Two-thumb technique is superior to two-finger technique during lone rescuer infant manikin CPR

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Chest compressions in newborn infants: a scoping review

AIM

The International Liaison Committee on Resuscitation Neonatal Life Support Task Force undertook a scoping review of the literature to identify evidence relating to neonatal cardiopulmonary resuscitation.

METHODS

MEDLINE complete, EMBASE and Cochrane database of Systematic reviews were searched from inception to November 2021. Two authors screened titles and abstracts and full text reviewed. Studies were eligible for inclusion if they were peer-reviewed and assessed one of five aspects of chest compression in the newborn infant including: (1) heart rate thresholds to start chest compressions (CC), (2) compression to ventilation ratio (C:V ratio), (3) CC technique, (4) oxygen use during CC and 5) feedback devices to optimise CC.

RESULTS

Seventy-four studies were included (n=46 simulation, n=24 animal and n=4 clinical studies); 22/74 were related to compression to ventilation ratios, 29/74 examined optimal technique to perform CC, 7/74 examined oxygen delivery and 15/74 described feedback devices during neonatal CC.

CONCLUSION

There were very few clinical studies and mostly manikin and animal studies. The findings either reinforced or were insufficient to change previous recommendations which included to start CC if heart rate remains <60/min despite adequate ventilation, using a 3:1 C:V ratio, the two-thumb encircling technique and 100% oxygen during CC.

The effect of hand position on chest compression quality during CPR in young children: Findings from the Videography in Pediatric Resuscitation (VIPER) collaborative

OBJECTIVE

To determine the effect of hand position on chest compression (CC) quality during CPR in young children.

METHODS

Prospective observational exploratory study. Patients < 8 years receiving CC for > 2 minutes were enrolled. Data was collected from video review and CC monitor device and analyzed in 'CC segments' (periods of CC by individual providers). Four techniques were compared: two thumbs (2 T), hands encircling the chest; two fingers (2F) on the sternum; one hand on sternum (1H); two hands on sternum (2H). Univariate analysis of CC rate and depth between hand positions was performed through nonparametric testing, stratified by age category.

RESULTS

47 patients received 824 minutes of CC. Among 270 CC segments in infants < 1 yo, 2 T was used in 27%; 2F 3%; 1H 18%; 2H 26%. Among 189 CC segments in children aged 1 to 8 yo, 1H was used in 26%; 2H 74%. Across all segments, median CC rate was 117 cpm (IQR 110-125). Median depth was 2.92 cm (IQR 2.44 - 4.04) in infants < 1 yo, 3.56 cm (IQR 2.92 - 4.14) in children 1 to 8 yo. 1H achieved greater depth than 2 T in infants (p < 0.01), and 2H achieved greater depth than 1H in children > 1 (p < 0.001).

CONCLUSIONS

In infants, 1H resulted in greater CC depth than 2 T. In children 1 to 8 yo, 2H resulted in greater depth than 1H.. These data suggest that different hand position during CPR in young children from what is currently recommended may result in better CPR quality.

Four Different Finger Positions and Their Effects on Hemodynamic Changes during Chest Compression in Asphyxiated Neonatal Piglets

Background: The Neonatal Life Support Consensus on Science With Treatment Recommendations states that chest compressions (CC) be performed preferably with the 2-thumb encircling technique. The aim of this study was to compare the hemodynamic effects of four different finger positions during CC in a piglet model of neonatal asphyxia. Methods: Seven asphyxiated post-transitional piglets were randomized to CC with 2-thumb-, 2-finger-, knocking-fingers-, and over-the-head 2-thumb-techniques for one minute at each technique. CC superimposed with sustained inflations were performed manually. Results: Seven newborn piglets (age 0-4 days, weight 2.0-2.1 kg) were included in the study. The mean (SD) slope rise of carotid blood flow was significantly higher with the 2-thumb-technique and over-the-head 2-thumb-technique (118 (45) mL/min/s and 121 (46) mL/min/s, respectively) compared to the 2-finger-technique and knocking-finger-technique (75 (48) mL/min/s and 71 (67) mL/min/s, respectively) (p < 0.001). The mean (SD) dp/dt_min (as an expression of left ventricular function) was significantly lower with the 2-thumb-technique, with -1052 (369) mmHg/s, compared to -568 (229) mmHg/s and -578(180) mmHg/s (both p = 0.012) with the 2-finger-technique and knocking-finger-technique, respectively. Conclusion: The 2-thumb-technique and the over-the-head 2-thumb-technique resulted in improved slope rises of carotid blood flow and dp/dtmin during chest compression.

Comparison of two infant cardiopulmonary resuscitation techniques explained by phone in a non-health professionals' population: Two-thumbs encircling hand technique vs. two-fingers technique, a randomised crossover study in a simulation environment

BACKGROUND

Paediatric out-of-hospital cardiac arrest (OHCA) is the reason for an emergency call in approximately 8/100,000 person-years. Improvement of OHCA resuscitation needs a quality chain of survival and a rapid start of resuscitation. The aim of this study was to compare the efficacy of two resuscitation techniques provided on a mannequin, the two-fingers technique (TFT) and the two-thumbs encircling hand technique (TTHT), explained by a trained emergency call responder on the phone in a population of non-health professionals.

METHODS

We conducted a randomised crossover study in the simulation lab of a University Hospital. The participants included in the study were non-health professional volunteers of legal age. The participants were assigned (1:1 ratio) to two groups: group A: TFT then TTHT, group B: TTHT then TFT. Scenario and techniques were discovered during the evaluation.

RESULTS

Thirty-five volunteers were randomised before the sessions and 33 ultimately came to the simulation lab. We found a better median QCPR global score during TTHT sessions than during TFT sessions (74 vs. 59, P = 0.046). Linear mixed models showed that the TTHT method was the only variable associated with a better QCPR global score [model 1: β = 14.3; 95% confidence interval (CI), 2.4-26.2; model 2: β = 14.5; 95% CI, 2.5-26.6].

CONCLUSION

Our study showed the superiority of TTHT for infant CPR performed by non-health professionals when an emergency call responder advised them over the phone. It seemed to be the best technique for a solo rescuer regardless of previous training.

Chest compressions and medications during neonatal resuscitation

Prolonged resuscitation in neonates, although quite rare, may occur in response to profound intractable bradycardia as a result of asphyxia. In these instances, chest compressions and medications may be necessary to facilitate return of spontaneous circulation. While performing chest compressions, the two thumb method is preferred over the two finger technique, although several newer approaches are under investigation. While the ideal compression to ventilation ratio is still uncertain, a 3:1 ratio remains the recommendation by the Neonatal Resuscitation Program. Use of feedback mechanisms to optimize neonatal cardiopulmonary resuscitation (CPR) show promise and are currently under investigation. While performing optimal cardiac compressions to pump blood, use of medications to restore spontaneous circulation will likely be necessary. Current recommendations are that epinephrine, an endogenous catecholamine be used preferably intravenously or by intraosseous route, with the dose repeated every 3-5 minutes until return of spontaneous circulation. Finally, while the need for volume replacement is rare, it may be considered in instances of acute blood loss or poor response to resuscitation.

New chest compression method in infant resuscitation: Cross thumb technique

Background

The two-thumb encircling technique (2TT) is superior to the two-finger technique (2FT) in infant cardiopulmonary resuscitation (CPR), but there are difficulties in providing ventilation as soon as possible. We modified the 2TT to the cross-thumb technique (CTT) to maintain good CPR performance at the same position as 2FT. We aimed to compare the quality of chest compression and brief hands-off times in 2FT, 2TT, and CTT by a single rescuer using an infant CPR manikin model.

Methods

This study was designed as a prospective randomized controlled simulation-based study. We used the Resusci® Baby QCPR (Laerdal Medical, Stavanger, Norway) as a simulated 3-month-old infant. Ventilation was performed by the mouth-to-mouth technique using a chest compression-to-ventilation ratio of 30:2 as a single rescuer. Data on CPR quality, such as locations, rates, depth and release of chest compressions, hands-off times, and proper ventilation, were recorded using the Resusci® Baby QCPR and SkillReporter. Also, the chest compression fraction (CCF) was automatically calculated.

Results

The depth of chest compression in 2FT, 2TT, and CTT were 40.0 mm (interquartile range [IQR] 39.0, 41.0), 42.0 mm (IQR 41.0, 43.0), and 42.0 mm (IQR 41.0, 43.0), respectively. The depth of chest compression in 2FT was shallower than that in the other two techniques (P<0.05). CCF in 2FT, 2TT, and CTT were 73.9% (IQR 72.2, 75.6), 71.2% (IQR 67.2, 72.2) and 71.3% (IQR 67.7, 74.1), respectively. CCF was higher in 2FT than in the other two techniques (P<0.05). Correct location in 2FT, 2TT, and CTT were 99.0% (IQR 86.0, 100.0), 100.0% (IQR 97.0, 100.0) and 100.0% (IQR 99.0, 100.0), respectively. Correct location in CTT and 2TT was higher than that in 2FT. Performing CTT, the subjective pain and fatigue score were lower than other two technique.

Conclusion

A new chest compression technique, CTT was better in chest compression depth compared with 2FT and may be helpful in maintaining correct chest compression location with less pain and fatigue in infant CPR.

A Comparison between Three Different Techniques Considering Quality Skills, Fatigue and Hand Pain during a Prolonged Infant Resuscitation: A Cross-Over Study with Lifeguards

The aim of the study was to compare the quality of CPR (Q-CPR), as well as the perceived fatigue and hand pain in a prolonged infant cardiopulmonary resuscitation (CPR) performed by lifeguards using three different techniques. A randomized crossover simulation study was used to compare three infant CPR techniques: the two-finger technique (TF); the two-thumb encircling technique (TTE) and the two-thumb-fist technique (TTF). 58 professional lifeguards performed three tests in pairs during a 20-min period of CPR. The rescuers performed compressions and ventilations in 15:2 cycles and changed their roles every 2 min. The variables of analysis were CPR quality components, rate of perceived exertion (RPE) and hand pain with numeric rating scale (NRS). All three techniques showed high Q-CPR results (TF: 86 ± 9%/TTE: 88 ± 9%/TTF: 86 ± 16%), and the TTE showed higher values than the TF (p = 0.03). In the RPE analysis, fatigue was not excessive with any of the three techniques (values 20 min between 3.2 for TF, 2.4 in TTE and 2.5 in TTF on a 10-point scale). TF reached a higher value in RPE than TTF in all the intervals analyzed (p < 0.05). In relation to NRS, TF showed significantly higher values than TTE and TTF (NRS minute 20 = TF 4.7 vs. TTE 2.5 & TTF 2.2; p < 0.001). In conclusion, all techniques have been shown to be effective in high-quality infant CPR in a prolonged resuscitation carried out by lifeguards. However, the two-finger technique is less efficient in relation to fatigue and hand pain compared with two-thumb technique (TF vs. TTF, p = 0.01).

Quantitative assessment of chest compression techniques on an infant manikin

BACKGROUND

Current cardiopulmonary resuscitation (CPR) guidelines recommend the two-finger technique (TFT) of chest compression (CC) in infants for a single rescuer. We hypothesized that healthcare providers cannot achieve adequate CC depth with TFT, even if using real-time visual feedback (RVF).

METHODS

This was a cross-over study, randomizing participants to perform three sets of 2-min continuous CC, comparing (i) TFT with RVF, (ii) the one-hand technique (OHT) without RVF, and (iii) OHT with RVF. A standard CPR trainer manikin of a 3-month-old infant and a monitor/defibrillator that displays and records the quantitative CC quality were used. We set a target compression depth of 40-50 mm and a target compression rate of 100-120/min. Data were analyzed using the Friedman test and Bonferroni correction. Statistical significance was defined as P-value of< 0.05.

RESULTS

Fifty-nine healthcare providers participated in the study. The mean compression depth was 24 mm (interquartile range [IQR], 22-26 mm) in TFT with RVF and 43 mm (IQR, 38-48 mm) in OHT without RVF, P < 0.001. The proportion of adequate CC depth was 0% (IQR, 0-0%) in TFT with RVF, 22% (IQR, 5-54%) in OHT without RVF, and 62% (IQR, 29-83%) in OHT with RVF. The mean compression rate was within the target range in all three techniques.

CONCLUSIONS

The TFT cannot produce the CC depth that meets the recommendation of the current CPR guidelines for an infant with RVF, whereas the OHT does.

Two-Thumb Technique Is Superior to Two-Finger Technique in Cardiopulmonary Resuscitation of Simulated Out-of-Hospital Cardiac Arrest in Infants

Background

To compare the 2‐finger and 2‐thumb chest compression techniques on infant manikins in an out‐of‐hospital setting regarding efficiency of compressions, ventilation, and rescuer pain and fatigue.

Methods and Results

In a randomized crossover design, 78 medical students performed 2 minutes of cardiopulmonary resuscitation with mouth‐to‐nose ventilation at a 30:2 rate on a Resusci Baby QCPR infant manikin (Laerdal, Stavanger, Norway), using a barrier device and the 2‐finger and 2‐thumb compression techniques. Frequency and depth of chest compressions, proper hand position, complete chest recoil at each compression, hands‐off time, tidal volume, and number of ventilations were evaluated through manikin‐embedded SkillReporting software. After the interventions, standard Likert questionnaires and analog scales for pain and fatigue were applied. The variables were compared by a paired t‐test or Wilcoxon test as suitable. Seventy‐eight students participated in the study and performed 156 complete interventions. The 2‐thumb technique resulted in a greater depth of chest compressions (42 versus 39.7 mm; P<0.01), and a higher percentage of chest compressions with adequate depth (89.5% versus 77%; P<0.01). There were no differences in ventilatory parameters or hands‐off time between techniques. Pain and fatigue scores were higher for the 2‐finger technique (5.2 versus 1.8 and 3.8 versus 2.6, respectively; P<0.01).

Conclusions

In a simulation of out‐of‐hospital, single‐rescuer infant cardiopulmonary resuscitation, the 2‐thumb technique achieves better quality of chest compressions without interfering with ventilation and causes less rescuer pain and fatigue.

Effect of two different chest compression techniques on ventilation during neonatal resuscitation

OBJECTIVE

To assess tidal volume (Vt) and minute ventilation (MV) during cardiopulmonary resuscitation (CPR) with two different chest compressions techniques: two-finger (TFT) or two-thumb technique (TTT) in a neonatal model.

METHODS

Vt and MV were continuously measured during consecutive periods of resuscitation in an intubated manikin. Thirty participants performed the two compression techniques in a random order for 2-min periods while performing positive pressure ventilation using a T-piece resuscitator (TPR) or a self-inflating bag (SIB).

RESULTS

Vt during CPR with TFT was significantly higher than TTT with either TPR: 44.9 ± 4.3 vs 39.2 ± 5.4 ml (p < 0.001) or SIB: 39.2 ± 5.7 vs 35.6 ± 6.5 ml (p < 0.023). Similarly MV was significantly higher in TFT than TTT with either mode: 1346 ± 130 vs 1175 ± 162 ml/min, respectively, with TPR (p < 0.001) and 1177 ± 170 vs 1069 ± 196 ml/min with SIB (p < 0.03).

CONCLUSIONS

Chest compressions during CPR using the TFT achieved higher Vt and MV than TTT in this model of neonatal resuscitation.

Dominant versus non-dominant hand during simulated infant CPR using the two-finger technique: a randomised study

Aims

The aim of this randomised study was to compare the two-finger technique (TFT) performance using dominant hand (DH) and non-dominant hand (NH) during simulated infant CPR (iCPR).

Methods

24 participants performed 3-min iCPR using TFT with DH or NH followed by 3-min iCPR with their other hand. Perceived fatigue was rated using visual analogue scale. Primary outcomes - (i) difference between DH and NH for compression depth (CCD), compression rate (CCR), residual leaning (RL) and duty cycle (DC); (ii) difference between first and last 30 s of iCPR performance with DH and NH. Secondary outcomes - (i) perception of fatigue between DH and NH; (ii) relationship between perception of fatigue and iCPR performance.

Results

No significant difference between DH and NH for any iCPR metric. CCR (DH: P = 0.02; NH: P = 0.004) and DC (DH: P = 0.04; NH: P < 0.001) were significantly different for the last 30 s for DH and NH. Perception of fatigue for NH (76.8 ± 13.4 mm) was significantly higher (t = -3.7, P < 0.001) compared to DH (62.8 ± 12.5 mm). No significant correlation between iCPR metrics and perception of fatigue for DH. However, a significant correlation was found for CCR (r = 0.43; P = 0.04) and RL (r = -0.48; P = 0.02) for NH.

Conclusion

No difference in performance of iCPR with DH versus NH was determined. However, perception of fatigue is higher in NH and was related to CCR and RL, with no effect on quality of performance. Based on our results, individuals performing iCPR can offer similar quality of infant chest compressions regardless of the hand used or the perception of fatigue, under the conditions explored in this study.

Chest compression by two-thumb encircling method generates higher carotid artery blood flow in swine infant model of cardiac arrest

Objective

Two-Thumb(TT) technique provides superior quality chest compressions compared with Two-Finger(TF) in an instrumented infant manikin. Whether this translates to differences in blood flow, such as carotid arterial blood flow(CABF), has not been evaluated. We hypothesized that TT-CPR generates higher CABF and Coronary Perfusion Pressure(CPP) compared with TF-CPR in a neonatal swine cardiac arrest model.

Methods

Twelve anesthetized & ventilated piglets were randomized after 3 min of untreated VF to receive either TT-CPR or TF-CPR by PALS certified rescuers delivering a compression rate of 100/min. The primary outcome, CABF, was measured using an ultrasound transonic flow probe placed on the left carotid artery. CPP was calculated and end-tidal CO₂(ETCO₂) was measured during CPR. Data(mean ± SD) were analyzed and p-value ≤0.05 was considered statistically significant.

Results

Carotid artery blood flow (% of baseline) was higher in TT-CPR (66.2 ± 35.4%) than in the TF-CPR (27.5 ± 10.6%) group, p = 0.013. Mean CPP (mm Hg) during three minutes of chest compression for TT-CPR was 12.5 ± 15.8 vs. 6.5 ± 6.7 in TF-CPR, p = 0.41 and ETCO₂ (mm Hg) was 29.0 ± 7.4 in TT-CPR vs. 20.7 ± 5.8 in TF-CPR group, p = 0.055.

Conclusion

TT-CPR achieved more than twice the CABF compared with TF-CPR in a piglet cardiac arrest model. Although CPP and ETCO₂ were higher during TT-CPR, these parameters did not reach statistical significance. This study provides direct evidence of increased blood flow in infant swine using TT-CPR and further supports that TT chest compression is the preferred method for CPR in infants.

European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

[Newborn resuscitation and support of transition of infants at birth]

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

Two-Thumb or Two-Finger Technique in Infant Cardiopulmonary Resuscitation by a Single Rescuer? A Meta-Analysis with GOSH Analysis

Out-of-hospital infant cardiopulmonary arrest is a fatal and uncommon event. High mortality rates and poor neurological outcomes may be improved by early cardiopulmonary resuscitation (CPR). The ongoing debate over two different infant CPR techniques, the two-thumb (TT) and the two-finger (TF) technique, has remained, especially in terms of the adequate compression depth, compression rate, and hands-off time. In this article, we searched three major databases, PubMed, EMBASE (Excerpta Medica database), and CENTRAL (Cochrane Central Register of Controlled Trials), for randomized control trials which compared the outcomes of interest between the TT and TF techniques in infant CPR. The results showed that the TT technique was associated with higher proportion of adequate compression depth (Mean difference (MD): 19.99%; 95%, Confidence interval (CI): 9.77 to 30.22; p < 0.01) than the TF technique. There was no significant difference in compression rate and hands-off time. In our conclusion, the TT technique is better in terms of adequate compression depth than the TF technique, without significant differences in compression rate and hands-off time.

Differences in the performance of resuscitation according to the resuscitation guideline terminology during infant cardiopulmonary resuscitation: "Approximately 4 cm" versus "at least one-third the anterior-posterior diameter of the chest"

Aim

This study was conducted to investigate the effect of resuscitation guideline terminology on the performance of infant cardiopulmonary resuscitation (CPR).

Methods

A total of 40 intern or resident physicians conducted 2-min CPR with the two-finger technique (TFT) and two-thumb technique (TT) on a simulated infant cardiac arrest model with a 1-day interval. They were randomly assigned to Group A or B. The participants of Group A conducted CPR with the chest compression depth (CCD) target of “approximately 4 cm” and those of Group B conducted CPR with the CCD target of “at least one-third the anterior-posterior diameter of the chest”. Single rescuer CPR was performed with a 15:2 compression to ventilation ratio on the floor.

Results

In both chest compression techniques, the average CCD of Group B was significantly deeper than that of Group A (TFT: 41.0 [range, 39.3–42.0] mm vs. 36.5 [34.0–37.9] mm, P = 0.002; TT: 42.0 [42.0–43.0] mm vs. 37.0 [35.3–38.0] mm, P < 0.001). Adequacy of CCD also showed similar results (Group B vs. A; TFT: 99% [82–100%] vs. 29% [12–58%], P = 0.001; TT: 100% [100–100%] vs. 28% [8–53%], P < 0.001).

Conclusions

Using the CCD target of “at least one-third the anterior-posterior diameter of the chest” resulted in deep and adequate chest compressions during simulated infant CPR in contrast to the CCD target of “approximately 4 cm”. Therefore, changes in the terminology used in the guidelines should be considered to improve the quality of CPR.

Trial registration

Clinical Research Information Service; cris.nih.go.kr/cris/en (Registration number: KCT0003486).

Rescuer Exertion and Fatigue Using Two-Thumb vs. Two-Finger Method During Simulated Neonatal Cardiopulmonary Resuscitation

Background: Rescuer fatigue during neonatal CPR can affect CPR quality leading to reduced cerebral and myocardial perfusion. Aim: To investigate rescuer fatigue during simulated neonatal CPR using both objective (heart rate and cardiac output) and subjective measures. Methods: A randomized crossover manikin study performed. Nineteen doctors working in neonatology were randomized to (a) two-thumb term, (b) two-finger term, (c) two-thumb preterm, or (d) two-finger preterm group. Cardiac output and heart rate were measured with a non-invasive cardiac output monitor. A Likert scale assessed participants' level of perceived exertion. Results: In the preterm group, the mean change in HR from rest to 5 min in the TT group was 11.58 bpm (SD 6.22) vs. 9.94 bpm (SD 8.48), (p-value 0.36). There was no difference in change in CO, 2.10 (SD 1.15) in the TT group vs. 1.39 (SD 1.63) in TF group (p value 0.23). There was no difference in BORG RPE rating. In the term group, the mean change in HR from rest to 5 min was 15 bpm (SD 8.40) in TT group and 13 bpm (SD 7.86) in TF group, (p-value 0.416). The median change in CO from rest to 5 min was 1.50 (0.78 to 2.42 IQR) in TT group vs. 1.60 (0.65 to 3.0 IQR) in TF group. Conclusion: Providing chest compressions is associated with an increase in both heart rate and cardiac output. We did not identify difference between objective and subjective measures of fatigue between either technique in a preterm or term model.

Comparison of standard and alternative methods for chest compressions in a single rescuer infant CPR: A prospective simulation study

Objective

The aims of this study were to develop a novel three-finger chest compression technique (pinch technique; PT) and an assistive device chest compression technique (plate-assisted technique; PAT) and compare these techniques with conventional techniques.

Design

Prospective, crossover manikin study

Setting

Pediatric emergency department at a tertiary care academic center

Subjects

Fifty medical doctors and medical students

Interventions

Using a manikin, fifty participants performed five different chest compression techniques—two 2-finger techniques (TFT1 and TFT2), two PTs (PT1 and PT2), and the PAT—for 2 minutes with 2 minutes of rest in a randomized sequence.

Measurements and main results

The compression depth (CD), compression rate, recoil, and finger position were recorded. At the study conclusion, each participant completed a 5-point Likert scale-based questionnaire on fatigue, satisfaction and difficulty of performing each technique. The mean CDs were 32.9 mm (TFT1), 30.3 mm (TFT2), 37.3 mm (PT1), 35.0 mm (PT2) and 40.1 mm (PAT) (p<0.001). TFT2 achieved the highest frequency of complete chest recoil, followed by PT1 and TFT1 (88.9%, 86.9%, and 81.4%, respectively, p = 0.003). The highest percentage of correct finger position was achieved by the PAT, followed by the PT1 and PT2 (93.4%, 83.1%, and 80.1%, respectively, p = 0.016). PAT use resulted in higher participant satisfaction, less fatigue, and less difficulty than the other four techniques.

Conclusion

Our new chest compression methods using three fingers and assistive plates showed better CD results than the conventional 2-finger technique.

Comparison of two-thumb encircling and two-finger technique during infant cardiopulmonary resuscitation with single rescuer in simulation studies: A systematic review and meta-analysis

BACKGROUND

The recommended chest compression technique for a single rescuer performing infant cardiopulmonary resuscitation is the two-finger technique. For 2 rescuers, a two-thumb-encircling hands technique is recommended. Several recent studies have reported that the two-thumb-encircling hands technique is more effective for high-quality chest compression than the two-finger technique for a single rescuer performing infant cardiopulmonary resuscitation. We undertook a systematic review and meta-analysis of infant manikin studies to compare two-thumb-encircling hands technique with two-finger technique for a single rescuer.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library for eligible randomized controlled trials published prior to December 2017, including cross-over design studies. The primary outcome was the mean difference in chest compression depth (mm). The secondary outcome was the mean difference in chest compression rate (counts/min). A meta-analysis was performed using Review Manager (version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014).

RESULTS

Six studies that had reported data concerning both chest compression depth and chest compression rate were included. The two-thumb-encircling hands technique was associated with deeper chest compressions compared with two-finger technique for mean chest compression depth (mean difference, 5.50 mm; 95% confidence interval, 0.32-10.69 mm; P = .04), but no significant difference in the mean chest compression rate (mean difference, 7.89 counts/min; 95% confidence interval, to 0.99, 16.77 counts/min; P = .08) was noted.

CONCLUSION

This study indicates that the two-thumb-encircling hands technique is a more appropriate technique for a single rescuer to perform high-quality chest compression in consideration of chest compression depth than the two-finger technique in infant manikin studies.

Simulating blood pressure and end tidal CO2 in a CPR training manikin

BACKGROUND AND OBJECTIVE

The American Heart Association supports titrating the mechanics of cardiopulmonary resuscitation (CPR) to blood pressure and end tidal carbon dioxide (ETCO2) thresholds during in-hospital cardiac arrest. However, current CPR manikin training systems do not prepare clinicians to use these metrics to gauge their performance, and currently provide only feedback on hand placement, depth, rate, release, and interruptions of chest compressions. We addressed this training hardware deficiency through development of a novel CPR training manikin that displays simulated blood pressure and ETCO2 waveforms in real time on a simulated clinical monitor visible to the learner, reflecting the mechanics of chest compressions provided to the manikin. Such a manikin could improve clinicians' CPR technique while also training them to titrate CPR quality to physiologic blood pressure and ETCO2 targets as performance indicators.

METHODS

We used data and key findings from 4 human and 6 animal studies (including 132 human subjects, 61 pigs, and 16 dogs in total) to develop an algorithm that simulates blood pressure and ETCO2 waveforms based on compression mechanics for a pediatric patient. We modified an off-the-shelf infant manikin to incorporate a microcontroller sufficient to process the aforementioned algorithm, and a tablet computer to wirelessly display the simulated waveform. We recruited clinicians with in-hospital CPR experience to perform compressions with the manikin and complete a post-test survey on their satisfaction with designated elements of the manikin and display.

RESULTS

34 clinicians performed CPR on the prototype manikin system that simulates real-time bedside monitoring of blood pressure and ETCO2. 100% of clinicians surveyed reported "satisfaction" with the blood pressure waveform. 97% said they thought depth was accurately reflected in blood pressure (0% inaccurate, 3% not sure). 88% reported an accurate chest compression rate modification effect on blood pressure and ETCO2 (3% inaccurate, 9% not sure) and 59% an accurate effect of leaning (6% inaccurate, 35% not sure). Most importantly, all 34 respondents responded "yes" when asked if they thought this system would be helpful for CPR training.

CONCLUSION

A CPR manikin that simulates blood pressure and ETCO2 was successfully developed with acceptable relevance, performance and feasibility as a CPR quality training tool.

Development and Evaluation of a New Chest Compression Technique for Cardiopulmonary Resuscitation in Infants

We designed the newly developed flexed two-finger chest compression technique for cardiopulmonary resuscitation (CPR) in infants to increase the quality of chest compression by considering the advantages and disadvantages of the two-thumb encircling hand technique and conventional two-finger technique. The aim of the study is to compare the performance of the flexed two-finger technique and the currently used two-thumb technique or two-finger technique for infant CPR. A total of 42 doctors conducted 2-min single-rescuer CPR on a cardiac arrest infant model using the two-thumb technique followed, in a random order, by the two-finger technique and the flexed two-finger technique. Although the ratio of the adequate compression depth was highest in the two-thumb technique, followed by the flexed two-finger technique and two-finger technique (100% [98-100] vs. 99% [80-100] vs. 76% [42-95], respectively, P < 0.001), the hand-off time of the two-thumb technique was significantly longer than in the two-finger technique and flexed two-finger technique (31 s [28-35] vs. 29 s [27-32] vs. 29 s [26-32], respectively, P < 0.001). The number of total chest compressions of the two-thumb technique was significantly lower than in the two-finger technique and flexed two-finger technique (150 [148-159] vs. 159 [149-173] vs. 162 [150-172], respectively, P < 0.001). The newly developed chest compression technique could provide adequate compression depth without increasing the hand-off time during single-rescuer infant CPR.Trial registration: Clinical Research Information Service, KCT0002730.

Comparison of two infant chest compression techniques during simulated newborn cardiopulmonary resuscitation performed by a single rescuer: A randomized, crossover multicenter trial

BACKGROUND

In newborns, ventilation is a key resuscitation element but optimal chest compression (CC) improves resuscitation quality. The study compared two infant CC techniques during simulated newborn resuscitation performed by nurses.

METHODS

The randomized crossover manikin, multicenter trial involved 52 nurses. They underwent training with two CC techniques: standard two-finger technique (TFT) and novel two-thumb technique (NTTT; two thumbs at 90° to the chest, fingers in a fist). One week later, the participants performed resuscitation with the two techniques. A Tory® S2210 Tetherless and Wireless Full-term Neonatal Simulator was applied, with a 3:1 compression to ventilation ratio. CC quality in accordance with the 2015 American Heart Association guidelines was assessed during the 2-min resuscitation.

RESULTS

Median CC depth was 30 mm for TFT and 37 mm for NTTT (p = 0.002). Correct hand placement reached 98% in both techniques; full chest relaxation was obtained in 97% vs. 94% for TFT and NTTT, respectively. CC fraction was slightly better for NTTT (74% vs. 70% for TFT; p = 0.044), the ventilation volume was comparable for both techniques. On a 100-degree scale (1 - no fatigue; 100 - extreme fatigue), the participant tiredness achieved 72 points (IQR 61-77) for TFT vs. 47 points (IQR 40-63) for NTTT (p = 0.034). For real resuscitation, 86.5% would choose NTTT and 13.5% TFT.

CONCLUSIONS

The NTTT technique proved superior to TFT. Evidence suggests that NTTT offers better CC depth in various medical personnel groups. One-rescuer TFT quality is not consistent with resuscitation guidelines.

Singapore Neonatal Resuscitation Guidelines 2016

We present the revised Neonatal Resuscitation Guidelines for Singapore. The 2015 International Liaison Committee on Resuscitation Neonatal Task Force's consensus on science and treatment recommendations (2015), and guidelines from the American Heart Association and European Resuscitation Council were debated and discussed. The final recommendations of the National Resuscitation Council, Singapore, were derived after the task force had carefully reviewed the current available evidence in the literature and addressed their relevance to local clinical practice.

Infant chest compression quality: A video-based comparison of two-thumb versus one-hand technique in the emergency department

AIM

To use video review to compare CC quality between 2-thumb encircling (2T) and one-hand anterior (1H) hand position in infants receiving CPR.

METHODS

Events where an infant received >2min of CC using a CPR monitor device while videorecorded were included. CC were measured in segments provided by a single compressor; segment duration, identity of the compressor, and hand position (2T vs 1H) was determined from video review. CC rate and depth were measured by the monitor device.

RESULTS

Seven infants received 111min of CCs from a total of 28 providers. 12/28 providers were assessed using both 2T and 1H; 6 providers used 2T and 1H in the same patient. 80 CC segments were analyzed; the median duration of CC segments was 74s (IQR 50-95s). Median CC rate across all segments was 127/min (IQR 115-142/min); median CC depth was 3.0cm (IQR 2.4-3.4cm). 2T position was used in 33/80 (41%) of segments. There was no significant difference in CC depth between 2T and 1H position (3.0±0.8 vs 3.0±0.6cm, p=0.81). 1H position was significantly associated with faster CC rate than 2T position (134±18 vs. 118±15 CC/min, p<0.001).

CONCLUSIONS

During CC in infants, 1H position was associated with a greater prevalence of inappropriately fast CC rate compared to 2T. There was no significant difference in depth between 2T and 1H. Future studies should evaluate the effect of hand position on clinical outcomes.

Two-Thumb Encircling Technique Over the Head of Patients in the Setting of Lone Rescuer Infant CPR Occurred During Ambulance Transfer: A Crossover Simulation Study

OBJECTIVE

The purpose of this study was to determine if the over-the-head 2-thumb encircling technique (OTTT) provides better overall quality of cardiopulmonary resuscitation compared with conventional 2-finger technique (TFT) for a lone rescuer in the setting of infant cardiac arrest in ambulance.

METHODS

Fifty medical emergency service students were voluntarily recruited to perform lone rescuer infant cardiopulmonary resuscitation for 2 minutes on a manikin simulating a 3-month-old baby in an ambulance. Participants who performed OTTT sat over the head of manikins to compress the chest using a 2-thumb encircling technique and provide bag-valve mask ventilations, whereas those who performed TFT sat at the side of the manikins to compress using 2-fingers and provide pocket-mask ventilations.

RESULTS

Mean hands-off time was not significantly different between OTTT and TFT (7.6 ± 1.1 seconds vs 7.9 ± 1.3 seconds, P = 0.885). Over-the-head 2-thumb encircling technique resulted in greater depth of compression (42.6 ± 1.4 mm vs 41.0 ± 1.4 mm, P < 0.001) and faster rate of compressions (114.4 ± 8.0 per minute vs 112.2 ± 8.2 per minute, P = 0.019) than TFT. Over-the-head 2-thumb encircling technique resulted in a smaller fatigue score than TFT (1.7 ± 1.5 vs 2.5 ± 1.6, P < 0.001). In addition, subjects reported that compression, ventilation, and changing compression to ventilation were easier in OTTT than in TFT.

CONCLUSIONS

The use of OTTT may be a suitable alternative to TFT in the setting of cardiac arrest of infants during ambulance transfer.

A randomized comparison of three chest compression techniques and associated hemodynamic effect during infant CPR: A randomized manikin study

INTRODUCTION

Pediatric cardiac arrest is an uncommon but critical life-threatening event requiring effective cardiopulmonary resuscitation. High-quality cardio-pulmonary resuscitation (CPR) is essential, but is poorly performed, even by highly skilled healthcare providers. The recently described two-thumb chest compression technique (nTTT) consists of the two thumbs directed at the angle of 90° to the chest while having the fingers fist-clenched. This technique might facilitate adequate chest-compression depth, chest-compression rate and rate of full chest-pressure relief.

METHODS

42 paramedics from the national Emergency Medical Service of Poland performed three single-rescuer CPR sessions for 10 minutes each. Each session was randomly assigned to the conventional two-thumb (TTHT), the conventional two-finger (TFT) or the nTTT. The manikin used for this study was connected with an arterial blood pressure measurement device and blood measurements were documented on a 10-seconds cycle.

RESULTS

The nTTT provided significant higher systolic (82 vs. 30 vs. 41 mmHg). A statistically significant difference was noticed between nTTT and TFT (p<.001), nTTT and TTHT (p<0.001), TFT and TTHT (p=0.003). The median diastolic preassure using nTTT was 16 mmHg compared with 9 mmHg for TFT (p<0.001), and 9.5 mmHg for TTHT (p<0.001). Mean arterial pressure using distinct methods varied and amounted to 40 vs. 22. vs. 26 mmHg (nTTT vs. TFT vs. TTHT, respectively). A statistically significant difference was noticed between nTTT and TFT (p<0.001), nTTT and TTEHT (p<0.001), and TFT and TTHT (p<0.001). The highest median pulse pressure was obtained by the nTTT 67.5 mmHg. Pulse pressure was 31.5 mmHg in the TTHT and 24 mmHg in the TFT. The difference between TFT and TTHT (p=0.025), TFT and nTTT (p<0.001), as well as between TTHT and nTTT (p<0.001) were statistically significant.

CONCLUSIONS

The new nTTT technique generated higher arterial blood pressures compared to established chest compression techniques using an infant manikin model, suggesting a more effective chest compression. Our results have important clinical implications as nTTT was simple to perform and could be widely taught to both healthcare professionals and bystanders. Whether this technique translates to improved outcomes over existing techniques needs further animal studies and subsequent human trials.

Evaluation of a newly developed infant chest compression technique: A randomized crossover manikin trial

BACKGROUND

Providing adequate chest compression is essential during infant cardio-pulmonary-resuscitation (CPR) but was reported to be performed poor. The "new 2-thumb technique" (nTTT), which consists in using 2 thumbs directed at the angle of 90° to the chest while closing the fingers of both hands in a fist, was recently introduced. Therefore, the aim of this study was to compare 3 chest compression techniques, namely, the 2-finger-technique (TFT), the 2-thumb-technique (TTHT), and the nTTT in an randomized infant-CPR manikin setting.

METHODS

A total of 73 paramedics with at least 1 year of clinical experience performed 3 CPR settings with a chest compression:ventilation ratio of 15:2, according to current guidelines. Chest compression was performed with 1 out of the 3 chest compression techniques in a randomized sequence. Chest compression rate and depth, chest decompression, and adequate ventilation after chest compression served as outcome parameters.

RESULTS

The chest compression depth was 29 (IQR, 28-29) mm in the TFT group, 42 (40-43) mm in the TTHT group, and 40 (39-40) mm in the nTTT group (TFT vs TTHT, P < 0.001; TFT vs nTTT, P < 0.001; TTHT vs nTTT, P < 0.01). The median compression rate with TFT, TTHT, and nTTT varied and amounted to 136 (IQR, 133-144) min versus 117 (115-121) min versus 111 (109-113) min. There was a statistically significant difference in the compression rate between TFT and TTHT (P < 0.001), TFT and nTTT (P < 0.001), as well as TTHT and nTTT (P < 0.001). Incorrect decompressions after CC were significantly increased in the TTHT group compared with the TFT (P < 0.001) and the nTTT (P < 0.001) group.

CONCLUSIONS

The nTTT provides adequate chest compression depth and rate and was associated with adequate chest decompression and possibility to adequately ventilate the infant manikin. Further clinical studies are necessary to confirm these initial findings.

A comparison between the two methods of chest compression in infant and neonatal resuscitation. A review according to 2010 CPR guidelines

AIM

The quality of chest compression (CC) delivered during neonatal and infant cardiopulmonary resuscitation (CPR) is identified as the most important factor to achieve the increase of survival rate without major neurological deficit to the patients. The objective of the study was to systematically review all the available studies that have compared the two different techniques of hand placement on infants and neonatal resuscitation, from 2010 to 2015 and to highlight which method is more effective.

METHODS

A review of the literature using a variety of medical databases, including Cochrane, MEDLINE, and SCOPUS electronic databases. The following MeSH terms were used in the search: infant, neonatal, CPR, CC, two-thumb (TT) technique/method, two-finger (TF) technique/method, rescuer fatigue, thumb/finger position/placement, as well as combinations of these.

RESULTS

Ten studies met the inclusion criteria; nine observational studies and a randomized controlled trial. All providers performed either continuous TF or TT technique CCs and the majority of CPR performance was taken place in infant trainer manikin.

CONCLUSIONS

The majority of the studies suggest the TT method as the more useful for infants and neonatal resuscitation than the TF.

Evaluation of new two-thumb chest compression technique for infant CPR performed by novice physicians. A randomized, crossover, manikin trial

BACKGROUND

The impact of high-quality chest compressions during CPR for the patients' outcome is undisputed, as it is essential for maintaining vital organ perfusion. The aim of our study is to compare the quality of chest compression (CC) and ventilation among the two current standard techniques with our novel "nTTT" technique in infant CPR.

METHODS

In this randomized crossover, manikin trial, participants performed CCs using three techniques in a randomized sequence: standard two finger technique (TFT); standard two thumb technique (TTHT), and the 'new two-thumb technique' (nTTT). The novel method of CCs in an infant consists in using two thumbs directed at the angle of 90° to the chest while closing the fingers of both hands in a fist.

RESULTS

Median depth compression using the distinct chest compression techniques varied and amounted to 26 [IQR, 25-28] mm for TFT, and 39 [IQR, 39-39] mm for TTHT as well as for nTTT. Best percentage of fully released compressions were received using TFT (100[100-100] %), then in the case of nTTT (99[98-100] %), and the worst in situation where TTHT (18[14-19] %). was used. The fastest chest compression rate was achieved with TFT (134[IQR, 129-135]/min) and the slowest when using nTTT (109 [IQR, 105-111]/min).

CONCLUSIONS

We found that our new nTTT technique's performance, in terms of compression depth, hands-off time, and ventilation quality, is comparable to the current standards. Based on our findings of this initial manikin study, the nTTT technique is superior to TFT in many of parameters that are vital to a quality chest compression during pediatric CPR.

Which Fingers Should We Perform Two-Finger Chest Compression Technique with When Performing Cardiopulmonary Resuscitation on an Infant in Cardiac Arrest?

This study compared the effectiveness two-finger chest compression technique (TFCC) performed using the right vs. left hand and the index-middle vs. middle-ring fingers. Four different finger/hand combinations were tested randomly in 30 healthcare providers performing TFCC (Test 1: the right index-middle fingers; Test 2: the left index-middle fingers; Test 3: the right middle-ring fingers; Test 4: the left middle-ring fingers) using two cross-over trials. The "patient" was a 3-month-old-infant-sized manikin. Each experiment consisted of cardiopulmonary resuscitation (CPR) consisting of 2 minutes of 30:2 compression: ventilation performed by one rescuer on a manikin lying on the floor as if in cardiac arrest. Ventilations were performed using the mouth-to-mouth method. Compression and ventilation data were collected during the tests. The mean compression depth (MCD) was significantly greater in TFCC performed with the index-middle fingers than with the middle-ring fingers regardless of the hand (95% confidence intervals; right hand: 37.8-40.2 vs. 35.2-38.6 mm, P = 0.002; left hand: 36.9-39.2 vs. 35.5-38.1 mm, P = 0.003). A deeper MCD was achieved with the index-middle fingers of the right versus the left hand (P = 0.004). The ratio of sufficiently deep compressions showed the same patterns. There were no significant differences in the other data. The best performance of TFCC in simulated 30:2 compression: ventilation CPR performed by one rescuer on an infant in cardiac arrest lying on the floor was obtained using the index-middle fingers of the right hand. Clinical Trial Registry at the Clinical Research Information Service (KCT0001515).