Sharda Udassi

Effect of alternative chest compression techniques in infant and child on rescuer performance

Objective: Current chest compression (CC) guidelines for an infant recommend a two-finger (TF) technique with lone rescuer and a two- thumb (TT) technique with two rescuers, and for a child either an one hand (OH) or a two hand (TH) technique with one or two rescuers. The effect of a 30:2 compression:ventilation ratio using these techniques on CC quality and rescuer fatigue is unknown. We hypothesized that during lone rescuer CC, TT technique, in infant and TH in child achieve better compression depth (CD) without additional rescuer fatigue compared with TF and OH, respectively. Design: Randomized observational study. Setting: University-affiliated pediatric hospital. Subjects: Adult healthcare providers certified in basic life support or pediatric advanced life support. Interventions: Laerdal baby advanced life support trainer and Resusci junior manikin were modified to digitally record CD, compression pressure (CP) and compression rate. Sixteen subjects were randomized to each of the four techniques to perform 5 minutes of lone rescuer 30:2 compression:ventilation cardiopulmonary resuscitation. Rescuer heart rate (HR) and respiratory rate were recorded continuously and the recovery time interval for HR/respiratory rate to return to baseline was determined. Subjects were blinded to data recording. Groups were compared using two-sample, two-sided Student’s t tests. Measurements and Main Results: Two-thumb technique generated significantly higher CD and peak CP compared with TF (p < 0.001); there was no significant difference between OH vs. TH. TF showed decay of CD and CP over time compared with TT. Compression rate (per minute) and actual compressions delivered were not significantly different between groups. No significant differences in fatigue and recovery time were observed, except the TT group had greater increase in the rescuer’s HR (bpm) from baseline compared with TF group (p = 0.04). Conclusions: Two-thumb compression provides higher CD and CP compared with TF without any evidence of decay in quality and additional rescuer fatigue over 5 minutes. There was no significant difference in child CC quality or rescuer fatigue between OH and TH. Two-thumb technique is preferred for infant CC and our data support the current guidelines for child CC.

Chest compression quality and rescuer fatigue with increased compression to ventilation ratio during single rescuer pediatric CPR

OBJECTIVE The effects of the recommended 30:2 compression:ventilation (C:V) ratio on chest compression rate (CR), compression depth (CD), compression pressure (CP) and rescuer fatigue is unknown during pediatric CPR. We hypothesized that a 30:2 C:V ratio will decrease compression depth and compression pressure and increase rescuer fatigue compared with a 15:2 ratio. DESIGN Randomized crossover observational study. METHODS Adolescent, child and infant manikins were modified to digitally record compression rate, compression depth, compression pressure and total compression cycles (CC). BLS or PALS certified volunteers were randomized to five CPR groups: adolescent (AD), child 1-hand (OH), child 2-hand (TH), infant two-finger (TF) and infant two-thumb (TT). Each rescuer performed each ratio for 5 min with the order randomized. Rescuer heart rate (HR) and respiratory rate (RR) were recorded continuously during CPR and used to determine the recovery time (RT) for HR/RR to return to baseline. Data (mean+/-S.D.) were contrasted by paired differences for quantitative data and the sign rank test for ordinal data. RESULTS Eighty subjects (16 per group) were randomized. The peak compression pressure and compression rate were not different within any group, but total compression cycle were higher in all 30:2 groups. Compression depth (mm) was not significantly different within any group. The rescuers HR (bpm) increased significantly during 30:2 CPR in AD and OH group with no significant differences in RR and recovery time. Subjects reported that 15:2 CPR was easier to perform (P<0.001). CONCLUSION During single rescuer pediatric BLS, more compression cycles were achieved with 30:2 C:V ratio without effect on compression depth, pressure and rate. Increased HR with 30:2 C:V ratio was noted during larger manikin CPR without subjective difference of reported fatigue. Most rescuers in AD and TF group did not achieve recommended compression depth regardless of C:V ratio.

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

OBJECTIVE Infant CPR guidelines recommend two-finger chest compression with a lone rescuer and two-thumb with two rescuers. Two-thumb provides better chest compression but is perceived to be associated with increased ventilation hands-off time. We hypothesized that lone rescuer two-thumb CPR is associated with increased ventilation cycle time, decreased ventilation quality and fewer chest compressions compared to two-finger CPR in an infant manikin model. DESIGN Crossover observational study randomizing 34 healthcare providers to perform 2 min CPR at a compression rate of 100 min(-1) using a 30:2 compression:ventilation ratio comparing two-thumb vs. two-finger techniques. METHODS A Laerdal Baby ALS Trainer manikin was modified to digitally record compression rate, compression depth and compression pressure and ventilation cycle time (two mouth-to-mouth breaths). Manikin chest rise with breaths was video recorded and later reviewed by two blinded CPR instructors for percent effective breaths. Data (mean+/-SD) were analyzed using a two-tailed paired t-test. Significance was defined qualitatively as p< or =0.05. RESULT Mean % effective breaths were 90+/-18.6% in two-thumb and 88.9+/-21.1% in two-finger, p=0.65. Mean time (s) to deliver two mouth-to-mouth breaths was 7.6+/-1.6 in two-thumb and 7.0+/-1.5 in two-finger, p<0.0001. Mean delivered compressions per minute were 87+/-11 in two-thumb and 92+/-12 in two-finger, p=0.0005. Two-thumb resulted in significantly higher compression depth and compression pressure compared to the two-finger technique. CONCLUSION Healthcare providers required 0.6s longer time to deliver two breaths during two-thumb lone rescuer infant CPR, but there was no significant difference in percent effective breaths delivered between the two techniques. Two-thumb CPR had 4 fewer delivered compressions per minute, which may be offset by far more effective compression depth and compression pressure compared to two-finger technique.

Novel adhesive glove device (AGD) for active compression–decompression (ACD) CPR results in improved carotid blood flow and coronary perfusion pressure in piglet model of cardiac arrest

OBJECTIVE ACD-CPR improves coronary and cerebral perfusion. We developed an adhesive glove device (AGD) and hypothesized that ACD-CPR using an AGD provides better chest decompression resulting in improved carotid blood flow as compared to standard (S)-CPR. DESIGN Prospective, randomized and controlled animal study. METHODS Sixteen anesthetized and ventilated piglets were randomized after 3 min of untreated VF to receive either S-CPR or AGD-ACD-CPR by a PALS certified single rescuer with compressions of 100 min(-1) and C:V ratio of 30:2. AGD consisted of a modified leather glove exposing the fingers and thumb. A wide Velcro patch was sewn to the palmer aspect of the glove and the counter Velcro patch was adhered to the pigs chest wall. Carotid blood flow was measured using ultrasound. Data (mean±SD) was analyzed using one way ANOVA and unpaired t-test; p-value ≤ 0.05 was considered statistically significant. RESULTS Right atrial pressure (mmHg) during the decompression phase was lower during AGD-ACD-CPR (-3.32±2.0) when compared to S-CPR (0.86±1.8, p=0.0007). Mean carotid blood flow was 53.2±27.1 (% of baseline blood flow in ml/min) in AGD vs. 19.1±12.5% in S-CPR, p=0.006. Coronary perfusion pressure (CPP, mmHg) was 29.9±5.8 in AGD vs. 22.7±6.9 in S-CPR, p=0.04. There was no significant difference in time to ROSC and number of epinephrine doses. CONCLUSION Active chest decompression during CPR using this simple and inexpensive adhesive glove device resulted in significantly better carotid blood flow during the first 2 min of CPR.

Use of impedance threshold device in conjunction with our novel adhesive glove device for ACD-CPR does not result in additional chest decompression

OBJECTIVE To evaluate the hemodynamic effects of using an adhesive glove device (AGD) to perform active compression-decompression CPR (AGD-CPR) in conjunction with an impedance threshold device (ITD) in a pediatric cardiac arrest model. DESIGN Controlled, randomized animal study. METHODS In this study, 18 piglets were anesthetized, ventilated, and continuously monitored. After 3min of untreated ventricular fibrillation, animals were randomized (6/group) to receive either standard CPR (S-CPR), active compression-decompression CPR via adhesive glove device (AGD-CPR) or AGD-CPR along with an ITD (AGD-CPR+ITD) for 2min at 100-120compressions/min. AGD is delivered using a fingerless leather glove with a Velcro patch on the palmer aspect and the counter Velcro patch adhered to the pigs chest. Data (mean±SD) were analyzed using one-way ANOVA with pair wise multiple comparisons to assess differences between groups. p-Value≤0.05 was considered significant. RESULTS Both AGD-CPR and AGD-CPR+ITD groups produced lower intrathoracic pressure (IttP, mmHg) during decompression phase (-13.4±6.7, p=0.01 and -11.9±6.5, p=0.01, respectively) in comparison to S-CPR (-0.3±4.2). Carotid blood flow (CBF, % of baseline mL/min) was higher in AGD-CPR and AGD-CPR+ITD (respectively 64.3±47.3%, p=0.03 and 67.5±33.1%, p=0.04) as compared with S-CPR (29.1±12.5%). Coronary perfusion pressure (CPP, mmHg) was higher in AGD-CPR and AGD-CPR+ITD (respectively 19.7±4.6, p=0.04 and 25.6±12.1, p=0.02) when compared to S-CPR (9.6±9.1). There was no statistically significant difference between AGD-CPR and AGD-CPR+ITD groups with reference to intra-thoracic pressure, carotid blood flow and coronary perfusion pressure. CONCLUSION Active compression decompression delivered by this simple and inexpensive adhesive glove device resulted in improved cerebral blood flow and coronary perfusion pressure. There was no statistically significant added effect of ITD use along with AGD-CPR on the decompression of the chest.

Adolescent with Fever, hypotension, and respiratory distress.

A previously healthy 15-year-old White girl presented to the pediatric clinic with chest pain and difficulty breathing. During the preceding week she had experienced a fever, sore throat, nonproductive cough, significant fatigue, and multiple episodes of nonbloody, nonbilious vomiting. She reported markedly reduced oral intake and decreasing urine output. She appeared fatigued and in severe respiratory distress. Her medical history was negative for smoking, drug use, or recent invasive dental procedures or orofacial illnesses. Her immunizations were up to date. She had noknowndrug allergies. A reviewof systemswas negative for headache, diarrhea, rash, or joint pain. She lived with her mother and stepfather and had no known sick contacts. In the clinic she received a nebulized albuterol treatment, with no improvement in her respiratory status. She was transferred to the pediatric emergency department, where she received a normal saline solution fluid bolus and was treated with intramuscular ceftriaxone. She was then admitted to the pediatric intensive care unit (PICU) because of continued hypotension, respiratory distress, and suspected septic shock. On arrival in the PICU, she was in moderate respiratory distress. Her vital signs were as follows: temperature, 38.3 C; respiratory rate, 50 breaths per minute; heart rate, 124 beats per minute; and blood pressure, 78/38 mmHg. She had a mean arterial pressure of 63 mmHg and oxygen saturation of 92% on 2 L per minute of oxygen administered by nasal cannula. She appeared jaundiced and had significant edema of the neck, abdomen, and lower extremities. Her head,

Ventricular Fibrillation-Induced Cardiac Arrest Results in Regional Cardiac Injury Preferentially in Left Anterior Descending Coronary Artery Territory in Piglet Model.

Objective. Decreased cardiac function after resuscitation from cardiac arrest (CA) results from global ischemia of the myocardium. In the evolution of postarrest myocardial dysfunction, preferential involvement of any coronary arterial territory is not known. We hypothesized that there is no preferential involvement of any coronary artery during electrical induced ventricular fibrillation (VF) in piglet model. Design. Prospective, randomized controlled study. Methods. 12 piglets were randomized to baseline and electrical induced VF. After 5 min, the animals were resuscitated according to AHA PALS guidelines. After return of spontaneous circulation (ROSC), animals were observed for an additional 4 hours prior to cardiac MRI. Data (mean ± SD) was analyzed using unpaired t-test; p value ≤ 0.05 was considered statistically significant. Results. Segmental wall motion (mm; baseline versus postarrest group) in segment 7 (left anterior descending (LAD)) was 4.68 ± 0.54 versus 3.31 ± 0.64, p = 0.0026. In segment 13, it was 3.82 ± 0.96 versus 2.58 ± 0.82, p = 0.02. In segment 14, it was 2.42 ± 0.44 versus 1.29 ± 0.99, p = 0.028. Conclusion. Postarrest myocardial dysfunction resulted in segmental wall motion defects in the LAD territory. There were no perfusion defects in the involved segments.

Reply to letter: Adhesive glove CPR: does it really fit alone?

We have read with interest the article by Shih et al.1 The dhesive glove device cardiopulmonary resuscitation (AGD-CPR), new technique to perform active compression–decompression PR (ACD-CPR) was tested in baby pigs. The device was reported o be much better than hands without the glove, but the authors eport that use of an impedance threshold device (ITD) did not make GD-CPR better. Several observations were made to suggest the title of he article may be misleading. It is well known that when he coronary perfusion pressure (CPP) is <20 mmHg, outcomes re generally poor.2 The authors report that CPP increased rom 9.6 ± 9.1 to 19.7 ± 4.6 to 25.6 ± 12.1 mmHg with stanard CPR, AGD-CPR and AGD-CPR + ITD. While the study was learly not sufficiently powered from a statistical perspective, ne must ask, how would you rather treat your baby, with or ithout the ITD? The CPP of 25.6 mmHg is the clear cut winer. Other questions remain with this report, including whether the ndotracheal tube was cuffed or not. The absence of seal may be eleterious for the ITD. Why were the right atrial pressures so igh? Too much compression force maybe? It seems by the method ection and the pictures that CPR has been performed with two ands. As the piglets weighed only ∼15 kg, this technique may ave resulted in too much compression force and may explain the arkedly elevated level of right atrial pressures. What ITD was sed? The one that is for standard CPR (that opens at 10 cm H2O) r the one for ACD-CPR (that opens at 16 cm H2O)? Perhaps most mportantly, did the anesthesia machine prevent the patient (or iglet) from breathing, and if so, did it close off the airway after ach positive pressure breath, and thus act like an ITD? While it is ot explicit in the article, the use of an automatic anesthesia venilator which produces volume breath at a fixed rate, and which oes not trigger an additional breath in respond to the negative ressure induced by lifting of the chest, implies that the ventilator nd breathing system did provide an impedance to the inspiraion of gasses in the decompression phase of ACD. We believe this an explain the lack of additional effect when ITD is add to the ystem. We have been using ACD-CPR in patients in France for any years and have consistently observed a further benet with the ITD. The very short ventricular fibrillation time f 3 min and CPR durations are strikingly different from what appens in the patients in the field, where CPR is generally erformed for 15–30 min. Further, the strength and force necssary to perform ACD-CPR on adults is much greater than n little piglets or a pediatric manikin.3,4 Unfortunately, by heir study design, the authors may have missed an important 4