Morbid obesity impairs adequacy of thoracic compressions in a simulation-based model

An Evaluation of the Quality of CPR Chest Compressions Performed on Football-Equipped and Obese Simulation Manikins

OBJECTIVE

Protective athletic equipment may hamper the delivery of effective chest compressions. Unfortunately, an algorithm for managing cardiac arrest emergencies with equipment-laden athletes has yet to be established by national CPR certifying agencies. Further, athletes classified as being overweight or obese carry adipose in the thoracic region, which has been reported to inhibit the ability of rescuers to provide quality chest compressions. Thus, the purpose of this study was two-fold. The first purpose was to assess the ability of emergency responders to perform CPR chest compressions on an obese manikin. The second purpose was to analyze the effect of American football protective equipment on the performance of chest compressions by emergency responders.

METHODS

Fifty emergency responders completed four 2-minute bouts of compression-only CPR. The scenarios included performing chest compressions on both traditional and obese CPR manikins, and performing chest compressions over a set of shoulder pads/chest protector that is used in the sport of American football on both traditional and obese manikins.

RESULTS

The most notable outcomes in this study were related to chest compression depth, which fell well below the minimum recommended depth published by the American Heart Association in all conditions. Mean compression depth was significantly lower when performed on the obese manikin (avg over pads = 32.8, SD = 9.2 mm; avg no pads = 38.2, SD = 9.1 mm) compared to the traditional manikin (avg over pads = 40.0, SD = 10.9 mm; avg no pads = 40.8, SD = 14.8 mm), with statistical analyses revealing a significant effect due to both manikin size (p < 0.001) and the presence of equipment (p = 0.003), and a statistically significant interaction effect (p = 0.035). Chest recoil data revealed a statistically significant effect due to both manikin size (p = 0.017) and the presence of chest/shoulder safety pads (p = 0.003).

CONCLUSION

Within this sample of emergency responders, chest compressions were adversely affected both by the equipment and obesity. Additionally, the traditional manikin received comparable chest compressions regardless of the presence or absence of football protective equipment, albeit both conditions resulted in poor depth performance.

The DIVERSE Study: Determining the Importance of Various gEnders, Races, and body Shapes for CPR Education using manikins

Certain demographic groups are less likely to receive efficient CPR, and poor representation of these groups in the manikins used for CPR simulation may play a role. The aim of the DIVERSE Study was to survey organizations that teach CPR to determine the demographic characteristics of the manikins they utilize for simulations. Institutions, businesses, and non-governmental organizations which provide CPR certification in North and Latin America were surveyed through a collaboration with the Emerging Leaders group of the Interamerican Society of Cardiology (SIAC). A total of 56 survey responses were received from North America (n=18; 869 total manikins) and Latin America (n=38; 1514 total manikins). Of the total manikins (n=2,383), 12% were non-white, 6% represented women, <1% represented a non-lean body habitus, and 1% represented pregnant individuals. Despite the importance of diverse manikin representation in simulation training, diverse representation is lacking in manikins used in North and Latin America.

Does the use of BariBoard™ improve adequacy of chest compressions in morbid obesity? A pilot study using a simulation model

BACKGROUND

Obesity is a growing health problem worldwide. Morbid obesity has been associated with significant barriers to effective thoracic cage compression during cardiopulmonary resuscitation.

OBJECTIVE

The BariBoard™ purports to improve adequacy of chest compressions in morbidly obese patients. This study uses a simulation model to evaluate this.

METHODS

This was a prospective blinded randomised-controlled crossover pilot trial using a simulation model of obesity. Participants, recruited from hospital departments and prehospital services, performed 2 minutes of continuous compressions on mannequins modified to emulate a morbidly obese patient. Participants were randomised by coin toss to a sequence of either control/intervention or intervention/control, with the BariBoard™ in the intervention arm. Accelerometers measured chest wall movement during compressions. The primary endpoint was a composite measure of compression adequacy (rate, depth, and recoil). Secondary endpoints comprised the individual components of the composite outcome, as both dichotomous outcomes (adequate vs. inadequate) and continuous variables. All endpoints were adjusted for potential confounders.

RESULTS

Of 205 participants recruited, 201 were analysed. There was a significant difference in the primary outcome between the control and intervention arms (13.4% vs. 4.5%, respectively, p = 0.001) and between the control and intervention arms for the secondary endpoints of adequate compression depth (31.3% vs. 15.9%, p < 0.001) and recoil (63.7% vs. 41.3%, p < 0.001). After adjustment for confounders and interactions, there was no difference in overall efficacy (odds ratio: 0.62, 95% confidence interval: 0.20-1.90, p = 0.40).

CONCLUSION

This pilot study describes the successful assessment of a device using a simulation model of obesity. Within these constraints and after adjustment for confounders, use of the BariBoard ™ did not improve efficacy of chest compressions.

Emergencies in obese patients: a narrative review

Obesity is associated to an increased risk of morbidity and mortality due to respiratory, cardiovascular, metabolic, and neoplastic diseases. The aim of this narrative review is to assess the physio-pathological characteristics of obese patients and how they influence the clinical approach during different emergency settings, including cardiopulmonary resuscitation. A literature search for published manuscripts regarding emergency and obesity across MEDLINE, EMBASE, and Cochrane Central was performed including records till January 1, 2021. Increasing incidence of obesity causes growth in emergency maneuvers dealing with airway management, vascular accesses, and drug treatment due to both pharmacokinetic and pharmacodynamic alterations. Furthermore, instrumental diagnostics and in/out-hospital transport may represent further pitfalls. Therefore, people with severe obesity may be seriously disadvantaged in emergency health care settings, and this condition is enhanced during the COVID-19 pandemic, when obesity was stated as one of the most frequent comorbidity. Emergency in critical obese patients turns out to be an intellectual, procedural, and technical challenge. Organization and anticipation based on the understanding of the physiopathology related to obesity are very important for the physician to be mentally and physically ready to face the associated issues.

A review of ECMO for cardiac arrest

Cardiac arrest is an important public health concern, affecting an estimated 356,500 people in the out-of-hospital setting and 209,000 people in the in-hospital setting each year. The causes of cardiac arrest include acute coronary syndromes, pulmonary embolism, dyskalemia, respiratory failure, hypovolemia, sepsis, and poisoning among many others. In order to tackle the enormous issue of high mortality among sufferers of cardiac arrest, ongoing research has been seeking improved treatment protocols and novel therapies. One of the mechanical devices that has been increasingly utilized for cardiac arrest is venoarterial extracorporeal membrane oxygenation (VA-ECMO). Presently there is only one published randomized controlled trial examining the use of VA-ECMO as part of cardiopulmonary resuscitation (CPR), a process referred to as extracorporeal cardiopulmonary resuscitation (ECPR). Recently there has been significant progress in providing ECPR for refractory cardiac arrest patients. This narrative review seeks to outline the use of ECPR for both in-hospital and out-of-hospital cardiac arrest, as well as provide information on the expected outcomes associated with its use.

The Crashing Obese Patient

The obesity pandemic now affects hundreds of millions of people worldwide. As obesity rates continue to increase, emergency physicians are called on with increasing frequency to resuscitate obese patients. This article discusses important anatomic, physiologic, and practical challenges imposed by obesity on resuscitative care. Impacts on hemodynamic monitoring, airway and ventilator management, and pharmacologic therapy are discussed. Finally, several important clinical scenarios (trauma, cardiac arrest, and sepsis), in which alterations to standard treatments may benefit obese patients, are highlighted.

Associations of thoracic cage size and configuration with outcomes of adult in-hospital cardiac arrest: A retrospective cohort study

BACKGROUND

To analyse the association of thoracic cage size and configuration with outcomes following in-hospital cardiac arrest (IHCA).

METHODS

A single-centred retrospective study was conducted. Adult patients experiencing IHCA during 2006-2015 were screened. By analysing computed tomography images, we measured thoracic anterior-posterior and transverse diameters, circumference, and both anterior and posterior subcutaneous adipose tissue (SAT) depths at the level of the internipple line (INL). We also recorded the anatomical structure located immediately posterior to the sternum at the INL.

RESULTS

A total of 649 patients were included. The median thoracic circumference was 88.6 cm. The median anterior and posterior thoracic SAT depths were 0.9 and 1.5 cm, respectively. The ascending aorta was found to be the most common retrosternal structure (57.6%) at the INL. Multivariate logistic regression analyses indicated that anterior thoracic SAT depth of 0.8-1.6 cm (odds ratio [OR]: 2.98, 95% confidence interval [CI]: 1.40-6.35; p-value = 0.005) and thoracic circumference of 83.9-95.0 cm (OR: 2.48, 95% CI: 1.16-5.29; p-value = 0.02) were positively associated with a favourable neurological outcome while left ventricular outflow track or aortic root beneath sternum at the level of INL was inversely associated with a favourable neurological outcome (OR: 0.37, 95% CI: 0.15-0.91; p-value = 0.03).

CONCLUSION

Thoracic circumference and anatomic configuration might be associated with IHCA outcomes. This proof-of-concept study suggested that a one-size-fits-all resuscitation technique might not be suitable. Further investigation is needed to investigate the method of providing personalized resuscitation tailored to patient needs.

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.