Michigan instruments Hlr User manual

Chapter

6A

The

Michigan

Instruments

Heart-Lung

Resuscitator

(HLR)

Heart-Lung

Resuscitators

(cardiopulmonary

resuscitators)

provide

for

both

artificial

ventilation

via

a

mechanical

respirator,

and

sternal

compression

via

a

pneumatically

powered piston.

Four

models are currently

in

use by Alcor: the Brunswick

HLR

50-90, and

the three variants

of

the Michigan Instruments

Mli-HLR.

This Chapter will cover operating

instructions in detail for the Michigan Instruments High Impulse CPR and the Simultaneous

Compression-Ventilation CPR units.

Heart-lung

resuscitators

are

utilized

in

the

transport

of

cryon1c

suspensiOn

patients

because manual cardiac compression and bag-valve ventilation lead to rapid exhaustion

of

personnel.

The

effectiveness

of

manual

CPR,

which

is

unsatisfactory

to

begin

with,

rapidly

deteriorates

as

operator

fatigue

sets

in.

The

very

long

periods

(4

to

8

hrs.;

perhaps less than 4 hrs.

if

the Patient Ice Bath (PIB) is used)

of

HLR

support

necessary

to reduce patient core temperature

to

a safe level (lO"C) mandates the use

of

a mechanical

device.

.. .

.·

.•

,__

.

....

·-

'::::::-..

Figure

6A-l:

The

Mil

Heart-Lung Resuscitator.

6A-l

' .

..

.

..

As soon as

legal

death

is

pronounced,

start

manual

cardiopu

lmonar

y

resuscitation,

using the bag-valve device to ventilate the patient.

If

the Portable Ice Bath (PIB)

is

not available, start manual

CPR

using

the

Thumper Board

or

just

the

Base

Plate

of

the MII-

HLR unit. As quickly

as

possible, insert the

EGT

A--or

endotracheal--tube.

Once a stable,

patent airway has been secured, initiate mechanical CPR with

the

HLR. Once the

HLR

has

been

installed

and

is

administering

chest

compressions,

connect

the

mask,

endotracheal

tube,

or

esophageal

airway

mask

to

the

ventilator

on

the

HLR

and

discontinue

valve

ventilation.

If

the PIB is available and

at

the bedside, set

up

the

HLR

on it,

but

don't

initiate

mechanical

CPR

until

t

he

patient

is

transferred

into

the

PIB,

so

that

no

delays

in

beginning external cooling occur. (Manual CPR must be carried

out

until mechanical CPR

can begin.)

It

is important to understand that manual CPR is very inefficient compared to machine

CPR

as

delivered by the

MII-HLRs

cu

rrently

in

use by Alcor. Therefore, every

effort

shou

ld

be

made

to

begin

mechanical

CP

R

and

external

cooling

as

rapidly

as

possible

.

Manual

CPR

should be used only

as

the

briefest possible bridge,

just

long enough

to

get

the airway secured

and

to organize

the

transfer

of

the

patient to

the

HLR

and

the PIB.

The

Michiean

Instr

uments HLRs

The

MII-HLRs

are

portable,

non-electrical

,

oxyge

n

-powered

resuscitators.

Using

pneumatic

and

me

chanica

l

means,

they

deliver

compression and artificial ventilation in a coordinated and synchronized manner.

cardiopulmonary

external

cardiac

Three kinds

of

MII-HLR

units

are

in use by Alcor

at

this time: high impulse

CPR

(HI-

CPR), simultaneous compression-ventilation CPR (SCV-CPR), and an older machine from which

these

are

derived. The new machines

are

both very similar

in

appearance, operation, and

application

to

the

patient.

However,

the

prin

ciples

upon

which

they

operate

differ

radically.

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;

Fi&ure 6A-2: Saw-toothed waveform typical

of

conventional manual

and

mechanical

CPR

(Top

)

vs. square waveform delivered

by

H

igh

Impul

se

CPR.

·

6A-2

HI-CPR

-

The

HI-CPR

unit

(Mll

"Thumper" Cardiopulmonary Resuscitator, Model 1005X)

is

designed to shape the wave

form

of

the impulse delivered to

the

patient's

chest during

cardiac compression.

The

normal

wave delivered

by

manual

or

mechanical

CPR

is

saw-

toothed, and results

in

prolonged high

intrathoracic

pressures.

The

HI-CPR

unit

delivers

a square wave with resulting very high acceleration

of

the chest wall.

The

heart

is thus

"selectively compressed"

by

the shock wave.

HI-CPR

has resulted in cardiac

output

two to

three times greater

than

that

achievable

with

conventional closed chest

CPR

and

without

the prolonged high intrathoracic pressure associated with conventional

CPR.

SCV-CPR

-

The

SCV-CPR

unit

(Mil

"Life Aid" Resuscitator, Model 1004X) works

on

a

completely

different

principle

than

HI-CPR.

SCV

-CPR

uses the

entire

chest

and

the

blood

vessels within

it

as a "thoracic pump".

This

is

achieved by raising the pressure inside

the chest to

very

high levels

during

cardiac compression

by

simultaneously compressing the

chest

and

ventilating the

patient

at very high airway pressures (55 to 95

mm

H20

rather

than the

normal

25 to 30 mm H20 used in ventilation).

The

unit

thus

delivers 80 strokes/respirations

per

minute

and

interposes a pause in

ventilation

for

exhalation

after

each

5th compression.

CAUTION:

SCV-CPR

is

contraindicated

in pulmonary disease where

high

airway

pressures

could

result

in

tension

pneumothorax

(such

as

emphysema,

adult

respiratory

distress

syndrome (ARDS),

patients

with

pre-existing

pneumothorax

from

lung-related

causes,

and

patients

with

long

histories

of

tobacco

abuse

in whom

lung

friability

is suspected).

Primary

or

secondary

carcinoma

of

the

lung

is

a

relative

contraindication:

the

patient's

condition

must

be evaluated by ASC

staff

before proceeding to use

SCV-CPR.

The

MII-HLR

HLRs

operate

on

compressed oxygen. In

other

words,

they

derive the

energy

required

to compress the chest

and

ventilate the lungs

from

a high pressure oxygen

supply. While these systems

free

the

operator

from

dependence

on

electric power,

they

have the

drawback

of

requiring large quantities

of

oxygen.

The

two

standard

"E"

cylinders

(20

cubic

feet,

or

570 liters

each

of

02) which come with the

HLR

in the

Alcor

rescue

kit

will provide approximately

20-30

minutes

of

operation

under

normal

circumstances

(no

more

than

20 minutes when using the SCV

-CPR

machine).

For

this reason,

the

£-cylinders

should

be used only where

other

sources

of

compressed oxygen

are

not

available

for

transport

of

the

patient.

It

is

preferable

to

use

a

hospital-provided

oxygen

supply,

either

in

the

form

of

an

H-cylinder

(220 cubic feet,

or

7100 liters)

or

the wall oxygen

outlet,

and

arrangements should be made

in

advance, wherever possible.

Switchover

from

E-cylinders

to

an

H-cylinder

or

hospital wall oxygen

supply

may be

done without

interruption

of

CPR,

since the

MII-HLRs

have a

buffer

tank

and

a special

Oxygen

Input

Hose which holds a

supply

of

oxygen

sufficient

for

4-7

cycles

of

the

HLR.

This

allows

the

device

to

continue

to

operate

during

the

brief

interval

required

for

switchover.

The

Oxygen

Input

Hose

is

equipped

with a

combination

check

valve/quick

disconnect

on

the

end

to be connected to the oxygen supply.

This

valve

prevents

S0-90 psi

gas

from

escaping

from

the Oxygen

Input

Hose

and

buffer

tank

when

the Oxygen

Input

Hose is

disconnected

from

one source

of

oxygen and

switched

over

to

another.

Regardless

of

whether

hospital

wall

oxygen

or

an

H-cylinder

is

to

be

used,

the

6A-3

Respiratory Therapy Department

of

the hospital must be contacted. Arrangements with them

must be made for

the

presence

of

an

H-cylinder

or

the availability

of

an adapter

or

coupler which will allow the

HLR

to tap into the wall oxygen outlet. In the event a wall

outlet

is

used,

a

regulator

will

be

unnecessary,

since

standard

hospital

delivery

pressure

for medical devices is 50

to

90 psi, the operating pressure required

by

the

HLR.

Wall

adapters

are

manufactured

in

a

variety

of

styles,

using

a

wide

range

of

operating principles. It will be necessary to obtain an adapter for

the

system which is

in use in the particular hospital the patient is in, and to make certain that the adapter

does not have any flow restrictions

or

other

devices attached

to

it

(such

as

an oxygen

flowmeter).

CAUTION:

It

is very important

that

the

check

valve/quick disconnect not be removed

from

the

Oxygen

Input

Hose when connecting

the

MII-HLR

to

wall

or

other

oxygen

sources. Removal

of

the

quick disconnect from

the

hose will allow compressed

gas

to

escape from

the

line and

buffer

tank,

resulting in

an

interruption

of

CPR during

switchover.

Circumstances

Of

Use

Of

The

MII-HLR

There may be some situations where the Pffi is not available

or

cannot be used.

Examples

of

such situations are:

a)

sudden emergency in which the Transport Technician

must travel by air with

the

rescue

kit

and the PIB (which,

due

to size, must

be

sent via

airfreight rather than taken as luggage) does not arrive before the emergency begins;

b)

situations

in

which

the

Coordinator

or

Transport

Technician

is

responding

alone

,

or

is

otherwise

unable

to

physically

transport

the

PIB

to

the

patient

(as

in

cases

of

sudden

local emergencies); c) situations

in

which

the

hospital will not allow

it

to be used,

or

where manpower sufficient

to

allow its use is not available.

In such situations,

it

will be necessary

to

apply the

Mll-HLR

to

the

patient and

to

use ice bags for external cooling. Protocols for use

of

the

MII-HLR

both with the PIB and

without

it

are

presented below:

Application

Of

The

HLR

Without

The

PIB

Where possible,

the

HLR

should be applied to the patient with only two interruptions

in manual resuscitation

of

not more than five seconds each. This requires the presence

of

three people on the rescue team,

or

the availability

of

bystanders (hospital personnel) to

provide some help.

After

the

unit

is

in

operation, only one person is required

to

monitor

its performance and insure an adequate airway.

The

HLR

should never be allowed to operate

without the patient being carefully monitored

and

a/tended

by

at least one knowledgeable

individual.

NOTE: Numbers in parentheses

(#}

refer to numbers which appear on the controls

of

the

MII-HLR.

(They

are the same for both models.) Names

of

HLR

controls in bold face

refer to the diagrams

of

the

Mli-HLR

unit, which appear at the beginnings

of

the

sections

on

the individual units.

6A-4

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Functional

Schematic

Of

The

Mil

High Impulse

Heart-Lung

Resuscitator

Figure

6A-4

VELCRO

STRAPS

POCKET

FOR

HLR

BASEPLATE

.. .. .

..... .

...

......

..

·

...

.

.. .. .

.....

.. .. .

.... .. ....

...

.

......

..

...

..

.

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Thumper

Board

6A-5

COLUMN

ARM

ASSEMBL

V

COLUMN

LABEL

(L__-\-_L__J

~

t---

ARM

-------+-~

-

DOME

WITH

LOCKING

KNOB

L,......_:J-----1

MARKING

RINGS

-

--

-

PRESSURE

__

___;;;;;=--{

·.

RELIEF

VALVE -

-

L..--

MASSAGER PAD

-

BREATHING --

-

~-

BASE

PLATE

HOSE--_;.-:::

--

=-=GJl---

NON

REBREATHING VALVE

Mil High Impulse

Heart-Lung Resuscitator

Figure 6A-S Side View

MAXIMUM

VENTILATION

PRESSURE

LIMIT

GAUGE

MAXIMUM

VENTILATION

PRESSURE

LIMIT

KNOB

(•5)-

OXYGEN

INLET

MASSAGER

VENTILATION

SWITCH

(•4)

MASTER

PAD

VENTILATOR

OUTLET

CARDIAC

COMPRESSION

VALVE

(•2)-------..,._

--t--t=--1

COLUMN

LABEL

CARRYING

-----l

HANDLE

COLUMN

LATCH _

_..~

VALVE

('1)

ARM

BASE

PLATE

Figure

6A-6

....__

__

ARM

LOCKING

KNOB

Mil High Impulse

Heart-Lung Resuscitator

Top

View

6A-6

TO

HLR

BASEPLAT

E

Fia:ure

6A-7

PRESSURE

RELIEF

VALVE

CONDUCTIVE

HOSE

Mil

Breathing

Hose

Assembly

High

Impulse CPR

Unit

(Mil

"Thumper" Cardiopulmonary Resuscitator)

.....

-

TO

MASK

OR

-+

ENDOTRACHEAL

TUBE

NON

REBREATHING

VALVE

I )

During

an

interruption

in

CPR

of

no

longer

than

five

seco

nd

s,

elevate

the

patient's

head

and

shoulders

(or

roll

the

patient

onto

his

side)

and

slip

the

Thumper

Board

of

the

'device

under

the

patient

with

the

patient's head

extending

over

the

hump

at

the top

of

the

Thumper

Board

(if

the

Thumper

Board has not already been positioned

under

the

patient

prior

to

the

start

of

manual

CPR).

This

extends

the

head

and

facilitates

opening

of

the airway

and

positioning

of

the pat

ient

for

intubat

ion,

if

it

has not been

carried

out

already. Manual cardiac compression

and

ventilation are then resumed.

If

the

Thumper

Board

is

not

available, place

the

base plate

of

the machine

under

the patient

at

the

start

of

manual CPR.

2) Insert the

MII-HLR

Base

Plate

into the

Thumper

Board.

To

accomplish this,

insert the

tip

of

the Base

Plate

into

the flared opening between the two plastic sheets

and push

it

into place until a positive stop is felt

(the

patient

need not be moved

or

lifted to accomplish this). (Figure

6A-8.)

Figure

6A-8

Figure

6A-9

6A-7

3)

Remove the Arm/Column Assembly

from

th

e storage case.

Holding

th

e column as

shown in Figure

6A-9

(with the

Cardiac

Compression Valve

(#2)

toward

the rescuer), loosen

the Arm

Lockln~

Knob and

sw

ing t

he

ar

m 90°

on

the

column

towards

the

patient's

feet

, then

tighten

th

e Arm

Lockin~

Knob slightly.

..,

•

-

, .

'i

•

Figure

6A-10

Figure

6A-11

4)

Atta

ch the Arm

/C

olumn Assembly to

the

base plate

of

the

HLR,

as shown

in

Figure

6A

-10. A

ccomp

lish this

by

tipping

the

column

slightly

forward,

slipping the "toe"

of

the

column base

in

to

its slot,

then

pulling the

column

back

sharply

until

it

is latched.

5)

Co

nn

ec

t

the

Pressure

Relief

Valve

(l

arge

green

fitting)

on

the

end

of

the

Breathin&

Hose

to the

Ventilator

Outlet

per

Figure

6A-l

1.

Be sure

that

the

end-tidal

C0

2

detector

has

been

installed

on

the

patient

end

of

the

breathing

hose

if

it

ha

s

not

been

previously

installed

between

the

EGT

A

(or

endotracheal

tube)

and

the

bag

-valve

resuscitator.

•

Fieure

6A-12

Figure

6A-13

6A-8

6) Verify that the Mas

ter

Valve

(#1)

is

in

it

s

"OFF'

position, then connect the

inlet end of the Oxygen

Input

Hose to a 50 to 90 psi oxygen source (

If

there is a valve on

the source, open it) and

the

black end (outlet)

of

th

e Oxygen

Input

Hose to the inlet

adjacent to the Master Valve

(#1)

(Figure

6A-J

2).

NOTE: Connection to the oxygen source must be done first. The hose is normally with the

£-cylinder Portable Oxygen

Pack

; if

it

is being used, the hose should be

left

connected.

7) Ve

rify

that

the

Cardiac Compression Valve

(#2)

is in the "OFF" position (Figure

6A-13),

and

that

the

Ventilation

Switch

(#4)

is

in

the "OFF"

position

(Fig

ure

6A-14).

Turn on the Master Valve.

' Q ;

' .

Figure 6A-14 Figure

6A-15

8) Grasp the Piston

ju

st above the Massager Pad and raise the Piston up into

it

s

cylinder until the white stripe

at

the top of

the

Chest Compressor Piston

is

even with the

9

em

marking on

the

clear pl

as

tic Dome. With

th

e

left

hand, suppo

rt

the Arm and hold the

Massager

Pad

in

place. With rig

ht

hand, loosen

the

Arm Locking Clamp. ·

CAUTION:

Wipe

the

patient's

chest

dry

of

any

perspiration,

electrode

pa

s

te

,

antiseptic

s,

melted ice/water,

or

any

other

material which might be present

and

which

might contaminate

the

shaft

of

the

Chest Compressor Piston.

It

is critical

that

the

piston not become wetted

or

contaminated with foreian material,

as

it

may seize-up and

cause

the

HLR

to stop operating.

Particular

care must

be

taken when transporting

the

patient, to avoid wetting

the

piston with water from

the

PIB.

9) During the next manual ventilation cycle, qui

ck

ly swing the Arm

over

the

patient's

chest, while lowering

it

at

th

e same time (Figure 6A- 15). Take care to keep the white

str

ip

even with

the

9

em

mark

ing. Position the Massager

Pad

on the lower half

of

the

pat

ient'

s s

ternum

,

and

with

the

ma

ssage

r's

long

axis

parall

el

to

the

s

tern

um.

Th

e

massager pad must n

ot

extend beyond

the

bottom

of

the patient's sternum (Figure 6A-16).

(Not over

th

e patient's xiphoid process.)

10) Read the first number

operator's

side

of

the

column

. which

Thi

s appears on the Column Label above

th

e arm on the

number

indi

c

at

es

the

recommended

initial

ste

r

nal

6A-9

Figure

6A-16

Figure

6A-17

deflection

setting

,

and

corresponds

to

20%

of

the

patient's

anterior-posterior

(AP)

diameter.

Caution!

The

top is

numbered

from

6

on

top to 3 on the bottom.

The

line below 5 JS

4

1/2,

not

5

1/2.

II)

Raise the Arm back

up

the column until the white stripe at the top

of

the

Chest

Compressor Piston is

at

the

numbered

marking corresponding

with

the

number

read from the

Column Label in Step

10.

(If

the

arm

is between two numbers,

adjust

the Compressor Piston

accordingly.) Lock the Arm into place.

12)

Turn

on

the

Cardiac

Compression Valve. This will initiate chest compressions.

Steps 8 through

12

should be repeatedly practiced so

that

the time required to set

chest

compressor

deflection

does

not

result

in

more

than

a

five

second

interruption

in

CPR.

13)

At

the same time as steps

9-12,

the

Technician

in charge

of

respirations should

attach the

End-

Tidal

C0

2 Detector above

the

endotracheal

tube

or

EGT

A.

14) Verify

that

the maximum ventilation setting is

at

the

normal

pre-setting

of

25-

30

em

of

H2

0.

This maximum pressure limit setting is read continuously·

on

the Maximum

Ventilation Pressure

Limit

Gauge once the

Master

Valve is

turned

on.

If

incorrect,

it

can

be

adjusted

by

rotating

the

Maximum

Ventilation

Pressure

Limit

Control

Knob

(#S)

(clockwise

to

increase,

counterclockwise

to

reduce).

When

the

ventilator

pressure

has

been so set, attach the

end

of

the

Breathing

Hose to the

End-Tidal

C0

2 Detector,

and

turn

the Ventilation

Switch

(#4)

to the

"ON"

position

(Figure

6A-18)

.

15)

The

carotid

arterial

pulse should

be

evaluated

and

verified

as present with each

chest

compression.

A

chest

rise

of

0.6

to

1.9

em,

dependent

upon

patient

size

and

measured

by

piston motion within the Dome, should be visible with

each

ventilation cycle.

End

tidal

C0

2 concentration should be

no

less

than

3%.

(If

it

is below 3%. something is

seriously

wrong.

See

Chapter

5,

Cardiopumonary

Support:

Evaluation

And

Intervention,

especially page

5-5,

for

possible corrective actions.)

6A-10

16)

The

Transport Technician should continue to monitor the unit

for

pr

oper equipment

function and

proper

settings,

and

mon

itor

the patie

nt

for palpable pulse, adequate chest

rise

during

v

entilation

, a

nd

adequate

end-tid

al

CO~.

If

th

e

pul

se is

weak

or

undetectable, ste

rn

al defl

ect

ion can be

in

creased

by

lowenng

the

co

lumn h

eight

.

If

chest

ri

se

is inadequate,

the

maximum ventilation pressure limit should

be

incr

eased

by

tur

ning

the Maximum Ventilation

Pressur

e Limit

Control

Knob

(#5)

clockwise to increase

th

e lim

it

pressure.

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Functional

Schematic

Of

The

Mil

Simultaneous

Compression

-Ventilation

Heart

-

lung

Resu

sci

tator

Figure

6A-19

6A-11

NOTE:

If

the

patient

is

intubated,

increased

ai

rway

resis

t

ance

imposed

by

the

endotracheal tube

may

require a higher

maximum

airway

pressure

in

order to achieve

adequate

chest

rise

.

With

the

proper

installation

of

a

cuffed

endotracheal

tube,

limiting ventilation pressure

may

be

increased as needed, up to 60

em

of

H2o.

NOTE

:

After

an

hour

of

CPR,

it

is

likely

that

the

patient's

chest

will

become

flattened

from

the

sternal

compressions.

In

order

to

maintain

adequate

compression

depth,

it

will

be

necessary to lower the plunger

fu

rther,

by

remeasuring with steps

8-

12 above.

CAUTION:

At

least

one

operator

must

continue

to

monitor

the

operation

of

the

HLR

and

the

responses

of

the

patient

at

all

times while

the

unit is in use.

MAXIMUM

VENTILATION

PRESSURE

LIMIT

GAUGE

MAXIMUM

VENTILATION

PRESSURE

LIMIT KN06

(•5)----.

VENTILATION

SWITCH

(•4)

VENTILATOR

OUTLET

CARDIAC

COMPRESSION

VALVE (•

2)------;:=~f:l:~

=--11

COLUMN

LA6EL

CARRVING

----J

HANDLE

OXVGEN

INLET

MASTER

VALVE

(•t)

ARM

MASSAGER

PAD

6ASE PLATE

COLUMN

LATCH

....___

__

ARM

LOCKING

KNOB

COMPRESSION

FORCE

CONTROL

KNOB

(•4)

Mil

Simultaneous Compression-Ventilation

Heart-lung

Resuscitator

Top View

'

Figure

6A-20

6A-12

COLUMN

ARM

ASSEMBLV

COLUMN

L

ABE

L·

irt---\.---L--4-

ARM

LOCKING

-----4----'•

KNOB

_

l.-~--~

~--CHEST

COMPRESSOR

PISTON

WITH MARKING RINGS

--

-

PRESSURE

--__,;:;;--f:

-

RELIEFVALVE =

L..--

MASSAGER PAD

-

--BASE

PLATE

BREATHING

HOSE------

-=-==~~NON

REBREATHING VALVE

Figure

6A-21

Mil

Simultaneous Com_pression-Ventilation

Heart-Lung Resuscitator

Side View

Simultaneous Compression-

Ventilation

CPR

Unit

(Mil

"Life

Aid"

Resuscitator)

I)

During

an

interruption

in

CPR

of

no

longer

than

five

seconds,

elevate

the

patient's

head

and

shoulders

(or

roll

the

patient

onto

his

side)

and

slip

the

Thumper

Board

of

the

device

under

the

patient

with

the

patient's

head

extending

over

the

hump

at

the

top

of

the

Thumper

Board

(if

the

Thumper

Board

has

not

already

been

positioned

under

the

patient

prior

to

the

start

of

manual

CPR).

This

extends

the

head

and

facilitates

opening

of

the

airway

and

positioning

of

the

patient

for

intubation,

if

it

has

not

been

carried

out

already. Manual

cardiac

compression

and

ventilation

are

then

resumed.

If

the

Thumper

Board

is

not

available, place

the

base plate

of

the

machine

under

the

patient

at

the

start

of

manual

CPR

.

2) Insert

the

MII-HLR

Base

Plate

into

the

Thumper

Board.

To

accomplish this,

insert

the

tip

of

the

Base

Plate

into

the

flared

opening

between

the

two plastic sheets

and

push

it

into place

until

a positive stop

is

felt (the

patient

need

not

be moved

or

lifted to accomplish this).

(Figure

6A-22.)

3)

Remove

the

Arm/Column

Assembly

from

the

storage case.

Holding

the

column

as

shown

in

Figure

6A-23

(with

the

Cardiac

Compression Valve

(#2)

toward

the

rescuer), loosen

the Arm

Locking

Knob

and

swing

the

arm

90"

on

the

column

towards

the

patient's

feet,

then

tighten

the

Arm

Locking

Knob slightly.

4)

Attach

the

Arm/Column

Assembly to

the

base plate

of

the

HLR,

as

shown

in

Figure

6A-24. Accomplish this by

tipping

the

column

slightly

forward,

slipping

the

"toe"

of

the

column

base

into

its slot,

then

pulling

the

column

back

sharply

until

it

is latched.

6A-13

Figure

6A-22

,

\j

·

Figure

6A-24

---

•

Figure

6A-23

Figure

6A-25

••

"'

5)

Connect

the

Pressure

Relief

Valve

(

larg

e

green

fitting)

on

the

end

of

the

Br

eat

hing Hose to the

Ventilator

Outlet

per

Figure 6A-25.

6)

Verify

that

the Master Valve

(#I)

is

in

its "OFF" position,

that

the Cardiac

Compression Valve

(#2)

is "OFF",

that

the Ventilation

Switch

(#4)

is

"OFF',

and

that

the

Compression Force Control Knob

(#3)

is

off

(fully counterclockwise).

Then

connect the

inlet

end

of

the Oxygen

Input

Hose to a 50 to 90 psi oxygen source (If the source has a

valve,

turn

it

on)

and

the

black

end

(o

utlet)

of

the

Oxygen

Input

Hose

to

the

inlet

adjacent

to the Master Valve

(#I)

(Figure 6A-26).

6A-14

Figure

6A-26

Figure

6A-27

NOTE: Connection to the oxygen source must

be

done first. The hose is normally with

the

E-cylinder

Portable

Oxygen

Pack;

if

it

is

being

used

,

the

hose

should

be

left

connected.

7)

Grasp

the

Piston

just

above the Massager

Pad

cylinder until the bottom marking ring

in

the piston is

cylinder. With the

left

hand,

support

the Arm

and

hold

right hand, loosen the Arm Locking Clamp.

and

raise

the

Piston

up

into

its

just

about

to

disappear

into the

the Massager

Pad

in

place. With

CAUTION:

Wipe

the

patient's

chest

dry

of

any

perspiration,

electrode

paste,

antiseptics,

melted

ice/water,

or

any

other

material

present which

might

contaminate

the

shaft

of

the

Chest Compressor Piston.

It

is

critical

that

the

piston

not

become

wetted

or

contaminated

with foreign

material,

as

it

may

seize-up

and

cause

the

HLR

to

stop operating.

Particular

care

must be

taken

when

transporting

the

patient

to

avoid

wettlng

the

piston with

water

from

the

PIB

.

I

'

.•..

:.

. .

.··.

Figure

6A-28

/

~

··

~~

·

r\

•

6A-15

·.

•

< ..

--

··

-~

·

·- .

~

.

_,f

, . .

'<

·.:·

.

·:

c;·

.

•

Ci

• • • .

"'<

~.

~.,

....

·-

..

. .

8) During the next manual ventilation cycle, quickly swing the Arm over

the

patient's

chest, while lowering

it

at

the same time (Figure

6A-27).

Take care to keep the bottom

marking ring just visible. Position

the

Massager Pad on the lower

half

of

the

patient's

sternum, and with the massager's long axis parallel to the sternum.

The

massager pad must

not extend beyond the bottom

of

the patient's sternum

(Figure

6A-

28). (Not over the

patient's xiphoid process.) Lock arm

in

place.

Figure

6A-29

Figure

6A-30

6A-16

9)

Turn

the Master Valve

(#l)

"ON",

and

confirm

that the force

on

the Compres.sor

Force Gauge

is

zero; then

turn

the

Cardiac

Compression Valve

(#2)

to "ON" (Figure 6A-31).

The

ventilator will begin to cycle with each compression once

the

Master Valve is

turned on.

10) Adult Setting: Gradually

turn

the Compression Force

Control

Knob

(#3)

(Figure 6A-

30) clockwise until the piston depresses the

sternum

20-25%

of

the chest

A-P

diameter.

With

full-grown

adults, displacement should be approximately

It"

to

2".

In

general,

this will

occur

when the Compressor Force

Gauge

("Force

On

Chest")

indicates 60 to 80

pounds

of

force.

Since displacement is

the

proper

criterion

for

setting the force, Marking Rings

on

the Piston are provided to facilitate this adjustment.

The

wide rings are

It"

apart;

the displacement

of

an

adult

chest should be approximately

the

space between two

of

these

wide

rings.

Additional

rings

are

provided

at

t"

intervals

to

aid

in

establishing

incrementally smaller

or

greater degrees

of

compression.

ARM LOCKING

CLAMP

COLUMN

--LABEL

READ

DEFELECT

ION

t---

BASE PLATE

Figure

6A-31

NOTE: Some later units have a Column Label and color coded Marking Rings on the Piston

which can

be

used

to

determine the correct chest deflection. The procedure for use

of

this feature is as follows:

a) Allow the

arm

of

the

HLR

to slide down the column until

the

bottom Marking Ring on

the Piston is

just

emerging

from

the cylinder which houses the Piston.

b)

Increase

Compressor

Force

Control

until

the

piston

matches

the

lowest

complete

picture on the column above the

arm

clamp (Figure 6A-31).

Steps 7 through 10 should be repeatedly

set chest compressor deflection does not result

CPR.

practiced

.

m more so

that

the

than

a five total time required to

second interruption in

II)

At

the same time as steps

8-10,

the Technician

in

charge

of

respirations should

attach the

End-Tidal

C0

2 Detector above the endotracheal tube

or

EGTA.

6A-17

..

,

'

.

.·

Figure

6A-32

12)

Verify

that

the

maximum ventilation se

tting

is

at

the

normal

pre-set

ting

of

60

em

of

H2

0.

This

maximum

pressure

limit

setting is

read

continuously on

the

Ventilation

Pressure Gauge

once

the

Master Valve is

turned

on.

If

incorrect,

it

can

be

adjusted

by

rotating

the

Ventilation

Pressure

Control

Knob

(

#5)

(clockwise

to

increase

,

counterclockwise to reduce). When

the

ventilator pressure has

been

so set,

attach

the

end

of

the

breathing

hose

to

the

endotracheal

tube

or

EGTA

and

turn

the

Ventilation

Switch

(#4)

to

the

"ON" position (Figure

6A-32)

.

13) Carotid

arterial

pulse should be evaluated

and

be

determined

to

be

present

with

each

chest

compression.

End

tidal co2

concentration

should

be

no

less

than

3%.

(If

it

is

below

3%,

something

is

seriously

wrong.

·

See

Chapter

5,

Cardiopulmonary

Support:

Evaluation And

Intervention,

especially

page

5-5,

for

possible corrective actions.)

14)

The

Transport

Technician

should

continue

to

monitor

the

unit

for

proper

equipment

function

and

proper

settings, and monitor

the

patient

for

palpable pulse,

adequate

chest

rise

during

ventilation,

and

adequate

end-tidal

C0

2.

If

the

pulse

is

weak

or

undetectable,

sternal

deflection

can

be

increased

by

lowering

the

column

height.

If

cardiac

output

is still

deemed

to be

inadequate

,

the

maximum

ventilation pressure limit

should be increased

by

turning

the

Ventilation

Pressure

Control

Knob

(#5)

clockwise to

increase

the

limit

pressure to

95

em

H20 (the

unmarked

upper

limit

of

the

red zone on the

gauge).

NOTE

:

After

an

hour

of

CPR,

it

is

likely

that

the

patient

's

chest

will

be

c

ome

flattened

from

the

sternal

compressions.

In

order

to

maintain

adequate

compression

depth,

it

will

be necessary to lower the plunger further,

by

remeasuring with steps

7-

10

above.

CAUTION: At

least

one

operator

must

continue

to

monitor

the

operation

of

the

HLR

and

the

responses

of

the

patient

at

all

times while

the

unit

is

in

use.

6A-18

Application

Of

The

MII-HLRs

With

the

PIB

The

procedure

for

application

of

the

MII-HLRs

using

the

PIB

differs

from

the

preceding protocols in the following ways (this presumes the PIB is

already

assembled):

1. Have

the

Backboard

in place

before

the

pat

i

ent

is

put

into the PIB.

2)

Slide the

Base

Plate

into the

cutout

provided in

the

side

of

the

Portable

Ice

Bath

(also

before

the

patient

is

put

into

the

bath,

if

possibl

e.)

3)

Attach the Column Arm to the Base

Plate

of

the

MII-HLR

per the preceding

instructions.

4)

Loosen the Arm Locking

Clamp

and

swing the Arm 90" away

from

the baseplate.

5)

Position the

MII-HLR

in

the PIB

frame

underneath

the

tank

so

that

the Piston will

not

be

too

far

up

on

the

patient's

chest

when

he is placed in the PIB.

.

6)

Connect the

Breathing

Hose

and

the Oxygen Supply Hose

per

instructions

above

.

7)

Interrupt

manual

CPR

and

lift/lower

the patient into the PIB.

The

patient will

probably have to be positioned as close to the Head

of

the PIB as possible.

8)

Grasp

the Piston

just

above the Massager

Pad

and

raise

it

up

into

its cylinder.

Holding

it

there,

loosen

the

Arm Locking Clamp

and

swing the

arm

over

towards the

patient's chest, while lowering it

at

the same time.

CVLINDER

PRESSURE

GAUGE

CARRVING

HANDLE

------CVLINDER

VALVE

~t-

--"T"-HANDLE

REGULATOR

-t---

TWO

WAV

SHUT-OFF--+--

t---

E

CVL

INDER

CONNECTOR

OXVGEN

INPUT~

LINE

---t--CARRVING

HANDLE

---SUPPORTS

Portable

Oxygen

Pack

Figure

6A-33

6A-19

Follow the rest

of

the

appropriate protocol (above) to install the

MII-HLR

and begin

mechanical CPR.

9)

If

possible, start external cooling

of

the patient by packing him

in

crushed ice

at

the

same time that application

of

the

HLR

is

being undertaken.

Be

sure not to place

any ice in

the

PIB be/ore placing the patient in it,

as

this will make proper application

of

the

HLR

impossible.

10) Stow the Portable Oxygen

Pack

on the PIB

and

transfer any IV bottles

to

the PIB ·

IV

pole.

The

patient

can

now be transported from the home, hospital,

or

nursing home.

Input Oxygen Pressure

When

used

with

the

portable

Oxygen

Pack

containing

two

£-cylinders,

the

oxygen

pressure

delivered

to

the

unit

is

preset

at

90

psi.

When

using

an

alternate

oxygen

source, such as hospital wall oxygen

or

a larger oxygen cylinder

and

regulator, the

input

pressure must be

in

the 50 to 90 psi range. This pressure assures delivery

of

up to

95

em

H20 pressure during ventilation

and

at least

125

pounds

of

compressor thrust.

If

the

pressure in

the

tanks falls below 40 psi,

the

maximum compressor thrust may decrease to

below

100

pounds

per

compression and may result

in

inadequate sternal excursion in larger

individuals.

If

the pressure drops further, the compression rate will decrease and the

unit will eventually fail to cycle. Thus,

it

is

imperative that a minimum input pressure

of

at

least

40

psi

be

maintained

at

the

oxygen

source

for

effective,

uninterrupted

resuscitation.

NOTE: The High Impulse

HLR

is very sensltlve to the

oxygen

input pressure. A higher

"specific impulse"

and

thus more

efficient

CPR can be achieved

by

operating the unit

at the high

end

of

the

50-90

psi range (i.e., at 90 psi).

CAUTION: Do

not

connect

the

HLR

to

any

oxygen source with a pressure

greater

than

110

psi,

or

the

unit

may be seriously damaged

and

promptly rendered inoperative.

Portable Oxygen Pack

The Portable Oxygen

Pack

is designed to hold two "E" sized oxygen cylinders, each

of

which

contains

approximately

570

liters

of

oxygen

(at

I

atm.,

70.F)

.

In

typical

adult

use, this will power

the

HLR

for

about 30 minutes (perhaps

as

much

as

10

MINUTES

LESS

for

the SCV

-CPR

unit).

The

Portable Oxygen

Pack

features a

pre-set

and locked regulator which

reduces

the

E-cylinder

pressure from 2300 psi and delivers

it

to

the

Oxygen

Input

Line at

90

psi,

±5%.

A check valve is included in each cylinder circuit, making

it

possible

to

remove and replace an

empty

cylinder while using oxygen from another cylinder.

Quick "in-and-out" cylinder exchange can be carried

out

with the Portable Oxygen

Pack

in either the horizontal

or

vertical position.

Additional cylinder sealing washers are stored in the middle orange

drawer

of

the

Emergency Medications Kit (Gray Box).

CAUTION: While oxygen

Is

Itself a non-flammable gas, It

can

greatly accelerate

the

rate

of

combustion

or

the

likelihood

of

ignition

of

other

materials.

Dramatically

increased rates

of

burning and burning

of

materials not normally

thought

of

as

being

6A-20

Michigan Instruments HLR User manual

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