Non-terrestrial Basic Life Support Simon N Evetts 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, King’s 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.

9. Year Mission Nation Event Significant Space Related Medical Occurrences 1967 Soyuz 1 USSR Spacecraft crashed – 1 death 1967 Apollo 1 US Command module fire – 3 deaths 1969 Apollo 11 US Type 1 decompression sickness 1970 Apollo 13 US Urinary tract infection 1971 Soyuz 11 USSR Depressurization – 3 deaths 1971 Apollo 15 US Arrhythmia during lunar EVA 1975 Apollo 18 US Nitrogen tetroxide pneumonitis 1985 Salyut 7 USSR Prostatis and sepsis 1985 Salyut 7 USSR Hypothermia 1986 Challenger US Spacecraft exploded - 7 deaths 1987 Mir Russia Arrhythmia requiring evacuation 1997 Mir Russia Depressurization after collision 1997 Mir Russia Toxic atmosphere after fire 2003 Columbia US Spacecraft disintegrated – 7 deaths

10. Year Mission Nation Event Significant Space Related Medical Occurrences 1967 Soyuz 1 USSR Spacecraft crashed – 1 death 1967 Apollo 1 US Command module fire – 3 deaths 1969 Apollo 11 US Type 1 decompression sickness 1970 Apollo 13 US Urinary tract infection 1971 Soyuz 11 USSR Depressurization – 3 deaths 1971 Apollo 15 US Arrhythmia during lunar EVA 1975 Apollo 18 US Nitrogen tetroxide pneumonitis 1985 Salyut 7 USSR Prostatis and sepsis 1985 Salyut 7 USSR Hypothermia 1986 Challenger US Spacecraft exploded - 7 deaths 1987 Mir Russia Arrhythmia requiring evacuation 1997 Mir Russia Depressurization after collision 1997 Mir Russia Toxic atmosphere after fire 2003 Columbia US Spacecraft disintegrated – 7 deaths

11. Year Mission Nation Event Significant Space Related Medical Occurrences 1967 Soyuz 1 USSR Spacecraft crashed – 1 death 1967 Apollo 1 US Command module fire – 3 deaths 1969 Apollo 11 US Type 1 decompression sickness 1970 Apollo 13 US Urinary tract infection 1971 Soyuz 11 USSR Depressurization – 3 deaths 1971 Apollo 15 US Arrhythmia during lunar EVA 1975 Apollo 18 US Nitrogen tetroxide pneumonitis 1985 Salyut 7 USSR Prostatis and sepsis 1985 Salyut 7 USSR Hypothermia 1986 Challenger US Spacecraft exploded - 7 deaths 1987 Mir Russia Arrhythmia requiring evacuation 1997 Mir Russia Depressurization after collision 1997 Mir Russia Toxic atmosphere after fire 2003 Columbia US Spacecraft disintegrated – 7 deaths

12. Year Mission Nation Event Significant Space Related Medical Occurrences 1967 Soyuz 1 USSR Spacecraft crashed – 1 death 1967 Apollo 1 US Command module fire – 3 deaths 1969 Apollo 11 US Type 1 decompression sickness 1970 Apollo 13 US Urinary tract infection 1971 Soyuz 11 USSR Depressurization – 3 deaths 1971 Apollo 15 US Arrhythmia during lunar EVA 1975 Apollo 18 US Nitrogen tetroxide pneumonitis 1985 Salyut 7 USSR Prostatis and sepsis 1985 Salyut 7 USSR Hypothermia 1986 Challenger US Spacecraft exploded - 7 deaths 1987 Mir Russia Arrhythmia requiring evacuation 1997 Mir Russia Depressurization after collision 1997 Mir Russia Toxic atmosphere after fire 2003 Columbia US Spacecraft disintegrated – 7 deaths

13. Year Mission Nation Event Significant Space Related Medical Occurrences 1967 Soyuz 1 USSR Spacecraft crashed – 1 death 1967 Apollo 1 US Command module fire – 3 deaths 1969 Apollo 11 US Type 1 decompression sickness 1970 Apollo 13 US Urinary tract infection 1971 Soyuz 11 USSR Depressurization – 3 deaths 1971 Apollo 15 US Arrhythmia during lunar EVA 1975 Apollo 18 US Nitrogen tetroxide pneumonitis 1985 Salyut 7 USSR Prostatis and sepsis 1985 Salyut 7 USSR Hypothermia 1986 Challenger US Spacecraft exploded - 7 deaths 1987 Mir Russia Arrhythmia requiring evacuation 1997 Mir Russia Depressurization after collision 1997 Mir Russia Toxic atmosphere after fire 2003 Columbia US Spacecraft disintegrated – 7 deaths

14. Year Mission Nation Event Significant Space Related Medical Occurrences 1967 Soyuz 1 USSR Spacecraft crashed – 1 death 1967 Apollo 1 US Command module fire – 3 deaths 1969 Apollo 11 US Type 1 decompression sickness 1970 Apollo 13 US Urinary tract infection 1971 Soyuz 11 USSR Depressurization – 3 deaths 1971 Apollo 15 US Arrhythmia during lunar EVA 1975 Apollo 18 US Nitrogen tetroxide pneumonitis 1985 Salyut 7 USSR Prostatis and sepsis 1985 Salyut 7 USSR Hypothermia 1986 Challenger US Spacecraft exploded - 7 deaths 1987 Mir Russia Arrhythmia requiring evacuation 1997 Mir Russia Depressurization after collision 1997 Mir Russia Toxic atmosphere after fire 2003 Columbia US Spacecraft disintegrated – 7 deaths

15. Year Mission Nation Event Significant Space Related Medical Occurrences 1967 Soyuz 1 USSR Spacecraft crashed – 1 death 1967 Apollo 1 US Command module fire – 3 deaths 1969 Apollo 11 US Type 1 decompression sickness 1970 Apollo 13 US Urinary tract infection 1971 Soyuz 11 USSR Depressurization – 3 deaths 1971 Apollo 15 US Arrhythmia during lunar EVA 1975 Apollo 18 US Nitrogen tetroxide pneumonitis 1985 Salyut 7 USSR Prostatis and sepsis 1985 Salyut 7 USSR Hypothermia 1986 Challenger US Spacecraft exploded - 7 deaths 1987 Mir Russia Arrhythmia requiring evacuation 1997 Mir Russia Depressurization after collision 1997 Mir Russia Toxic atmosphere after fire 2003 Columbia US Spacecraft disintegrated – 7 deaths

16. 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.

17. 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),

19. 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).

20. 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.

23. 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.

25. 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.

26. 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.

27. +1Gz - Earth

28. 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)

29. +0.16 Gz - The Moon

30. +0.16 Gz - The Moon

31. 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)

32. +0.38 Gz - Mars

33. +0.38 Gz - Mars

34. +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 wasn’t looking too good!!

35. +0.38 Gz - Mars

36. 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.

39. What can be done about off planet BLS? • Assisted CPR. • Using a restraint system.

40. What can be done about off planet BLS? • Assisted CPR. • Using a restraint system. • Using assistance devices.

41. What can be done about off planet BLS? • Assisted CPR. • Using a restraint system. • Using assistance devices. • Multiple person CPR.

42. Technique of compression Equipment Description What can be done about off planet BLS? Standard Nil Normal terrestrial CPR method. Heimlich CPR Method Nil Rescuer behind patient, chest compression by elbow flexion. Abdominal compression Nil Abdomen compressed to utilize pure abdominal pump mechanism. Mass momentum method Nil Dropping from a height provides potential energy. The force may be applied by the hands or the feet.

43. Technique of compression Equipment Description What can be done about off planet BLS? Standard Nil Normal terrestrial CPR method. Heimlich CPR Method Nil Rescuer behind patient, chest compression by elbow flexion. Abdominal compression Nil Abdomen compressed to utilize pure abdominal pump mechanism. Mass momentum method Nil Dropping from a height provides potential energy. The force may be applied by the hands or the feet.

44. Technique of compression Equipment Description What can be done about off planet BLS? Standard Nil Normal terrestrial CPR method. Heimlich CPR Method (RBH) Nil Rescuer behind patient, chest compression by elbow flexion. Abdominal compression Nil Abdomen compressed to utilize pure abdominal pump mechanism. Mass momentum method Nil Dropping from a height provides potential energy. The force may be applied by the hands or the feet.

45. Technique of compression Equipment Description What can be done about off planet BLS? Standard Nil Normal terrestrial CPR method. Heimlich CPR Method Nil Rescuer behind patient, chest compression by elbow flexion. Abdominal compression Nil Abdomen compressed to utilize pure abdominal pump mechanism. Mass momentum method Nil Dropping from a height provides potential energy. The force may be applied by the hands or the feet.

46. Technique of compression Equipment Description What can be done about off planet BLS? Standard Nil Normal terrestrial CPR method. Heimlich CPR Method Nil Rescuer behind patient, chest compression by elbow flexion. Abdominal compression Nil Abdomen compressed to utilize pure abdominal pump mechanism. Mass momentum method Nil Dropping from a height provides potential energy. The force may be applied by the hands or the feet.

47. ER Method Nil Patient thorax encircled by rescuer legs to enable additional force application through hip/knee flexion. What can be done about off planet BLS? Added mass Weights Standard method with added masses (e.g. on a weight belt). Assist device Elastic compression assist device Large ‘elastic band’ placed around the patient’s back and over the rescuer’s shoulders/back provides additional force. Modified Hand-stand Method (HS) Opposing ‘walls’ approx 2m apart. Modification of the microgravity hand-stand method.

48. ER Method Nil Patient thorax encircled by rescuer legs to enable additional force application through hip/knee flexion What can be done about off planet BLS? Added mass Weights Standard method with added masses (e.g. on a weight belt). Assist device Elastic compression assist device Large ‘elastic band’ placed around the patient’s back and over the rescuer’s shoulders/back provides additional force. Modified Hand-stand Method (HS) Opposing ‘walls’ approx 2m apart. Modification of the microgravity hand-stand method.

49. ER Method Nil Patient thorax encircled by rescuer legs to enable additional force application through hip/knee flexion What can be done about off planet BLS? Added mass Weights Standard method with added masses (e.g. on a weight belt). Assist device Elastic compression assist device Large ‘elastic band’ placed around the patient’s back and over the rescuer’s shoulders/back provides additional force. Modified Hand-stand Method (HS) Opposing ‘walls’ approx 2m apart. Modification of the microgravity hand-stand method.

50. ER Method Nil Patient thorax encircled by rescuer legs to enable additional force application through hip/knee flexion What can be done about off planet BLS? Added mass Weights Standard method with added masses (e.g. on a weight belt). Assist device Elastic compression assist device Large ‘elastic band’ placed around the patient’s back and over the rescuer’s shoulders/back provides additional force. Modified Hand-stand Method (HS) Opposing ‘walls’ approx 2m apart. Modification of the microgravity hand-stand method.