Simulation and educationDoes a more “physiological” infant manikin design effect chest compression quality and create a potential for thoracic over-compression during simulated infant CPR?☆
Introduction
Current European and UK Resuscitation Council's (ERC; UKRC) guidelines for infant cardiopulmonary resuscitation (CPR) emphasise that improved chest compression quality may improve survival rates.1, 2 The International Liaison Committee of Resuscitation (ILCOR), ERC and UKRC recommend the use of either the two-thumb (TT) or two-finger (TF) chest compression technique. Current chest compression recommendations include: compression depths of at least one-third the external anterior–posterior (AP) thoracic diameter (≈40 mm); compression rates of 100–120 min−1; complete release of the chest; 30–50% duty cycle (i.e. the proportion of each cycle with active chest compression).1, 2, 3, 4, 5, 6
The ERC and UKRC recommend that resuscitators push “hard and fast” to achieve the chest compression guidelines.1, 2 Whilst the maximum chest compression depth (CDmax) of industry-leading infant resuscitation manikins broadly correlate with the minimum clinical requirement (≈40 mm), manikin-based studies typically report that participants perform shallow chest compressions across a broad range of rates.7, 8, 9, 10, 11 The prevention of excessively deep chest compressions is also important as, for example, chest compression depths >46 mm have the potential to cause intra-thoracic injury in 90% of patients and thus hinder the possibility of full recovery.12, 13, 14, 15, 16, 17, 18
Previous studies have used manikins to investigate resuscitator performance7, 8, 9, 10, 11; however, with a CDmax limited to ≈40 mm, it is argued that this may have prevented resuscitators from achieving representative chest compressions.11, 19 This study develops a more “physiological” manikin design, thus enabling resuscitators to perform chest compression on a more representative model. The study will determine whether the new design encourages improved chest compression performance during training and greater compliance with the recommended guidelines, whilst also evaluating whether resuscitators inadvertently perform chest compressions to excessive depths.
Section snippets
Modified infant manikin design
A commercially available CPR training manikin (Laerdal® ALS Baby; Laerdal Medical, Stavanger, Norway), representing a three month old 5 kg male infant, was modified to allow CDmax to be varied between the original manikin specification (i.e. 40 mm; CDmax40), and the physiological internal chest depth of a three month old male infant (i.e. 56 mm; CDmax56).12 Manikin chest deflections, during simulated CPR, were measured by an infra-red sensor (Sharp Corporation, Osaka, Japan), with the 50 Hz output
Results
Forty certified EPLS instructors (22 female) participated in this study: 16 were resuscitation officers; 12 were doctors; eight were registered nurses; two were operating department practitioners and two were paramedics. The simulated chest compression quality measures observed by this study are illustrated against internationally recommended targets in Fig. 1.
For both the TT and TF techniques, the more “physiological” manikin design was observed to increase chest compression depths and reduce
Discussion
This study is the first to utilise a more “physiological” infant manikin design during simulated CPR, with results demonstrating improved chest compression depth and compression duty cycle compliance for both infant chest compression techniques. Despite these improvements, chest compression quality remained poor for both chest compression techniques, with <8% of all chest compressions complying with all four quality targets and both TT and TF chest compression techniques observed to
Conclusions
This study is the first to develop a more “physiological” manikin design that enabled resuscitators to perform chest compressions to greater depths. This manikin design improved the compliance of both chest compression depths and compression duty cycles with internationally recommended targets, whilst introducing the potential risks of thoracic over-compression during infant CPR. Despite this, overall chest compression compliance during simulated infant CPR remained very poor primarily due to
Conflict of interest statement
There are no competing financial interests, organisational ties or other relationships which may create an actual or apparent conflict of interest in regard to our study.
Acknowledgments
The authors would like to thank Dr. Ian Maconochie for his valuable comments in our preparation of this manuscript, and the staff and technicians at the Cardiff University Schools of Engineering and Medicine for their assistance throughout the performance of our investigation. The authors would also like to thank the EPLS training course organisers and NHS Trusts for hosting and helping organise this research, and the EPLS training course instructors that consented to participate in this study.
References (29)
- et al.
European Resuscitation Council Guidelines for Resuscitation 2010 Section 6
Paediatric life support Resuscitation
(2010) - et al.
Comparison of a two-finger versus two-thumb method for chest compressions by healthcare providers in an infant mechanical model
Resuscitation
(2000) - et al.
Chest compression quality and rescuer fatigue with increased compression to ventilation ratio during single rescuer pediatric CPR
Resuscitation
(2008) - et al.
Two-thumb technique is superior to two-finger technique during lone rescuer infant manikin CPR
Resuscitation
(2010) - et al.
Evaluation of the Neonatal Resuscitation Program's recommended chest compression depth using computerized tomography imaging
Resuscitation
(2010) - et al.
Pediatric injuries from cardiopulmonary resuscitation
Ann Emerg Med
(1996) - et al.
Skeletal chest injuries secondary to cardiopulmonary resuscitation
Resuscitation
(2004) - et al.
Complications of cardiac resuscitation
Chest
(1987) - et al.
Does cardiopulmonary resuscitation cause rib fractures in children? A systematic review
Child Abuse Negl
(2006) - et al.
Compression range for pediatric CPR training mannequin should match physiological parameters
Resuscitation
(2010)
Effect of residual leaning force on intrathoracic pressure during mechanical ventilation in children
Resuscitation
Depth of sternal compression and intra-arterial blood pressure during CPR in infants following cardiac surgery
Resuscitation
The effect of applied chest compression force on systemic arterial pressure and end-tidal carbon dioxide concentration during CPR in human beings
Ann Emerg Med
Relationship of blood pressure and flow during CPR to chest compression amplitude: evidence for an effective compression threshold
Ann Emerg Med
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2021, Resuscitation PlusCitation Excerpt :The equipment used to analyse iCPR performance included: (i) a baby manikin representing a 5 kg, three-month-old infant (Laerdal® ALS Baby, Laerdal Medical, Stavanger, Norway). This manikin was modified during a previous study to allow a maximum compression depth of 56 mm30 and was instrumented with (ii) two accelerometers (one fixed on the manikin’s chest and the other on the board where the manikin was placed, acting as a differential, for the surface on which the CPR was conducted). Data were acquired by (iii) a data acquisition unit (LabView), connected to a (iv) personal computer (PC) and (v) a power supply.
Part 7: Neonatal resuscitation. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations
2015, ResuscitationCitation Excerpt :For the critical outcomes of time to ROSC, survival rates, or neurologic injury, we found no data. For the critical outcome of improved perfusion and gas exchange during CPR, we identified low-quality evidence from 9 randomized controlled trials (downgraded for indirectness and imprecision)182–190 and 6 nonrandomized controlled trials (downgraded for indirectness, imprecision, and high risk of bias)191–196 identifying higher blood pressure generation with the 2-thumb versus the 2-finger method. For the important outcome of compressor fatigue, we identified low-quality evidence from 4 randomized controlled trials (downgraded for indirectness and imprecision), with 2183,197 identifying less fatigue with the 2-thumb versus the 2-finger technique, and 2 studies finding no difference.189,198
Real-time feedback can improve infant manikin cardiopulmonary resuscitation by up to 79%-A randomised controlled trial
2013, ResuscitationCitation Excerpt :This study utilised a commercially available CPR manikin (Laerdal® ALS Baby, Laerdal Medical, Stavanger, Norway), representing a three month old 5 kg male infant. The manikin had previously been modified to enable a more “physiological” maximum chest compression depth (i.e. an increase from 40 mm to 56 mm),15,16 whilst maintaining a chest compression stiffness consistent with that of the original design.15 The manikin was instrumented to measure chest deflections through analysing the output voltage of an infra-red distance measuring sensor (Sharp Corporation, Osaka, Japan).
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.10.005.