Thais Russomano MD PhD

1
Non-terrestrial Basic Life SupportSimon N Evetts
PhD
CPR in Microgravity Simon N Evetts PhD

• Thais Russomano MD PhD
• John Ernsting MBBS PhD
• Subhajit Sarkar MRCS
• Lisa Evetts RGN
• João Castro MD
• Microgravity Laboratory, PUCRS, Porto Alegre,
  Brazil.
• Human Physiology and Aerospace Medicine Group,
  Kings College London.

2
Introduction

• Non-terrestrial as opposed to microgravity.

3
Introduction

• Non-terrestrial as opposed to microgravity.
• Basic Life Support

4
Introduction

• Non-terrestrial as opposed to microgravity.
• Basic Life Support
• Cardiopulmonary Resuscitation without equipment
  or other resources.

5
Introduction

• Non-terrestrial as opposed to microgravity.
• Basic Life Support
• Cardiopulmonary Resuscitation without equipment
  or other resources.

6
Introduction

• Non-terrestrial as opposed to microgravity.
• Basic Life Support
• Cardiopulmonary Resuscitation without equipment
  or other resources.
• Single rescuer, not multiple care-giver.

7
Introduction

• Non-terrestrial as opposed to microgravity.
• Basic Life Support
• Cardiopulmonary Resuscitation without equipment
  or other resources.
• Single rescuer, not multiple care-giver.
• Emphasis on chest compression, mouth-to-mouth
  ventilation secondary consideration.

8
The Space Environment

• Space exploration is inherently dangerous.

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Significant Space Related Medical Occurrences
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Significant Space Related Medical Occurrences
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Significant Space Related Medical Occurrences
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Significant Space Related Medical Occurrences
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Significant Space Related Medical Occurrences
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Significant Space Related Medical Occurrences
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Significant Space Related Medical Occurrences
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Pulseless victim

• The Space Medicine Configuration Control Board of
  NASA has approved a list of 442 medical
  conditions (the Patient Condition Database) that
  appear possible during long duration spaceflight
  on the ISS.

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Pulseless victim

• The Space Medicine Configuration Control Board of
  NASA has approved a list of 442 medical
  conditions (the Patient Condition Database) that
  appear possible during long duration spaceflight
  on the ISS.
• Of these conditions 106 (24 ) are classified as
  critical requiring use of critical care
  procedures.

18
Pulseless victim

• The Space Medicine Configuration Control Board of
  NASA has approved a list of 442 medical
  conditions (the Patient Condition Database) that
  appear possible during long duration spaceflight
  on the ISS.
• Of these conditions 106 (24 ) are classified as
  critical requiring use of critical care
  procedures.
• including cardiac conditions (e.g. myocardial
  infarction, ventricular fibrillation, ventricular
  tachycardia, and asystole),

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Pulseless victim

• The Space Medicine Configuration Control Board of
  NASA has approved a list of 442 medical
  conditions (the Patient Condition Database) that
  appear possible during long duration spaceflight
  on the ISS.
• Of these conditions 106 (24 ) are classified as
  critical requiring use of critical care
  procedures.
• including cardiac conditions (e.g. myocardial
  infarction, ventricular fibrillation, ventricular
  tachycardia, and asystole),
• and respiratory conditions (e.g. acute airway
  obstruction, laryngeal oedema from anaphylaxis
  and inhalation injuries).

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Pulseless victim

• It has been estimated that the risk to an ISS
  crew member of developing a serious medical
  condition requiring medical evacuation is 6 per
  year,

Johnston, S. L., Marshburn, T. H., and
Lindgren, K., 2000. Predicted Incidence of
Evacuation-Level Illness/Injury During Space
Station Operation. 71st Annual Scientific Meeting
of the Aerospace Medical Association, Houston,
Texas. May 2000.
21
Pulseless victim

• It has been estimated that the risk to an ISS
  crew member of developing a serious medical
  condition requiring medical evacuation is 6 per
  year,
• and 1 per year risk of a life-threatening
  condition.

Johnston, S. L., Marshburn, T. H., and
Lindgren, K., 2000. Predicted Incidence of
Evacuation-Level Illness/Injury During Space
Station Operation. 71st Annual Scientific Meeting
of the Aerospace Medical Association, Houston,
Texas. May 2000.
22
Pulseless victim

• It has been estimated that the risk to an ISS
  crew member of developing a serious medical
  condition requiring medical evacuation is 6 per
  year,
• and 1 per year risk of a life-threatening
  condition.
• A figure of 0.15/yr of CAD related event
  occurring in 35-45 yr old flight personnel has
  been cited.

Johnston, S. L., Marshburn, T. H., and
Lindgren, K., 2000. Predicted Incidence of
Evacuation-Level Illness/Injury During Space
Station Operation. 71st Annual Scientific Meeting
of the Aerospace Medical Association, Houston,
Texas. May 2000.
Ball, C.G., Hamilton, D.R. and Kirkpatrick, A.
2004. Primary prevention approach to mitigating
cardiac risk in astronauts. 75th Annual
Scientific Meeting of the Aerospace Medical
Association, Houston, Anchorage. May 2004.
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Pulseless victim

• As has the figure of 0.06 persons/year with
  regards to the risk of a healthy astronaut
  receiving a significant injury or developing a
  significant medical condition in space.

Mukai, C. and Charles, J. B. 2004.
Psychological and medical challenges for Mars
crew composition as considered against similar
challenges faced by the Lewis and Clark
Expedition. 75th Annual Scientific Meeting of the
Aerospace Medical Association, Houston,
Anchorage. May 2004.
24
Pulseless victim

• As has the figure of 0.06 persons/year with
  regards to the risk of a healthy astronaut
  receiving a significant injury or developing a
  significant medical condition in space.
• The potential for a serious medical incident
  resulting in a pulseless apneic state requiring
  intervention, therefore is real.

Mukai, C. and Charles, J. B. 2004.
Psychological and medical challenges for Mars
crew composition as considered against similar
challenges faced by the Lewis and Clark
Expedition. 75th Annual Scientific Meeting of the
Aerospace Medical Association, Houston,
Anchorage. May 2004.
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Recent and current CPR guidelines (1Gz)

• European Resuscitation Council 1998
• Mouth-to-mouth ventilation requiring tidal
  volumes of 400 600 ml.
• Chest compression depth of 40 50 mm.
• Chest compression rate of 100
  compressions.min-1.

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Recent and current CPR guidelines (1Gz)

• European Resuscitation Council 1998
• Mouth-to-mouth ventilation requiring tidal
  volumes of 400 600 ml.
• Chest compression depth of 40 50 mm.
• Chest compression rate of 100
  compressions.min-1.

• European Resuscitation Council 2001
• Tidal volumes of 700 1000 ml.
• Chest compression depth of 40 50 mm.
• Chest compression rate in excess of 100 min-1.

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1Gz - Earth
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Chest Compression Depth According to Rescuer Body
Weight
Earth Gravity 9.8 m.s-1
Big patient/low compliance chest
Average compliance chest
93 kg person
76 kg person
Min required depth
Force (N)
41 kg person
Small patient/high compliance chest
Compression Depth (cm)
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0.16 Gz - The Moon
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0.16 Gz - The Moon
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Chest Compression Depth According to Rescuer Body
Weight
Lunar Gravity
Average compliance chest
Force (N)
Small patient/high compliance chest
93 kg
76 kg
41 kg
Compression Depth (cm)
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0.38 Gz - Mars
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0.38 Gz - Mars
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0.38 Gz - Mars
Spaceman Spiff wrestles with his Galactic Mk 3
Mars Lander, but what with muscle wastage,
deconditioning and Martian death rays, the
landing wasnt looking too good!!
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0.38 Gz - Mars
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Chest Compression Depth According to Rescuer Body
Weight
Mars Gravity
Average compliance chest
Small patient/high compliance chest
Force (N)
93 kg
76 kg
41 kg
Compression Depth (cm)
37
Mean Mass Rescuer Mean Chest Compliance Patient
76 kg Rescuer
On Earth
Force (N)
On Mars
On Moon
Compression Depth (cm)
38
What can be done about off planet BLS?

• Assisted CPR.
• Using a restraint system.

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What can be done about off planet BLS?

• Assisted CPR.
• Using a restraint system.

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What can be done about off planet BLS?

• Assisted CPR.
• Using a restraint system.
• Using assistance devices.

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What can be done about off planet BLS?

• Assisted CPR.
• Using a restraint system.
• Using assistance devices.
• Multiple person CPR.

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What can be done about off planet BLS?
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What can be done about off planet BLS?
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What can be done about off planet BLS?
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What can be done about off planet BLS?
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What can be done about off planet BLS?
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What can be done about off planet BLS?
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What can be done about off planet BLS?
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What can be done about off planet BLS?
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What can be done about off planet BLS?
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N.B.

• A major limitation of all microgravity BLS
  methods is the lack of back/neck/head support!

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N.B.

• A major limitation of all microgravity BLS
  methods is the lack of back/neck/head support!
• A decision will need to be made as whether a
  potential back/neck injury poses a greater risk
  than not receiving adequate CPR.

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Lets Walk Before We Can Run
(Fly before we bound)

• Can Cardiopulmonary Resuscitation be performed
  by anyone, anywhere when off planet?

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Lets Walk Before We Can Run

• Can Cardiopulmonary Resuscitation be performed
  by anyone, anywhere when off planet?
• Current unrestrained Basic Life Support methods.

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Lets Walk Before We Can Run

• Can Cardiopulmonary Resuscitation be performed
  by anyone, anywhere when off planet?
• Current unrestrained Basic Life Support methods.
• Hand stand method

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Hand Stand method
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Lets Walk Before We Can Run

• Can Cardiopulmonary Resuscitation be performed
  by anyone, anywhere when off planet?
• Current unrestrained Basic Life Support methods.
• Hand stand method
• Reverse bear-hug (Heimlich).

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Reverse Bear-hug (Modified Heimlich).
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Lets Walk Before We Can Run

• Can Cardiopulmonary Resuscitation be performed
  by anyone, anywhere when off planet?
• Current unrestrained Basic Life Support methods.
• Hand stand method
• Reverse bear-hug (Heimlich).
• Limitations.

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Lets Walk Before We Can Run

• Can Cardiopulmonary Resuscitation be performed
  by anyone, anywhere when off planet?
• Current unrestrained Basic Life Support methods.
• Hand stand method
• Reverse bear-hug (Heimlich).
• Limitations.
• Can a method of CPR (with fewer limitations than
  current methods) be performed by anyone, anywhere
  when off planet?

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Kings/PUCRS CPR in Microgravity Study
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ER CPR method chest compression potential.
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ER CPR method chest compression potential.
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ER CPR method chest compression potential.
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ER CPR method chest compression potential.
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ER method ventilation potential.
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ER method ventilation potential.
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Manikin trials.
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Manikin trials.
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Manikin trials.
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Results
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Results
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Results

• P lt 0.05

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Results
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Results
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Discussion

• Reasons for insufficient rate of chest
  compression and greater variation of measures in
  microgravity.

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Discussion

• Reasons for insufficient rate of chest
  compression and greater variation of measures in
  microgravity.
• Novelty of environment.

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Discussion

• Reasons for insufficient rate of chest
  compression and greater variation of measures in
  microgravity.
• Novelty of environment.
• Variable acceleration forces and shortness of
  microgravity exposure.

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Discussion

• Reasons for insufficient rate of chest
  compression and greater variation of measures in
  microgravity.
• Novelty of environment.
• Variable acceleration forces and shortness of
  microgravity exposure.
• Use of 1Gz manikin (albeit adapted for
  microgravity use).

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Discussion

• ER compared to other methods of performing CPR
  in microgravity.

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Discussion

• Jay, Lee, Goldsmith, Battat, Maurer and Suner,
  2003. CPR effectiveness in microgravity
  Comparisons of thee positions and a mechanical
  device. Aviat Space Environ Med, 74(11) 1183-9

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Discussion
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Discussion
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Discussion
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Discussion
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Discussion

• Effectiveness of the ER method for all
  populations will need to be ascertained before it
  can be considered a viable method for universal
  use.

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Discussion

• Effectiveness of the ER method for all
  populations will need to be ascertained before it
  can be considered a viable method for universal
  use.

• Strength
• Anthropometric indices
• Cardiovascular fitness

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Discussion

• Effectiveness of the ER method for all
  populations will need to be ascertained before it
  can be considered a viable method for universal
  use.
• Strength
• Anthropometric indices
• Cardiovascular fitness
• Indications are that ER CPR should be possible
  for almost anyone, anywhere off planet.

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Conclusion

• Non-terrestrial CPR - will one size fit all?

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Conclusion

• Non-terrestrial CPR - will one size fit all?
• Off planet (no artificial gravity).

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Conclusion

• Non-terrestrial CPR - will one size fit all?
• Off planet (no artificial gravity).
• Large habitat, no immediate access to equipment
  and requirement to conduct CPR for mins not secs.

ER CPR
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Conclusion

• Non-terrestrial CPR - will one size fit all?
• Off planet (no artificial gravity).
• Large habitat, no immediate access to equipment
  and requirement to conduct CPR for mins not secs.

ER CPR
Assisted methods

• Large habitat, access to appropriate equipment
  e.g. CPR assist band, compression assist device.

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Conclusion

• Non-terrestrial CPR - will one size fit all?
• Off planet (no artificial gravity).
• Large habitat, no immediate access to equipment
  and requirement to conduct CPR for mins not secs.

ER CPR
Assisted methods

• Large habitat, access to appropriate equipment
  e.g. CPR assist band, compression assist device.

• Small habitat, no immediate access to equipment
  and requirement to conduct CPR for hours not mins.

HS CPR
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Conclusion

• Non-terrestrial CPR - will one size fit all?
• Off planet (no artificial gravity).
• On planet (within habitat).

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Conclusion

• Non-terrestrial CPR - will one size fit all?
• Off planet (no artificial gravity).
• On planet (within habitat).
• Gravity greater than 0.5Gz.

Conventional CPR ?
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Conclusion

• Non-terrestrial CPR - will one size fit all?
• Off planet (no artificial gravity).
• On planet (within habitat).
• Gravity greater than 0.5Gz.

Conventional CPR ?

• Gravity less than 0.5Gz, large habitat, no
  immediate access to equipment.

ER CPR
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Conclusion

• Non-terrestrial CPR - will one size fit all?
• Off planet (no artificial gravity).
• On planet (within habitat).
• Gravity greater than 0.5Gz.

Conventional CPR ?

• Gravity less than 0.5Gz, large habitat, no
  immediate access to equipment.

ER CPR
Assisted methods

• Gravity less than 0.5Gz, large habitat, access
  to appropriate equipment.

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Conclusion

• Non-terrestrial CPR - will one size fit all?
• Off planet (no artificial gravity).
• On planet (within habitat).
• Gravity greater than 0.5Gz.

Conventional CPR ?

• Gravity less than 0.5Gz, large habitat, no
  immediate access to equipment.

ER CPR
Assisted methods

• Gravity less than 0.5Gz, large habitat, access
  to appropriate equipment.

• Gravity less than 0.5Gz, small habitat, no
  immediate access to equipment, CPR required for
  hours not mins.

HS CPR
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Conclusion
Assisted methods
Conventional CPR
HS CPR
ER CPR

• Train in multiple CPR techniques?

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Conclusion
Assisted methods
Conventional CPR
HS CPR
ER CPR

• Train in multiple CPR techniques?
• Mission oriented training.

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Conclusion
Assisted methods
Conventional CPR
HS CPR
ER CPR

• Train in multiple CPR techniques?
• Mission oriented training.
• CPR techniques appropriate for habitat and risks
  according to mission tasks.

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Conclusion
Assisted methods
Conventional CPR
HS CPR
ER CPR

• Train in multiple CPR techniques?
• Mission oriented training.
• CPR techniques appropriate for habitat and risks
  according to mission tasks.
• Foreseeable future will probably require 1 or 2
  methods to be learnt for each mission.

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Thank you for your timeAny questions?
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• E-mail address
• simon.n.evetts_at_kcl.ac.uk