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

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).

The new European resuscitation council guidelines on newborn resuscitation and support of the transition of infants at birth: An educational article

In this educational article, we summarize the changes in the new European Resuscitation Council guidelines on Newborn Resuscitation and Support of the Transition of Infants at Birth, emphasizing important aspects for the pediatric anesthesiologist including umbilical cord management, airway management, inflation pressure, and oxygen in relation with gestational age and situation. Using a fictitious case to illustrate the main points, we give a summary of the changes and the evidence behind them.

New European Resuscitation Council guidelines for pediatric life support and their implications for pediatric anesthesia: An educational article

In this educational article, we summarize the changes in the new European Resuscitation Council guidelines for Pediatric Life Support, emphasizing the most important aspects for the anesthesiologist. Among these are: the use of two-thumb-encircling technique for thorax compressions in infants, 10 ml/kg as the standard volume fluid bolus and ventilation after intubation at an age-dependent rate. Using a fictitious case, we present a point-by-point summary of the changes and briefly mention some of the evidence behind them, referring the reader to the full guidelines for further evidence. We also give a summary of the incidence, causes, challenges, treatment, and prognosis of pediatric cardiac arrest in the operating room.

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.

Singapore Paediatric Resuscitation Guidelines 2021

We present the 2021 Singapore Paediatric Resuscitation Guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, which was published in October 2020, and the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council, were reviewed and discussed by the committee. These recommendations were derived after deliberation of peer-reviewed evidence updates on paediatric resuscitation and took into consideration the local setting and clinical practice.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

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: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Development of Smart-Ring-Based Chest Compression Depth Feedback Device for High Quality Chest Compressions: A Proof-of-Concept Study

Recently, a smart-device-based chest compression depth (CCD) feedback system that helps ensure that chest compressions have adequate depth during cardiopulmonary resuscitation (CPR) was developed. However, no CCD feedback device has been developed for infants, and many feedback systems are inconvenient to use. In this paper, we report the development of a smart-ring-based CCD feedback device for CPR based on an inertial measurement unit, and propose a high-quality chest compression depth estimation algorithm that considers the orientation of the device. The performance of the proposed feedback system was evaluated by comparing it with a linear variable differential transformer in three CPR situations. The experimental results showed compression depth errors of 2.0 ± 1.1, 2.2 ± 0.9, and 1.4 ± 1.1 mm in the three situations. In addition, we conducted a pilot test with an adult/infant mannequin. The results of the experiments show that the proposed smart-ring-based CCD feedback system is applicable to various chest compression methods based on real CPR situations.