
effect of unmeasured confounders), or the strategy used to deploy the mechanical
device. In particular, the team that deployed the device in Ong et al.’s study [40] had
received focussed team training to optimise device deployment, thereby minimising
pauses associated with its use. Overall, the findings of these studies with their inherent
risk of bias do not support the routine use of mechanical CPR in the ED.

In-hospital cardiac arrest

In contrast to the OHCA setting, few studies have sought to evaluate the routine use of
mechanical CPR in the IHCA setting. A recent systematic review and meta-analysis identified
only three randomised controlled trials which enrolled 234 patients [41].
The largest of these trials, and the only study published in the last 20 years, enrolled 150
in-hospital cardiac arrest patients who were randomised to receive either mechanical CPR

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delivered by a piston device or manual CPR [42]. The study report is available only in Chinese.
After translation, unfortunately, key patient characteristics, such as initial rhythm, are not
reported. The study reported that the use of a mechanical device improved survival to hospital
discharge (OR 2.81, 95% CI 1.26, 6.24). This trial, alongside the two other trials [43, 44], are
summarised in Table 2.
The meta-analysis of the three randomised trials alongside six (455 patients) observational
studies found very low quality evidence supporting an association between mechanical CPR use
and increased likelihood of ROSC (OR 2.14, 95% CI 1.11, 4.13) and survival to hospital
discharge/30 days (OR 2.34, 95% CI 1.42, 3.85) [41]. Neurological outcome was not assessed
in any study. The results of the meta-analysis were broadly consistent between the sub-groups
of randomised controlled trials and observational studies.
These findings seemingly contrast with research findings from out-of-hospital studies [22].
Reasons for this apparent discrepancy may reflect differences in either the quality of evidence
or clinical characteristics between the two settings, such that mechanical devices may be more
effective than manual chest compressions in the hospital setting. Examples of such
characteristics include the opportunity for early device deployment and the challenges of
delivering effective manual chest compressions on a bed mattress.

Table 2 Summary of randomized controlled trials comparing routine use of mechanical CPR with manual
CPR in IHCA
Load-distributing band trials Piston-device trials
Piston-device trials Halperin Taylor et al. [43] Lu et al. [42]a
et al. [44]
Design Efficacy superiortity single- Efficacy superiortity Efficacy superiority
centre RCT single-centre RCT single-centre RCT
Randomisation Patient (ratio 1:1) Patient (ratio 1:1) Patient (ratio 1:1
Inclusion IHCA of less than 20-min IHCA of less than 10- IHCA of less than 10-min
criteria duration following tracheal min duration duration
intubation and adrenaline
administration
Number of 34 50 150
cases analysed
Setting US US China
Sponsor Academicb Academic Unclear
Device used Load-distributing band Thumper device Thumper device
device
Primary ROSC Manual 18% vs One-hour survival STD Manual 15% vs
outcome mechanical 47%, OR 4.15 Manual 38% vs mechanical 33%, OR 2.81
(95% CI 0.86, 19.92) mechanical 42%, OR (95% CI 1.26, 6.24)
1.14 (95% CI 0.37, 3.55)
Key secondary 24-h survival: Manual 6% vs STD: Manual 8% vs ROSC: Manual 38% vs
outcomes mechanical 18% mechanical 13%, OR mechanical 55%, OR 2.03
1.71 (95% CI 0.26, (95% CI 1.06, 3.90)

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 11.26)
a
Published only in Chinese
b
Nine authors report equity interest in company holding device patent
IHCA in-hospital cardiac arrest, RCT randomised controlled trial, STD survival to discharge

Based on this discrepancy, the need for a randomised controlled trial in the in-
hospital setting was recently highlighted as a research priority [45]. The ongoing
COMPRESS-RCT (ISRCTN38139840) study is assessing the feasibility of undertaking
such a trial.

Risk of injury during mechanical device use

Injuries secondary to manual chest compression are common and well-reported
[46]. Common injuries include fractures (rib, sternal), pneumothoraces, and visceral
organ damage (liver, spleen, heart) [46–48]. Several case reports have purportedly
linked mechanical device use with clinically important injuries, thereby driving concern
that mechanical devices may increase risk of injury compared with manual CPR [49–
51]. Whilst evidence from cohort studies has produced mixed results, interpretation of
these studies is challenging as they are prone to selection bias and the quality of manual
CPR delivered, as the comparator group, is generally not recorded [52–55]. The
PARAMEDIC, LINC, and CIRC trials were designed to examine the clinical
effectiveness of mechanical devices, rather than to specifically examine injury, but it is
noteworthy that these trials did not report a difference in injury patterns or severity
between patients receiving manual and mechanical chest compression [17–19].
Koster et al. recently published a non-inferiority randomised controlled trial that
provided the most robust evidence in relation to injury attributable to mechanical chest
compression devices [56]. In total, 374 patients were randomised to receive LUCAS
CPR, Autopulse CPR, or to continue to receive manual CPR [56]. The primary outcome
was serious or life-threatening resuscitation-related visceral organ damage. Outcome
data were available for 90% of participants. Compared to manual CPR, the non-
inferiority analysis showed that LUCAS did not increase the risk of injury. However, an
increase in injury could not be ruled out with the Autopulse device. The depth of
manual chest compressions delivered in the manual CPR arm was 48 mm (SD 9), which
is slightly lower than the current recommended target depth of 50 mm [6].

Adjunct to advanced treatments

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pPCI and CT scan
Delivery of high quality manual chest compressions during imaging procedures,
such as coronary angiography or CT scan, is practically challenging due to the required
positioning of the radiology equipment. Several case series describe the experience of
specialist centres in performing intra-arrest coronary angiography and pPCI facilitated
by mechanical CPR, with reported hospital survival rates of approximately 25% [57–
59]. Wagner et al. [58] acknowledge that movement during CPR increases the
complexity of the procedure, but recommend strategies such as a brief CPR pause
during stenting to overcome this challenge. Whether the routine transfer of patients in
refractory cardiac arrest for pPCI during on-going CPR improves patient outcome
remains to be determined.
Transporting a patient in cardiac arrest to the CT scanner is rarely likely to improve
management. However, there may be cases where a patient scheduled for a CT scan has
a cardiac arrest just prior to the commencement of the scan. In these circumstances, it
may be reasonable to proceed with the scan to confirm the presence of a treatable
reversible cause, such as a massive pulmonary embolism. In such patients, imaging of
acceptable quality can be obtained whilst CPR is delivered by a mechanical device [60].

Extracorporeal CPR
Extracorporeal CPR (E-CPR) is a cardiac arrest treatment strategy whereby patients
are placed on cardiopulmonary bypass. Whilst evidence supporting E-CPR is limited
and based on observational studies, a number of regions have established systems where
E-CPR may be offered to patients who might narrow inclusion criteria [61, 62]. Several
of these systems use mechanical CPR to facilitate the insertion of the E-CPR
intravascular cannulae [63–65].
In Paris, for example, mechanical CPR has been used as a bridge to pre-hospital E-
CPR in 156 patients, with an overall ROSC rate of 77.8% [63]. Similarly, the Australian
CHEER study included 26 patients in refractory cardiac arrest that were treated with a
care protocol comprising mechanical CPR, therapeutic hypothermia, E-CPR, and pPCI
[64]. Fourteen (54%) survived to hospital discharge, all of whom had full neurological
recovery.
The ongoing Prague-based Hyperinvasive Approach in Cardiac Arrest trial
(NCT01511666) will provide important new information about the role of mechanical

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CPR as a bridge to E-CPR [66].

Organ donation
Uncontrolled donation after circulatory death (uDCD) provides a system whereby
organs can be retrieved after sudden cardiac arrest in cases where it has not been
possible to obtain a ROSC [67]. This enables the retrieval of organs such as lungs,
kidneys, and liver. Whilst this concept poses legal, ethical, and practical challenges, it
provides an opportunity to increase the number of viable donor organs [67, 68].
The use of mechanical CPR as a bridge to non-heart beating donation has also been
described in a number of countries [37, 67]. The use of mechanical CPR provides a
system to limit warm ischaemic time [68] whilst potentially providing a controlled
setting in which consent for donation can be sought. In Spain, a comparable number of
organs were transplanted with a similar graft failure rate following implementation of
mechanical CPR as part of a uDCD protocol [69]. The study also highlighted the
challenge of delivering such a system through its report that three patients, following
protocol implementation and initiation of mechanical CPR, obtained ROSC, of which
one made a good recovery.
Clinical decisions to refer for advanced lifesaving interventions (e.g. E-CPR) versus
organ donation present ethical dilemmas that require careful consideration [70].

Optimising clinical use of mechanical devices

Timing of deployment
In systems where mechanical devices are available, a key challenge for the clinician
is the decision as to the time point during the cardiac arrest at which to deploy the
mechanical chest compression device. In a meta-regression of out-of-hospital data,
Bonnes et al. [71] identified an association between improved outcome and earlier
device deployment.
A sub-group analysis in the PARAMEDIC trial identified decreased 30-day
survival in patients treated with a mechanical device that presented in a shockable
rhythm (odds ratio 0.71, 95% CI 0.52, 0.98) [19]. One plausible explanation for this is
that the study protocol required deployment of the mechanical device prior to
defibrillation, leading to delays in defibrillation in the mechanical CPR arm, although
this delay was not measured in the trial. In contrast, the LINC study, which adopted a

12
modified mechanical CPR treatment algorithm, found no difference in outcome between
treatment groups in patients presenting in a shockable rhythm (e.g. hospital discharge
treatment difference 0.6%, 95% CI − 5.6, 6.9), despite an increased median time to first
shock in the mechanical CPR arm (mechanical 4 min (IQR 2,5) vs manual 3 min (IQR
2, 4), P < 0.001) [72].
Delivery of high-quality manual chest compressions for a prolonged period of time
is physically exhausting [11, 73]. In the context of a prolonged cardiac arrest with
limited personnel available, use of a mechanical chest compression device may be a
reasonable strategy to avoid the potential harm associated with suboptimal chest
compression delivery.
Based on these data, it would seem reasonable to deploy devices early in
circumstances where high-quality manual chest compressions cannot be safely
delivered. In patients where high-quality CPR is deliverable, delayed deployment would
seem prudent in patients in a shockable rhythm.

Deployment
The key modifiable risk associated with mechanical device use is the pause
associated with device deployment. There is a risk that prolonged pauses associated
with device deployment during the early part of a cardiac arrest event may offset the
subsequent potential benefit of improved CPR.
In clinical practice, published literature reports marked variability in the hands-off
time during device deployment, with pauses in excess of 1 minute being reported [74].
In the LINC trial, the median reported chest compression pause associated with device
deployment was 36.0 s (IQR 19.5, 45.5) [75]. However, subsequent improvement in
flow-fraction following device deployment meant that the median flow-fraction over the
first 10 minutes of the cardiac arrest was higher in the mechanical CPR arm (mechanical
0.84 (IQR 0.78, 0.91) vs manual 0.79 (IQR 0.70, 0.86), p < 0.001). A similar pattern
was observed in the CIRC trial [17].
High-quality training that focuses on minimising pauses is an effective strategy to
reduce chest compression pauses associated with device deployment [40, 76]. Levy et
al. [76] implemented a system which incorporated a choreographed team approach to
device deployment, debriefing, mock resuscitation drills, and adaptations to the
deployment process to minimise pauses. The implementation of this system was

13
associated with a significant reduction in the median pause immediately prior to the first
mechanical chest compression (21 (IQR 15, 31) vs 7 (IQR 4, 12) s, p < 0.001).
Whenever mechanical CPR systems are deployed, a careful system of quality assurance
should be initiated to ensure optimal device deployment and avoidance of prolonged
interruptions in chest compressions.

Future developments
The integration of mechanical CPR with other technologies, such as active
compression–decompression technology or impedance threshold devices [77], has the
potential to impact on the efficacy of currently marketed mechanical chest compression
devices. However, a recent study found that the integration of active compression–
decompression technology with a LUCAS mechanical chest compression device did not
improve end tidal carbon dioxide, compared with use of a LUCAS without the
technology [78].
There may be the opportunity in the future for mechanical chest compression
devices to titrate chest compression delivery to physiological endpoints, such as end-
tidal carbon dioxide or arterial blood pressure [79].

Conclusions
The provision of high-quality CPR is a key modifiable factor associated with
survival in cardiac arrest. Mechanical chest compression devices consistently deliver
high-quality chest compressions, but this does not translate into improved patient
outcomes when devices are routinely used in OHCA. Further trials are needed to
evaluate the routine use of mechanical devices in IHCA.
The use of mechanical devices in specific circumstances (e.g. ambulance/helicopter
transport, pPCI) where high-quality chest compressions cannot be safely delivered may
be a reasonable strategy. In all situations where mechanical devices are used, clinicians
must ensure that the device is deployed with minimal interruption to chest compression
delivery.

Abbreviations
CPR: Cardiopulmonary resuscitation; E-CPR: Extracorporeal cardiopulmonary
resuscitation; ED: Emergency department; EMS: Emergency Medical Service; IHCA:

14
In-hospital cardiac arrest; ILCOR: International Liaison Committee on Resuscitation;
OHCA: Out-of-hospital cardiac arrest; pPCI: Primary percutaneous coronary
intervention; ROSC: Return of spontaneous circulation; uDCD: Uncontrolled donation
after circulatory death

Funding
KC and JY are supported as NIHR post-doctoral research fellows. GDP is an NIHR
senior investigator.

Authors’ contributions
All authors contributed to the planning and writing of the review. All authors
reviewed and approved the final manuscript.

Competing interests
KC and GDP have received NIHR funding to evaluate the use of mechanical chest
compression devices.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.

Author details
1
Warwick Medical School, University of Warwick, Coventry, UK. 2South Central
Ambulance Service NHS Foundation Trust, Bicester, UK. 3University Hospitals
Birmingham NHS Foundation Trust, Birmingham, UK. 4West Midlands Ambulance
Service NHS Foundation Trust, Brierly Hill, UK

15
 Mekanin CPR: Siapa? Kapan? Bagaimana?

Kurtis Poole1,2, Keith Couper1,3, Michael A. Smyth1,4, Joyce Yeung1,3 and Gavin D. Perkins1,3*

Department of Anesthesiology and Pain Medicine, Gwangju Christian Hospital, Gwangju, Korea

Abstrak
Pada serangan jantung, resusitasi kardiopulmoner (CPR) berkualitas tinggi adalah
penentu utama kelangsungan hidup pasien. Namun, pemberian kompresi dada yang
efektif seringkali tidak konsisten, rentan terhadap kelelahan dan secara praktis
menantang. Perangkat CPR mekanis menyediakan cara otomatis untuk memberikan
CPR berkualitas tinggi. Namun, uji coba terkontrol acak besar dari penggunaan rutin
perangkat mekanis di luar rumah sakit tidak menemukan bukti peningkatan hasil pasien
pada pasien yang diobati dengan CPR mekanis, dibandingkan dengan CPR manual.
Data terbatas tentang penggunaan selama serangan jantung di rumah sakit memberikan
data awal yang mendukung penggunaan perangkat mekanis, tetapi hal ini perlu diuji
secara kuat dalam uji coba terkontrol secara acak.

Dalam situasi di mana kompresi dada manual berkualitas tinggi tidak dapat dilakukan
dengan aman, penggunaan alat mekanis mungkin merupakan pendekatan klinis yang
masuk akal. Contoh situasi seperti itu termasuk transportasi ambulans, intervensi
koroner perkutan primer, sebagai jembatan ke CPR ekstrakorporeal dan untuk
memfasilitasi donasi organ yang tidak terkendali setelah kematian peredaran darah.

Titik waktu yang tepat selama henti jantung untuk menggunakan alat mekanis tidak
pasti, terutama pada pasien yang datang dengan ritme yang dapat dikejutkan. Proses
penyebaran membutuhkan interupsi dalam kompresi dada, yang mungkin berbahaya
jika jeda berkepanjangan. Direkomendasikan agar penggunaan perangkat mekanis
hanya dilakukan dalam sistem yang memiliki mekanisme jaminan kualitas untuk
memantau dan mengelola jeda yang terkait dengan penyebaran. Singkatnya, perangkat
CPR mekanis dapat memberikan tambahan yang berguna untuk perawatan standar
dalam situasi tertentu, tetapi bukti saat ini tidak mendukung penggunaan rutinnya.

Keywords: Henti jantung, Resusitasi jantung paru, CPR mekanis, Tinjauan

1
Latar Belakang
Kompresi dada berkualitas tinggi adalah komponen penting dalam rantai bertahan
hidup serangan jantung [1]. Meskipun penting, pemberian resusitasi kardiopulmoner
(CPR) berkualitas tinggi yang berkelanjutan jarang dicapai dalam praktik klinis [2,3].
Perangkat kompresi dada mekanis memberikan kompresi dada eksternal berkualitas
tinggi, menggantikan penyelamat manusia. Sejumlah perangkat saat ini dipasarkan,
tetapi perangkat dapat dikategorikan secara luas sebagai perangkat pita distribusi beban
atau piston, berdasarkan mekanisme yang digunakan untuk memberikan kompresi.
Autopulse (Zoll Medical, Chelmsford, MA, USA) adalah perangkat pita pendistribusi
beban, yang terdiri dari pelat belakang besar yang diposisikan di belakang pasien dan
pita yang melingkari dada pasien untuk memberikan kompresi dengan kecepatan 80 per
menit dan kedalaman 20% dari tinggi dada anterior posterior. LUCAS (Physio-Control
Inc./Jolife AB, Lund, Swedia) adalah contoh perangkat piston, yang juga menyertakan
mekanisme rekoil dada aktif. Ini terdiri dari dua bagian (pelat belakang dan mekanisme
piston), yang terhubung bersama untuk mengelilingi pasien. Perangkat secara konsisten
memberikan kompresi dengan kecepatan 102 per menit dan kedalaman 5,3 cm pada
pasien dengan tinggi sternum lebih dari 18,5 cm. Manfaat teoretis utama untuk
penggunaan perangkat tersebut adalah kemampuannya untuk secara konsisten
memberikan kompresi dada berkualitas tinggi, yang telah dikaitkan dengan profil
hemodinamik intra-arrest yang lebih baik [4,5].
Tujuan dari tinjauan ini adalah untuk memberikan informasi terbaru tentang
penggunaan perangkat mekanis untuk henti jantung di luar rumah sakit (OHCA) dan
henti jantung di rumah sakit (IHCA), ikhtisar tentang penggunaan perangkat dalam
keadaan khusus, dan panduan penerapan di pengaturan klinis.

Pentingnya CPR berkualitas tinggi

Pedoman internasional menyoroti pentingnya kompresi dada berkualitas tinggi,
yang didefinisikan sebagai kompresi pada kedalaman 5-6 cm dan kecepatan 100-120
per menit, memungkinkan rekoil dada penuh antara kompresi, dan meminimalkan
interupsi.6,7].
Meskipun data pengamatan yang konsisten menunjukkan hubungan antara kualitas
CPR dan hasil pasien [8,9], pemberian kompresi dada manual berkualitas tinggi

2
merupakan tantangan baik di luar rumah sakit maupun di dalam rumah sakit [2,3].
Hambatan khusus termasuk kelelahan penyedia [10,11], upaya fisik untuk mengatasi
kekakuan sangkar toraks pasien [12], dan permukaan bawah yang dapat dimampatkan,
seperti kasur, yang dapat menyebabkan kompresi dada yang dangkal [13,14]. Misalnya,
dalam analisis terhadap 9136 pasien OHCA, hanya 45% yang menerima panduan
kedalaman kompresi dada yang direkomendasikan [15].
Berbeda dengan kompresi dada manual, perangkat mekanis tidak tunduk pada
keterbatasan fisik penyelamat dan mampu memberikan kompresi dada berkualitas tinggi
secara konsisten.
Rekomendasi pengobatan saat ini
Pada tahun 2015, International Liaison Committee on Resuscitation's (ILCOR)
konsensus tentang sains dan proses rekomendasi pengobatan mengevaluasi penggunaan
alat kompresi dada mekanis dalam praktik klinis [16]. Proses evaluasi bukti membuat
rekomendasi perawatan tunggal untuk mencakup semua pengaturan dan semua jenis
perangkat mekanis.
Berdasarkan tinjauan ahli terhadap data yang tersedia, ILCOR membuat
rekomendasi yang lemah (bukti kualitas sedang) terhadap penggunaan rutin alat
mekanis dalam praktik klinis. Namun, tinjauan tersebut mengakui situasi di mana
pemberian kompresi dada manual berkualitas tinggi mungkin tidak praktis atau
berbahaya bagi penyelamat. Dalam keadaan seperti itu, ILCOR membuat rekomendasi
yang lemah berdasarkan bukti berkualitas rendah yang mendukung penggunaan
perangkat mekanis. Komentar yang menyertai rekomendasi perawatan menyoroti
kekhawatiran bahwa pemasangan perangkat mekanis tanpa pelatihan yang tepat dapat
menyebabkan bahaya pada pasien melalui peningkatan waktu tanpa aliran selama
bagian awal serangan jantung dan menunda defibrilasi pada pasien dengan ritme yang
dapat dikejutkan.

Henti jantung di luar Rumah Sakit

Penerapan rutin di OHCA
Penyebaran rutin perangkat mekanis telah diuji secara kuat dalam pengaturan pra-
rumah sakit dalam uji coba terkontrol acak berkualitas tinggi yang besar. Pada 2014–
2015, CIRC (Circulation Improving Resuscitation Care) [17], LINC (LUCAS dalam

3
Henti Jantung) [18], dan PARAMEDI (Penilaian Acak Prehospital dari Mekanis
Perangkat Kompresi Dada pada Henti Jantung) [19] percobaan diterbitkan. Studi-studi
ini, bersama dengan dua studi acak kecil sebelumnya [20,21], dirangkum dalam Tabel1.
Uji coba CIRC adalah uji coba yang disponsori industri, dirancang untuk
menentukan kesetaraan, keunggulan, atau inferioritas dalam kelangsungan hidup untuk
keluar dari rumah sakit untuk pasien OHCA yang diacak dalam rasio 1:1 untuk
menerima CPR manual atau CPR Autopulse [17]. Studi dihentikan lebih awal, sesuai
dengan aturan penghentian yang telah ditentukan sebelumnya, setelah 4753 pasien acak
terdaftar. Dari mereka yang diacak, 4231 dimasukkan dalam analisis intention-to-treat.
Secara keseluruhan, CPR manual menunjukkan peningkatan jumlah kelangsungan
hidup hingga keluar dari rumah sakit dibandingkan dengan CPR Autopulse (11,0 versus
9,4%). Rasio odds yang disesuaikan (OR) adalah 1,06 (interval kepercayaan 95% (CI)
0,83, 1,37) setelah penyesuaian untuk analisis kovariat dan interim. Ini jatuh dalam
wilayah kesetaraan yang telah ditentukan sebelumnya (OR 0,69-1,44), meskipun lebar
margin kesetaraan menggabungkan potensi kerugian dan manfaat yang signifikan [22].
Tingkat kelangsungan hidup rumah sakit secara keseluruhan lebih tinggi daripada yang
dilaporkan dalam penelitian serupa (kelangsungan hidup 30 hari PARAMEDIC 6,6%;
kelangsungan hidup rumah sakit LINC 8,0%). Ini mungkin mencerminkan kriteria
inklusi studi yang ketat dan pelatihan intensif serta pengawasan oleh tim studi yang
menekankan pentingnya CPR berkualitas tinggi.
Uji coba LINC juga merupakan uji coba efikasi yang disponsori industri, di mana
pasien OHCA diacak dalam rasio 1:1 untuk menerima LUCAS atau CPR manual.18].
Uji coba menggunakan algoritme perawatan yang dimodifikasi untuk lengan LUCAS
yang menggabungkan defibrilasi tanpa penilaian ritme dan periode 3 menit di antara
penilaian ritme. Studi ini mengacak 2593 pasien, dimana 1589 termasuk dalam analisis
intention-to-treat. Sehubungan dengan hasil utama kelangsungan hidup 4 jam, LUCAS
tidak lebih unggul dari kompresi dada manual (perbedaan pengobatan 0,05%, 95% CI -
3,3, 3,2).
Studi PARAMEDIC adalah uji coba acak klaster pragmatis akademis, di mana
kendaraan ambulans diacak dalam rasio 2:1 untuk menerima CPR manual atau CPR
LUCAS. Alokasi perawatan pasien individu ditentukan oleh kendaraan pertama yang
tiba di tempat kejadian. Studi ini melibatkan 4471 pasien, dimana 4470 termasuk dalam

4
analisis primer. Sehubungan dengan hasil utama kelangsungan hidup 30 hari, LU-CAS
tidak lebih unggul dari kompresi manual (OR 0,86 yang disesuaikan, 95% CI 0,64,
1,15). Studi tersebut mengalami insiden ketidakpatuhan yang tinggi pada lengan CPR
LUCAS, sehingga hanya 60% yang menerima CPR mekanis. Analisis CACE
(kompilasi efek kausal rata-rata), yang memperhitungkan ketidakpatuhan, menghasilkan
temuan serupa dengan analisis utama [23].
Studi PARAMEDIC juga mengumpulkan data efektivitas biaya dan kualitas hidup
setelah keluar dari rumah sakit [24–26]. Analisis hasil jangka panjang (hingga 12 bulan)
ditemukan

Table 1 Ringkasan uji coba terkontrol secara acak yang membandingkan penggunaan rutin CPR mekanis
dengan CPR manual di OHCA
Uji coba band yang Uji coba perangkat piston
mendistribusikan beban
Hallstrom et al. CIRC [17] Smekal et LINC [18] PARAMEDIC
[20] a al. [21] [19]
Desain Keunggulan Kesetaraan RCT Keunggulan Keunggulan
khasiat RCT khasiat RCT multisenter khasiat RCT khasiat RCT
multisenter multisenter percontohan multisenter multisenter
Pengacakan Cluster-stasiun Pasien (rasio Pasien Pasien (rasio Cluster- ambulans
EMS (rasio 1:1) 1:1) (rasio 1:1) 1:1) (rasio 2 manual:1
mekanis)
Kriteria Dewasa non- OHCA Dewasa Dewasa tak Dewasa non-
inklusi traumatis dewasa dari non- terduga traumatis OHCA
OHCA etiologi traumatis OHCA non- tempat kendaraan
jantung. OHCA traumatis uji coba pertama
kedatangan dimana kali ambulans di
EMS waktu resusitasi tempat kejadian
≤16 mnt tepat
Jumlah kasus 1071 (1071 4231 (4753 149 2589 (2593 4470 (4471
yang dianilis diacak) diacak) diacak) diacak)
Pengaturan US/Kanada US /Eropa Swedia Eropa Inggris
b
Sponsor Industri Industri Academik Industri Academik
Perangkat Autopulse Autopulse LUCAS LUCAS LUCAS
yang
digunakan
Pengeluaran Kelangsungan STD Manual Tidak Kelangsungan Kelangsungan
utama hidup 4 jam: 11.0% vs spesifik hidup 4 jam hidup 30 hari
Manual 29.5% mekanis Manual 23.7% Manual 7% vs
vs mekanis 9.4%, adj. OR vs mekanis mekanis 6%, adj.
28.5%, p = 0.74 1.06 (95% CI 23.6%, OR 0.86 (95% CI
c
0.83, 1.37) perbedaan 0.64, 1.15)
perlakuan −
0.05 (95% CI
− 3.3, 3.2)

5
Kunci Kelompok ROSC ROSC: STD: Manual ROSC: Manual
sekunder hasil etiologi jantung berkelanjutan: Manual 9.2% vs 31% vs mekanis
(n = 767): STD: Manual 32% vs mekanis 32%, adj. OR 0.99
Manual 9.9% 32.3% vs mechanical 9.0%, (95% CI 0.86,
vs mekanis mekanis 41%, p = perbedaan 1.14) hasil
5.8%, p = 0.06 28.6%, adj. 0.30 STD: perlakuan − neurologis yang
(disesuaikan) OR 0.84 Manual 0.15 (95% CI baik: Manual 6%
Hasil (95% CI 0.73, 10% vs − 2.4, 2.1) vs mekanis 5%,
neurologis yang 0.96) hasil mechanical hasil adj. OR 0.72 (95%
baik: Manual neurologis 8%, p = neurologis CI 0.52, 0.99)
7.5% vs yang baik 0.78 yang baik:
mekanis 3.1%, pada pasien: Manual 7.3%
p = 0.006 Manual vs mekanis
48.1% vs 8.1%,
mekanis perlakuan
44.4%, adj. berbeda 0.78
OR 0.80 (95% CI −
(95% CI 0.47, 1.3, 2.8)
1.37)
a
Uji coba dihentikan lebih awal oleh papan pemantauan data
b
Seorang penulis menerima biaya konsultasi dari produsen perangkat
c
Hasil hasil primer dalam batas kesetaraan yang telah ditentukan sebelumnya. Uji coba dihentikan lebih
awal sesuai dengan aturan penghentian yang ditentukan sebelumnya EMS Layanan Medis Darurat,
OHCA henti jantung di luar rumah sakit, RCT uji coba terkontrol secara acak, STD kelangsungan hidup
untuk dibuang, adj ATAU rasio odds yang disesuaikan

tidak ada perbedaan yang penting secara klinis antara kelompok dalam kaitannya
dengan hasil seperti kelangsungan hidup, hasil neurologis, dan kualitas hidup pada 3
bulan dan 12 bulan, meskipun analisis tunduk pada risiko bias atrisi yang tinggi [24].
Analisis efektivitas biaya menemukan bahwa penggunaan rutin perangkat CPR mekanis
di luar rumah sakit tidak hemat biaya [25].
Tinjauan sistematis dan meta-analisis oleh Gates et al. [22] menggabungkan kelima
uji coba terkontrol secara acak, seperti yang dirangkum dalam Tabel1, dengan total
populasi pasien 12.206. Meta-analisis efek-acak menemukan bahwa CPR mekanis tidak
lebih unggul dari CPR manual, dalam kaitannya dengan hasil utama seperti kembalinya
sirkulasi spontan (OR 0,96, 95% CI 0,85, 1,10), kelangsungan hidup saat keluar dari
rumah sakit/30 hari (OR 0,89, 95% CI 0,77, 1,02), atau hasil neurologis yang baik (OR
0,76, 95% CI 0,53, 1,11).
Singkatnya, data ini tidak mendukung penggunaan rutin CPR mekanis di OHCA.
Digunakan selama transfer ke Rumah Sakit
Aturan Penghentian Resusitasi Universal memandu tim klinis saat

6
mempertimbangkan pemindahan dari tempat kejadian serangan jantung ke rumah sakit
dengan CPR yang sedang berlangsung [27]. Indikasi lain untuk pemindahan meliputi
situasi di mana perawatan yang berpotensi menyelamatkan jiwa tidak dapat dilakukan di
luar rumah sakit, seperti CPR ekstra-korporeal, penghangatan kembali setelah serangan
jantung hipotermia, dan prosedur invasif (misalnya intervensi koroner perkutan primer
(pPCI)) [28]. Proses transportasi intra-arrest biasanya membutuhkan dua fase: pelepasan
pasien ke ambulans dan transfer kendaraan ke rumah sakit. Di setiap fase ini, tantangan
utama bagi kru EMS adalah pengiriman CPR berkualitas tinggi yang aman dan
berkelanjutan.
Mayoritas OHCA terjadi di rumah pasien [29]. Dengan demikian, tantangan utama
dalam tahap pelepasan adalah bermanuver melewati rintangan dan turun sambil terus
memberikan CPR. Dalam studi observasional, peneliti menganalisis jeda yang terkait
dengan proses ini sebelum dan setelah pengenalan CPR mekanis untuk memfasilitasi
proses pelepasan [30]. Pada periode pertama di mana CPR manual diberikan, jeda
kompresi dada median selama pelepasan adalah 270 detik (kisaran interkuartil (IQR)
201, 387), dengan beberapa jeda tercatat lebih dari 10 menit. Di dalam Sebaliknya,
setelah pengenalan CPR mekanis, kompresi dada dilakukan terus menerus selama
pelepasan, kecuali untuk jeda yang diperlukan untuk menggunakan perangkat mekanis
(median 39 detik (IQR 29, 47).
Untuk tahap pemindahan kendaraan ke rumah sakit, ada tiga perhatian utama.
Pertama, pengiriman CPR manual dalam kendaraan yang bergerak pada dasarnya tidak
aman, dan membuat pasien dan penyedia EMS berisiko cedera atau kematian [31,32].
Kedua, ada risiko pengiriman CPR suboptimal karena gaya akselerasi selama
transportasi ambulans [33]. Namun, bukti dari studi klinis telah dicampur dengan
beberapa melaporkan kualitas kompresi dada manual yang sama sebelum dan selama
pemindahan, sementara penelitian lain telah melaporkan penurunan terkait pemindahan
atau peningkatan variabilitas dalam kualitas [30,34–36]. Terakhir, pertimbangan ruang,
seperti dalam konteks pengangkutan dengan helikopter, dapat menyebabkan pengiriman
CPR manual menjadi sulit atau tidak mungkin dilakukan. Dalam pengaturan ini,
perangkat kompresi dada mekanis telah digunakan untuk secara efektif memberikan
CPR berkelanjutan selama transportasi [37].
Berdasarkan data ini, khususnya masalah keamanan yang terkait dengan pemberian

7
CPR manual selama pengangkutan, tampaknya masuk akal untuk mempertimbangkan
penggunaan CPR mekanis selama pengangkutan ke rumah sakit.

Digunakan di Instalasi Gawat Darurat

Populasi henti jantung di unit gawat darurat (ED) terdiri dari pasien OHCA yang
memiliki ROSC pra-rumah sakit dan pasien yang mengalami henti jantung di unit gawat
darurat. Mengingat personel yang terbatas dan campuran kasus yang kemungkinan
mencakup serangan jantung yang berkepanjangan, penggunaan perangkat mekanis di
UGD mungkin tampak sebagai solusi yang menarik. Sebuah studi observasi multi-
senter Jepang baru-baru ini menganalisis hasil dari 6537 pasien serangan jantung (5619
CPR manual, 918 CPR mekanis) yang dirawat di UGD [38]. Penggunaan perangkat
dikaitkan dengan penurunan kemungkinan ROSC (OR yang tidak disesuaikan 0,90,
95% CI 0,77, 1,06; disesuaikan 0,71, 95% CI 0,53, 0,94) dan kelangsungan hidup
rumah sakit (OR yang tidak disesuaikan 0,97, 95% CI 0,62, 1,51; disesuaikan 0,40, 95%
CI 0,20, 0,78). Namun, keputusan apakah akan menggunakan alat mekanis atau tidak
dibuat berdasarkan pasien per pasien, sehingga ada risiko tinggi bahwa pendaftaran
selektif memperkenalkan variabel pengganggu yang tidak terukur yang mungkin
membiaskan hasilnya.
Dalam penelitian sebelum-sesudah di dua rumah sakit Singapura, para peneliti
membandingkan hasil pasien sebelum dan sesudah penerapan perangkat Autopulse
sebagai bagian dari perawatan untuk serangan jantung ED [39]. Secara total, 1011 (459
periode CPR manual; 552 periode CPR mekanis) pasien dipelajari. OR yang tidak
disesuaikan menunjukkan hubungan antara perawatan pada periode CPR mekanis dan
peningkatan ROSC (OR 1,89, 95% CI 1,43, 2,50), kelangsungan hidup di rumah sakit
(OR 2,55, 95% CI 1,00, 6,47), dan hasil neurologis yang baik (OR 8,7, 95% CI 1,1,
71,6), tetapi interpretasi dari temuan ini rumit oleh perbedaan yang mencolok dalam
karakteristik pasien awal (misalnya irama awal, lokasi penangkapan). Analisis yang
disesuaikan menunjukkan hubungan antara pengobatan pada periode CPR mekanis dan
ROSC (OR 1,60, 95% 1,16, 2,22), tetapi tidak ada hubungan yang diamati dalam
kaitannya dengan hasil lainnya.
Alasan untuk kontras yang tampak dalam temuan mungkin mencerminkan
perbedaan dalam populasi pasien, risiko studi bias (bias seleksi, efek pembaur yang
tidak terukur), atau strategi yang digunakan untuk menggunakan perangkat mekanis.

8
Secara khusus, tim yang menyebarkan perangkat dalam studi Ong et al. [ 40] telah
menerima pelatihan tim terfokus untuk mengoptimalkan penerapan perangkat, sehingga
meminimalkan jeda yang terkait dengan penggunaannya. Secara keseluruhan, temuan
studi ini dengan risiko bias yang melekat tidak mendukung penggunaan rutin CPR
mekanis di UGD.

Henti jantung di Rumah Sakit

Berbeda dengan pengaturan OHCA, beberapa studi telah berusaha untuk
mengevaluasi penggunaan rutin CPR mekanis dalam pengaturan IHCA. Tinjauan
sistematis dan meta-analisis baru-baru ini mengidentifikasi hanya tiga uji coba
terkontrol acak yang melibatkan 234 pasien [41].
Yang terbesar dari uji coba ini, dan satu-satunya studi yang diterbitkan dalam 20
tahun terakhir, mendaftarkan 150 pasien henti jantung di rumah sakit yang diacak untuk
menerima CPR mekanis yang diberikan oleh perangkat piston atau CPR manual.42].
Laporan studi hanya tersedia dalam bahasa Cina. Sayangnya, setelah translasi,
karakteristik utama pasien, seperti ritme awal, tidak dilaporkan. Studi tersebut
melaporkan bahwa penggunaan alat mekanis meningkatkan kelangsungan hidup hingga
keluar dari rumah sakit (OR 2.81, 95% CI 1.26, 6.24). Uji coba ini, di samping dua uji
coba lainnya [43,44], dirangkum dalam Tabel2.
Meta-analisis dari tiga uji coba acak bersama enam (455 pasien) studi observasional
menemukan bukti kualitas yang sangat rendah yang mendukung hubungan antara
penggunaan CPR mekanis dan kemungkinan peningkatan ROSC (OR 2.14, 95% CI
1.11, 4.13) dan kelangsungan hidup setelah keluar dari rumah sakit. /30 hari (ATAU
2,34, 95% CI 1,42, 3,85) [41]. Hasil neurologis tidak dinilai dalam penelitian apa pun.
Hasil meta-analisis secara luas konsisten antara sub-kelompok uji coba terkontrol secara
acak dan studi observasional.
Temuan ini tampaknya kontras dengan temuan penelitian dari studi di luar rumah
sakit [22]. Alasan untuk perbedaan ini mungkin mencerminkan perbedaan kualitas bukti
atau karakteristik klinis antara dua pengaturan, sehingga perangkat mekanis mungkin
lebih efektif daripada kompresi dada manual di rumah sakit. Contoh dari karakteristik
tersebut termasuk peluang untuk pemasangan perangkat lebih awal dan tantangan untuk
memberikan kompresi dada manual yang efektif di kasur tempat tidur.

9
Table 2 Ringkasan uji coba terkontrol secara acak yang membandingkan penggunaan rutin CPR mekanis
dengan CPR manual di IHCA
Uji coba pita yang Uji coba perangkat piston
mendistribusikan beban Taylor et al. [43] Lu et al. [42]a
Halperin et al. [44]
Desain Kemanjuran keunggulan Kemanjuran keunggulan Kemanjuran keunggulan
pasien RCT pusat pasien RCT pusat pasien RCT pusat
Pengacakan Pasien (ratio 1:1) Pasien (ratio 1:1) Pasien (ratio 1:1
Kriteria inklusi IHCA dengan durasi kurang IHCA dengan durasi IHCA dengan durasi
dari 20 menit setelah kurang dari 10 menit kurang dari 10 menit
intubasi trakea dan
pemberian adrenalin
Jumlah kasus 34 50 150
yang dianalisis
Setting Amerika Amerika Cina
b
Sponsor Academik Academik Tidak jelas
Perangkat yang Load-distributing band Thumper device Thumper device
digunakan device
Hasil utama ROSC Manual 18% vs Kelangsungan hidup STD Manual 15% vs
mekanis 47%, OR 4.15 dalam 1 jam Manual mekanis 33%, OR 2.81
(95% CI 0.86, 19.92) 38% vs mekanis 42%, (95% CI 1.26, 6.24)
OR 1.14 (95% CI 0.37,
3.55)
Hasil sekunder Kelangsungan hidup selama STD: Manual 8% vs ROSC: Manual 38% vs
kedua 24 jam: Manual 6% vs mekanis 13%, OR 1.71 mekanis 55%, OR 2.03
mekanis 18% (95% CI 0.26, 11.26) (95% CI 1.06, 3.90)
a
Diterbitkan hanya dalam bahasa Cina
b
Sembilan penulis melaporkan minat ekuitas di perusahaan yang memegang paten perangkat
IHCA henti jantung di rumah sakit, RCT uji coba terkontrol secara acak, STD kelangsungan hidup untuk
dibuang

Berdasarkan perbedaan ini, kebutuhan untuk uji coba terkontrol secara acak di
rumah sakit baru-baru ini disorot sebagai prioritas penelitian [45]. Studi COMPRESS-
RCT (ISRCTN38139840) yang sedang berlangsung menilai kelayakan melakukan uji
coba semacam itu.

Risiko cedera selama penggunaan perangkat mekanis

Cedera sekunder akibat kompresi dada manual sering terjadi dan dilaporkan dengan
baik [46]. Cedera umum termasuk patah tulang (tulang rusuk, tulang dada),
pneumotoraks, dan kerusakan organ visceral (hati, limpa, jantung) [46–48]. Beberapa
laporan kasus konon menghubungkan penggunaan perangkat mekanis dengan cedera
yang penting secara klinis, sehingga menimbulkan kekhawatiran bahwa perangkat
mekanis dapat meningkatkan risiko cedera dibandingkan dengan CPR manual [49–51].

10
Sementara bukti dari studi kohort telah menghasilkan hasil yang beragam, interpretasi
studi ini menantang karena rentan terhadap bias seleksi dan kualitas CPR manual yang
diberikan, sebagai kelompok pembanding, umumnya tidak tercatat [52–55]. Uji coba
PARAMEDIC, LINC, dan CIRC dirancang untuk memeriksa efektivitas klinis
perangkat mekanis, bukan untuk memeriksa cedera secara khusus, tetapi patut dicatat
bahwa uji coba ini tidak melaporkan perbedaan dalam pola cedera atau tingkat
keparahan antara pasien yang menerima dada manual dan mekanik. kompresi [17–19].
Koster dkk. baru-baru ini menerbitkan uji coba terkontrol acak non-inferioritas
yang memberikan bukti paling kuat dalam kaitannya dengan cedera yang disebabkan
oleh perangkat kompresi dada mekanis [56]. Secara total, 374 pasien diacak untuk
menerima LUCAS CPR, Autopulse CPR, atau untuk terus menerima CPR manual [56].
Hasil utama terkait resusitasi yang serius atau mengancam jiwa kerusakan organ viseral.
Data hasil tersedia untuk 90% peserta. Dibandingkan dengan CPR manual, analisis non-
inferioritas menunjukkan bahwa LUCAS tidak meningkatkan risiko cedera. Namun,
peningkatan cedera tidak dapat dikesampingkan dengan perangkat Autopulse.
Kedalaman kompresi dada manual yang diberikan pada lengan CPR manual adalah 48
mm (SD 9), yang sedikit lebih rendah dari kedalaman target yang direkomendasikan
saat ini yaitu 50 mm [6].
Tambahan untuk perawatan lanjutan
pPCI dan CT scan
Pemberian kompresi dada manual berkualitas tinggi selama prosedur pencitraan,
seperti angiografi koroner atau CT scan, secara praktis menantang karena posisi
peralatan radiologi yang diperlukan. Beberapa rangkaian kasus menggambarkan
pengalaman pusat spesialis dalam melakukan angiografi koroner intra-arrest dan pPCI
yang difasilitasi oleh CPR mekanik, dengan tingkat kelangsungan hidup rumah sakit
yang dilaporkan sekitar 25% [57–59]. Wagner dkk. [58] akui bahwa gerakan selama
CPR meningkatkan kompleksitas prosedur, tetapi merekomendasikan strategi seperti
jeda CPR singkat selama stenting untuk mengatasi tantangan ini. Apakah transfer rutin
pasien henti jantung refraktori untuk pPCI selama CPR yang sedang berlangsung
meningkatkan hasil pasien masih harus ditentukan.
Memindahkan pasien henti jantung ke pemindai CT jarang sekali dapat
meningkatkan penatalaksanaan. Namun, mungkin ada kasus di mana pasien yang

11
dijadwalkan untuk CT scan mengalami serangan jantung sesaat sebelum dimulainya
pemindaian. Dalam keadaan ini, mungkin masuk akal untuk melanjutkan pemindaian
untuk memastikan adanya penyebab reversibel yang dapat diobati, seperti penyakit paru
massif emboli. Pada pasien tersebut, pencitraan dengan kualitas yang dapat diterima
dapat diperoleh sementara CPR diberikan oleh alat mekanis [60].

CPR Extracorporeal
Extracorporeal CPR (E-CPR) adalah strategi pengobatan serangan jantung dimana
pasien ditempatkan pada cardiopulmonary bypass. Sementara bukti yang mendukung E-
CPR terbatas dan berdasarkan studi observasional, sejumlah wilayah telah menetapkan
sistem di mana E-CPR dapat ditawarkan kepada pasien yang mungkin mempersempit
kriteria inklusi [61,62]. Beberapa dari sistem ini menggunakan CPR mekanis untuk
memfasilitasi penyisipan kanula intravaskular E-CPR [63–65].
Di Paris, misalnya, CPR mekanis telah digunakan sebagai jembatan menuju E-CPR
pra-rumah sakit pada 156 pasien, dengan tingkat ROSC keseluruhan sebesar 77,8%
[63]. Demikian pula, studi CHEER Australia melibatkan 26 pasien henti jantung
refrakter yang dirawat dengan protokol perawatan yang terdiri dari CPR mekanik,
hipotermia terapeutik, E-CPR, dan pPCI [64]. Empat belas (54%) bertahan hidup
hingga keluar dari rumah sakit, semuanya mengalami pemulihan neurologis penuh.
Pendekatan Hiperinvasif berbasis Praha yang sedang berlangsung dalam percobaan
Henti Jantung (NCT01511666) akan memberikan informasi baru yang penting tentang
peran CPR mekanis sebagai jembatan menuju E-CPR [66].

Donasi organ
Sumbangan yang tidak terkendali setelah kematian peredaran darah (uDCD)
menyediakan sistem di mana organ dapat diambil setelah henti jantung mendadak dalam
kasus di mana tidak mungkin untuk mendapatkan ROSC [67]. Ini memungkinkan
pengambilan organ seperti paru-paru, ginjal, dan hati. Sementara konsep ini
menimbulkan tantangan hukum, etika, dan praktis, ini memberikan peluang untuk
meningkatkan jumlah organ donor yang layak [67,68].
Penggunaan CPR mekanis sebagai jembatan untuk donasi non-detak jantung juga
telah dijelaskan di sejumlah negara [ 37,67]. Penggunaan CPR mekanik menyediakan
sistem untuk membatasi waktu iskemik hangat [68] sambil berpotensi memberikan

12
pengaturan yang terkendali di mana persetujuan untuk donasi dapat dicari. Di Spanyol,
sejumlah organ yang sebanding ditransplantasikan dengan tingkat kegagalan cangkok
yang serupa setelah penerapan CPR mekanis sebagai bagian dari protokol uDCD [69].
Studi ini juga menyoroti tantangan dalam memberikan sistem seperti itu melalui
laporannya bahwa tiga pasien, setelah penerapan protokol dan inisiasi CPR mekanis,
memperoleh ROSC, yang salah satunya sembuh dengan baik.
Keputusan klinis untuk merujuk intervensi penyelamatan nyawa tingkat lanjut
(misalnya E-CPR) versus donasi organ menghadirkan dilema etika yang memerlukan
pertimbangan cermat [70].
Mengoptimalkan penggunaan klinis perangkat mekanis
Waktu penerapan
Dalam sistem di mana perangkat mekanis tersedia, tantangan utama bagi dokter
adalah keputusan tentang titik waktu selama henti jantung untuk menggunakan
perangkat kompresi dada mekanis. Dalam meta-regresi data di luar rumah sakit, Bonnes
et al. [71] mengidentifikasi hubungan antara peningkatan hasil dan penerapan perangkat
sebelumnya.
Analisis subkelompok dalam uji coba PARAMEDIC mengidentifikasi penurunan
kelangsungan hidup 30 hari pada pasien yang diobati dengan alat mekanis yang
disajikan dalam ritme yang dapat dikejutkan (rasio odds 0,71, 95% CI 0,52, 0,98) [ 19].
Salah satu penjelasan yang masuk akal untuk hal ini adalah bahwa protokol penelitian
memerlukan penerapan perangkat mekanis sebelum defibrilasi, yang menyebabkan
penundaan defibrilasi pada lengan CPR mekanik, meskipun penundaan ini tidak diukur
dalam uji coba. Sebaliknya, studi LINC, yang mengadopsi algoritme perawatan CPR
mekanis yang dimodifikasi, tidak menemukan perbedaan hasil antara kelompok
perawatan pada pasien yang menunjukkan ritme yang dapat dikejutkan (misalnya
perbedaan perawatan di rumah sakit 0,6%, 95% CI − 5,6, 6,9), meskipun peningkatan
waktu median untuk kejut pertama pada lengan CPR mekanis (mekanik 4 menit (IQR
2,5) vs manual 3 menit (IQR 2, 4), P<0,001) [72].
Pengiriman kompresi dada manual berkualitas tinggi untuk jangka waktu lama
melelahkan secara fisik [11,73]. Dalam konteks henti jantung berkepanjangan dengan
personel terbatas, penggunaan perangkat kompresi dada mekanis mungkin merupakan
strategi yang masuk akal untuk menghindari potensi bahaya yang terkait dengan

13
pemberian kompresi dada yang kurang optimal.
Berdasarkan data ini, tampaknya masuk akal untuk menerapkan perangkat lebih
awal dalam keadaan di mana kompresi dada manual berkualitas tinggi tidak dapat
dilakukan dengan aman. Pada pasien di mana CPR berkualitas tinggi dapat diberikan,
penempatan yang tertunda akan tampak bijaksana pada pasien dengan ritme yang dapat
dikejutkan.

Penyebaran
Risiko utama yang dapat dimodifikasi yang terkait dengan penggunaan perangkat
mekanis adalah jeda yang terkait dengan penerapan perangkat. Ada risiko bahwa jeda
berkepanjangan yang terkait dengan penyebaran perangkat selama bagian awal kejadian
henti jantung dapat mengimbangi manfaat potensial selanjutnya dari peningkatan CPR.
Dalam praktik klinis, laporan literatur yang diterbitkan menandai variabilitas waktu
hands-off selama penyebaran perangkat, dengan jeda lebih dari 1 menit yang dilaporkan
[74 ]. Dalam uji coba LINC, median jeda kompresi dada yang dilaporkan terkait dengan
penyebaran perangkat adalah 36,0 detik (IQR 19,5, 45,5) [75]. Namun, peningkatan
selanjutnya dalam fraksi aliran setelah penyebaran perangkat berarti bahwa fraksi aliran
median selama 10 pertama menit serangan jantung lebih tinggi pada lengan CPR
mekanik (mekanik 0,84 (IQR 0,78, 0,91) vs manual 0,79 (IQR 0,70, 0,86), p<0,001)
Pola serupa diamati dalam percobaan CIRC [17].
Pelatihan berkualitas tinggi yang berfokus pada meminimalkan jeda adalah strategi
yang efektif untuk mengurangi jeda kompresi dada yang terkait dengan pemasangan
perangkat [40,76]. Retribusi dkk. [76] menerapkan sistem yang menggabungkan
pendekatan tim koreografi untuk penerapan perangkat, pembekalan, latihan resusitasi
tiruan, dan adaptasi pada proses penerapan untuk meminimalkan jeda. Implementasi
sistem ini dikaitkan dengan pengurangan jeda median yang signifikan segera sebelum
kompresi dada mekanik pertama (21 (IQR 15, 31) vs 7 (IQR 4, 12), p<0,001) Setiap kali
sistem CPR mekanis digunakan, sistem jaminan kualitas yang hati-hati harus dimulai
untuk memastikan pemasangan perangkat yang optimal dan menghindari gangguan
kompresi dada yang berkepanjangan.

Perkembangan masa depan

Integrasi CPR mekanis dengan teknologi lain, seperti teknologi kompresi-

14
dekompresi aktif atau perangkat ambang impedansi [77], memiliki potensi untuk
berdampak pada kemanjuran perangkat kompresi dada mekanik yang saat ini
dipasarkan. Namun, penelitian terbaru menemukan bahwa integrasi teknologi
kompresidekompresi aktif dengan alat kompresi dada mekanis LUCAS tidak
meningkatkan karbon dioksida end tidal, dibandingkan dengan penggunaan LUCAS
tanpa teknologi tersebut [78].
Mungkin ada kesempatan di masa depan untuk perangkat kompresi dada mekanis
untuk mentitrasi pengiriman kompresi dada ke titik akhir fisiologis, seperti karbon
dioksida end-tidal atau tekanan darah arteri [79].

Conclusions
Penyediaan CPR berkualitas tinggi merupakan faktor kunci yang dapat
dimodifikasi yang terkait dengan kelangsungan hidup dalam serangan jantung.
Perangkat kompresi dada mekanis secara konsisten menghasilkan kompresi dada
berkualitas tinggi, tetapi hal ini tidak memberikan hasil yang lebih baik bagi pasien saat
perangkat digunakan secara rutin di OHCA. Uji coba lebih lanjut diperlukan untuk
mengevaluasi penggunaan rutin perangkat mekanis di IHCA.
Penggunaan perangkat mekanis dalam keadaan tertentu (mis. transportasi
ambulans/helikopter, pPCI) di mana kompresi dada berkualitas tinggi tidak dapat
dilakukan dengan aman dapat menjadi strategi yang masuk akal. Dalam semua situasi di
mana alat mekanis digunakan, dokter harus memastikan bahwa alat tersebut dipasang
dengan gangguan minimal pada pemberian kompresi dada.

Singkatan
CPR:Resusitasi jantung paru; E-CPR: Resusitasi kardiopulmoner ekstrakorporeal;
ED: Unit Gawat Darurat; EMS: Layanan Medis Darurat; IHCA: Henti jantung di rumah
sakit; ILCOR: Komite Penghubung Internasional untuk Resusitasi; OHCA: henti
jantung di luar rumah sakit; pPCI: Intervensi koroner perkutan primer; ROSC:
Kembalinya sirkulasi spontan; uDCD: Donasi yang tidak terkontrol setelah kematian
peredaran darah.

Pendanaan
KC dan JY didukung sebagai peneliti pasca-doktoral NIHR. GDP adalah penyelidik
senior NIHR.

15
Kontribusi penulis
Semua penulis berkontribusi pada perencanaan dan penulisan ulasan. Semua
penulis meninjau dan menyetujui naskah akhir.

Kepentingan yang bersaing

KC dan GDP telah menerima dana NIHR untuk mengevaluasi penggunaan alat
kompresi dada mekanis.

Catatan Penerbit
Springer Nature tetap netral sehubungan dengan klaim yurisdiksi dalam peta yang
diterbitkan dan afiliasi kelembagaan.

Data penulis
1
Warwick Medical School, University of Warwick, Coventry, UK. 2South Central
Ambulance Service NHS Foundation Trust, Bicester, UK. 3University Hospitals
Birmingham NHS Foundation Trust, Birmingham, UK. 4West Midlands Ambulance
Service NHS Foundation Trust, Brierly Hill, UK

16
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