Verification of the Optimal Chest Compression Depth for Children in the 2015 American Heart Association Guidelines: Computed Tomography Study

Chest Compression Depth Targets in Critically Ill Infants and Children Measured With a Laser Distance Meter: Single-Center Retrospective Study From Japan, 2019-2022

OBJECTIVES

Current resuscitation guidelines recommend target chest compression depth (CCd) of approximately 4cm for infants and 5cm for children. Previous reports based on chest CT suggest these recommended CCd targets might be too deep for younger children. Our aim was to examine measurements of anterior-posterior chest diameter (APd) with a laser distance meter and calculate CCd targets in critically ill infants and children.

DESIGN

A retrospective descriptive study.

SETTING

Single-center PICU, using data from May 2019 to May 2022.

PATIENTS

All critically ill children admitted to PICU and under 8 years old were eligible to be included in the retrospective cohort.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The chest APd measurements using a laser distance meter are part of our usual practice on the PICU. Target CCd and the over-compression threshold CCd for each age group was calculated as 1/3 and 1/2 of APd, respectively. In 555 patients, the median (interquartile range) of the calculated target CCd for each age group was: 2.7 cm (2.5-2.9 cm), 2.9 cm (2.7-3.2 cm), 3.2 cm (3-3.5 cm), 3.4 cm (3.2-3.6 cm), 3.4 cm (3.2-3.6 cm), 3.6 cm (3.4-3.8 cm), 3.6 cm (3.4-4 cm), and 4 cm (3.5-4.2 cm), for 0, 2, 3-5, 6-8, 9-11, 12-17, 18-23, 24 to less than 60, and 60 to less than 96 months, respectively. Using guideline-recommended absolute CCd targets, 4 cm for infants and 5 cm for children, 49% of infants between 0 and 2 months, and 45.5% of children between 12 and 17 months would be over-compressed during cardiopulmonary resuscitation.

CONCLUSIONS

In our cohort, the 1/3 CCd targets calculated from APd measured by laser meter were shallower than the guideline-recommended CCd. Further studies including evaluating hemodynamics during cardiopulmonary resuscitation with these shallower CCd targets are needed.

Optimal Chest Compression Point During Pediatric Resuscitation: Implications for Pediatric Resuscitation Practice by CT Scans

OBJECTIVES

Current European guidelines for pediatric cardiopulmonary resuscitation (CPR) recommend the lower half of the sternum as the chest compression point (CP). In this study, we have used thoracic CT scans to evaluate recommended and optimal CP in relation to cardiac anatomy and structure.

DESIGN

Analysis of routinely acquired thoracic CT scans acquired from 2000 to 2020.

SETTING

Single-center pediatric department in a German University Hospital.

PATIENTS

Imaging data were obtained from 290 patients of 3-16 years old.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We measured and analyzed 14 thoracic metrics in each thoracic CT scan. In 44 of 290 (15.2%) scans, the recommended CP did not match the level of the cardiac ventricles. Anatomically, the optimal CP was one rib or one vertebral body lower than the recommended CP, that is, the optimal CP was more caudal to the level of the body of the sternum in 67 of 290 (23.1%) scans. The recommended compression depth appeared reasonable in children younger than 12 years old. At 12 years old or older, the maximum compression depth of 6 cm is less than or equal to one-third of the thoracic depth.

CONCLUSIONS

In this study of thoracic CT scans in children 3-16 years old, we have found that optimal CP for CPR appears to be more caudal than the recommended CP. Therefore, it seems reasonable to prefer to use the lower part of the sternum for CPR chest compressions. At 12 years old or older, a compression depth similar to that used in adults-6 cm limit-may be chosen.

Comparison of paediatric basic life support guidelines endorsed by member councils of Resuscitation Council of Asia

Background

Paediatric cardiac arrest outcomes, especially for infants, remain poor. Due to different training, resource differences, and historical reasons, paediatric cardiac arrest algorithms for various Asia countries vary. While there has been a common basic life support algorithm for adults by the Resuscitation Council of Asia (RCA), there is no common RCA algorithm for paediatric life support.We aimed to review published paediatric life support guidelines from different Asian resuscitation councils.

Methods

Pubmed and Google Scholar search were performed for published paediatric basic and advanced life support guidelines from January 2015 to June 2023. Paediatric representatives from the Resuscitation Council of Asia were sought and contacted to provide input from September 2022 till June 2023.

Results

While most of the components of published paediatric life support algorithms of Asian countries are similar, there are notable variations in terms of age criteria for recommended use of adult basic life support algorithms in the paediatric population less than 18 years old, recommended paediatric chest compression depth targets, ventilation rates post-advanced airway intra-arrest, and first defibrillation dose for shockable rhythms in paediatric cardiac arrest.

Conclusion

This was an overview and mapping of published Asian paediatric resuscitation algorithms. It highlights similarities across paediatric life support guidelines in Asian countries. There were some differences in components of paediatric life support which highlight important knowledge gaps in paediatric resuscitation science. The minor differences in the paediatric life support guidelines endorsed by the member councils may provide a framework for prioritising resuscitation research and highlight knowledge gaps in paediatric resuscitation.

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.

[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.

What is the potential for over-compression using current paediatric chest compression guidelines? - A chest computed tomography study

Aim

We explored the potential for over-compression from current paediatric chest compression depth guidelines using chest computed tomography(CT) images of a large, heterogenous, Asian population.

Methods

A retrospective review of consecutive children, less than 18-years old, with chest CT images performed between from 2005 to 2017 was done. Demographic data were extracted from the electronic medical records. Measurements for internal and external anterior-posterior diameters (APD) were taken at lower half of the sternum. Simulated chest compressions were performed to evaluate the proportion of the population with residual internal cavity dimensions less than 0 mm (RICD < 0 mm, representing definite over-compression; with chest compression depth exceeding internal APD), and RICD less than 10 mm (RICD < 10 mm, representing potential over-compression).

Results

592 paediatric chest CT studies were included for the study. Simulated chest compressions of one-third external APD had the least potential for over-compression; no infants and 0.3% children had potential over-compression (RICD < 10 mm). 4 cm simulated chest compressions led to 18% (95% CI 13%-24%) of infants with potential over-compression, and this increased to 34% (95% CI 27%-41%) at 4.4 cm (upper limit of "approximately" 4 cm; 4 cm + 10%). 5 cm simulated compressions resulted in 8% (95% CI 4%-12%) of children 1 to 8-years-old with potential over-compression, and this increased to 22% (95% CI 16%-28%) at 5.5 cm (upper limit of "approximately" 5 cm, 5 cm + 10%).

Conclusion

In settings whereby chest compression depths can be accurately measured, compressions at the current recommended chest compression of approximately 4 cm (in infants) and 5 cm (in young children) could result in potential for over-compression.

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.

Applicability of Anatomical Landmarks for Chest Compression Depth in Cardiopulmonary Resuscitation for Children

We evaluated the applicability of the neck and sternal notch (SN) as anatomical landmarks for paediatric chest compression (CC) depth using chest computed tomography. The external anteroposterior diameter (EAPD) of the neck and chest at the SN level, mid-point between two landmarks (mid-landmark), and EAPD of the chest at the lower half of the sternum (EDLH) were measured. To estimate the depths of the landmarks from a virtual point at the same height as the position for CC, we calculated the differences between the EAPDs of the neck, SN, mid-landmark, and EDLH. We analysed the relationship between the depths of the landmarks and one-third EDLH using Bland–Altman plots. In all, 506 paediatric patients aged 1–9 years were enrolled. The depths of the neck, SN, and mid-landmark were 53.7 ± 10.0, 37.8 ± 8.5, and 45.8 ± 9.0 mm, respectively. The mean one-third EDLH was 46.8 ± 7.0 mm. The means of the differences between the depths of the neck and one-third EDLH, depths of the SN and one-third EDLH, and depths of the mid-landmark and one-third EDLH were 9.0, −6.9, and 1.0 mm, respectively. The SN and neck are inappropriate landmarks to guide compression depth in paediatric CPR.

The effects of thoracic cage dimension and chest subcutaneous adipose tissue on outcomes of adults with in-hospital cardiac arrest: A retrospective study

BACKGROUND

The associations between thoracic cage dimension, chest subcutaneous adipose tissue (SAT) depth and outcomes of adults with in-hospital cardiac arrest (IHCA) remain unknown.

METHODS

We retrospectively evaluated IHCA patients between January 2016 and October 2017. The thoracic cage transverse diameter, internal AP diameter, cross-sectional area, anterior and posterior SAT depths were measured in computed-tomography (CT) images. Using logistic regression models, we determined the adjusted associations between thoracic cage dimension, SAT depths and the prognosis for IHCA. The primary outcome was sustained return of spontaneous circulation (ROSC) and the secondary outcome was survival to hospital discharge.

RESULTS

Among 423 IHCA patients, 258 patients achieved ROSC and 70 survived to discharge. Smaller cross-sectional area and posterior SAT depth were significantly related to ROSC. Smaller posterior SAT depth was associated with ROSC. After multivariate adjustment, the smaller cross-sectional area was independently associated with ROSC (Odds ratio [OR] 0.99, 95% confidence interval [95%CI] 0.99-1.00; p = 0.008) and survival to discharge (OR 0.99, 95%CI 0.98-1.00; p = 0.024), and the smaller posterior SAT depth was independently related to ROSC (OR 0.65, 95%CI 0.44-0.96; p = 0.030), whereas no relation to survival to discharge was found.

CONCLUSIONS

In adults with IHCA, the smaller thoracic cage dimension and posterior SAT depth are associated with better survival. An adjustable compression depth based on the thoracic cage dimension might be better than the "one-size-fits-all" compression depth for resuscitating CA patients. In addition, physicians should pay extra attention to compression efficacy when resuscitating obese patients.