Original Contribution
Evaluation of new two-thumb chest compression technique for infant CPR performed by novice physicians. A randomized, crossover, manikin trial

https://doi.org/10.1016/j.ajem.2016.12.045Get rights and content

Abstract

Background

The impact of high-quality chest compressions during CPR for the patients' outcome is undisputed, as it is essential for maintaining vital organ perfusion. The aim of our study is to compare the quality of chest compression (CC) and ventilation among the two current standard techniques with our novel “nTTT” technique in infant CPR.

Methods

In this randomized crossover, manikin trial, participants performed CCs using three techniques in a randomized sequence: standard two finger technique (TFT); standard two thumb technique (TTHT), and the ‘new two-thumb technique’ (nTTT). The novel method of CCs in an infant consists in using two thumbs directed at the angle of 90° to the chest while closing the fingers of both hands in a fist.

Results

Median depth compression using the distinct chest compression techniques varied and amounted to 26 [IQR, 25–28] mm for TFT, and 39 [IQR, 39–39] mm for TTHT as well as for nTTT. Best percentage of fully released compressions were received using TFT (100[100  100] %), then in the case of nTTT (99[98–100] %), and the worst in situation where TTHT (18[14–19] %). was used. The fastest chest compression rate was achieved with TFT (134[IQR, 129–135]/min) and the slowest when using nTTT (109 [IQR, 105–111]/min).

Conclusions

We found that our new nTTT technique's performance, in terms of compression depth, hands-off time, and ventilation quality, is comparable to the current standards. Based on our findings of this initial manikin study, the nTTT technique is superior to TFT in many of parameters that are vital to a quality chest compression during pediatric CPR.

Introduction

Pediatric cardiac-arrest is a life-threatening event that requires timely and effective intervention. There are > 5000 out-of-hospital pediatric cardiac-arrests in the United States annually [1], [2]. Despite resuscitation efforts, it is associated with poor outcomes and only 25% of out-of-hospital survival and subsequent hospital admission [3]. Overall survival rate is low and is reported to range between 0 and 19% with significant neurological sequelae [3], [4], [5]. In a recent study using a large national registry, 8.2% of children survived to hospital discharge, which is unchanged from survival rates twenty years ago [4], [6]. The vast majority of patients are less than two years of age, and are less likely to survive compared to older children [3], [4].

The impact of high-quality chest compressions during CPR for the patients' outcome is undisputed, as it is essential for maintaining vital organ perfusion [7]. Consequently, current CPR guidelines strongly suggest, that interruptions of chest compressions, the so called hands-off time, during CPR should be kept as short as possible [8], [9]. However, chest compressions during pediatric CPR are often suboptimal [10], [11]. For infant resuscitation, AHA recommends 2-finger technique (TFT) for lone rescuer and the 2-thumb–encircling hands (TTHT) technique for two rescuers [12]. TTHT works by placement of two thumbs on lower two-thirds of the sternum and hands encircling the ribcage and back to generate a circumferential force. TTHT has consistently demonstrated to achieve higher blood and coronary perfusion pressures than TFT in a variety of animal and manikin models [13], [14], [15]. A recent study including pediatric Advanced Life Support instructors, reported that the cardiac compression depth of the TFT and the TTHT technique was less than one-third of the chest anterior-posterior diameter and the chest compression rate was clearly above the recommended threshold of about 100 chest compressions per minute [16]. The observation that highly skilled providers using the commonly recommended TFT and the TTHT failed to achieve adequate CPR, clearly indicates need for improvement to optimize cardiac compression during pediatric CPR [17].

We devised a novel chest-compression technique that potentially yield improved compression rate, compression depth, and decreased ventilation hands-off time compared to the existing methods. Our ‘new two-thumb technique’ (nTTT) consists of two thumbs directed at the angle of 90° to the chest while closing the fingers of both hands in a fist (Fig. 1). The alignment of thumbs with the arms allows the upper body strength directed downward to the sternum which theoretically generate higher force compared to TFT which primarily rely on finger and hand strength. Rescuer fatigue, a commonly reported phenomenon in TFT and TTHT, might be less in nTTT due to reduced reliance on small hand muscles [18], [19]. One major disadvantage of the TTHT technique is that it is not applicable when the hand size of the rescuer is too small to adequately wrap around the chest of the infant [9]. The effectiveness of the TTHT technique is limited when the pinching power between the thumb and 4 fingers of the rescuer is weak, which likely results in insufficient cardiac compression and/or rapid exhaustion.

The aim of our study is to compare the quality of chest compression and ventilation among the two current standard techniques with our novel “nTTT” technique in infant CPR. We therefore evaluated chest compression depth, compression rate, ventilation quality and hands-off time for these resuscitation approaches by lone rescuers using an infant manikin model.

Section snippets

Methods

This study was approved by the Institutional Review Board of the Polish Society of Disaster Medicine (approval No.: IRB N23.07.2016). Each participant received oral and written information about the study and the study protocol before providing their written informed consent. 52 novice physicians participated in the current study.

Results

Fifty-two novice physicians (31 female; 59.6%) participated in this study. Mean age was 25.4 ± 1.6 years. All participants had < 1 year experience in medicine. Participants mean height was 169 ± 17.5 cm, and mean weight was 68.5 ± 18.5 kg.

Median depth compression using the distinct chest compression techniques varied and amounted to 26 [IQR, 25–28] mm for TFT, and 39 [IQR, 39–39] mm for TTHT as well as for nTTT (Fig. 3).

Deep enough compressions were obtained best when TTHT or nTTT techniques were used (

Discussion

The most important finding of our study is, that the newly described two-thumb chest compression technique was associated with adequate chest compression depth, compression rate per minute, and high rate of full chest pressure relief.

High quality chest compression is undoubtedly a crucial part of successful CPR. Optimal chest compression includes a compressions rate of at least 100 per minute and at least one third of the anterior-posterior diameter of the chest or at least 4 cm in infants and

Conclusion

In summary, our study evaluated the performance of a novel ‘two-thumb technique’ CPR technique. The basis of our study stems from the deficiencies of current standard techniques and the belief that compression techniques can be optimized. We found that the nTTT technique's performance, in terms of compression depth, hands-off time, and ventilation quality, is comparable to the current standards. Based on our findings of this initial manikin study, the nTTT technique is superior to TFT in many

Author's contributions

JS, LS, AS, KR, SL contributed significantly to the planning of the study and the study design. LS, JS and recruited the participants and collected data. JS and LS were principal investigators of this study and did major manuscript preparation. JS, KR and LS prepared statistical analysis. JS, LS, AS, KR and SL contributed significantly for manuscript editing and expertise.

Source of support

No sources of financial and material support to be declared.

References (28)

  • D.L. Atkins et al.

    Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest

    Circulation

    (2009)
  • A.A. Topjian et al.

    Pediatric out-of-hospital cardiac arrest

    Circulation

    (2012)
  • K.D. Young et al.

    A prospective, population-based study of the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest

    Pediatrics

    (2004)
  • V. Nadkarni et al.

    Pediatric resuscitation. An Advisory Statement From the Pediatric Working Group of the International Liaison Committee on Resuscitation

    Circulation

    (1997)
  • Cited by (39)

    • Chest compressions and medications during neonatal resuscitation

      2022, Seminars in Perinatology
      Citation Excerpt :

      A variation of this technique, the ‘knocking fingers’ technique, in which the healthcare provider flexes their distal and proximal interphalangeal joints to utilize the dorsum of the phalanges to provide CC, while placing the tip of the thumb against the palmar side of the middle phalanx of the index finger (Fig. 2), demonstrated increased CC rate compared to other techniques, however, the ratio of correct CC depth was lower. A further technique is the ‘new two thumb technique (nTTT)’22 (Fig. 3), which has been examined in several manikin studies.23-29 These manikin studies reported that the nTTT-technique i) generated higher systolic, diastolic and median pulse pressures,27,29 ii) highest percentage of compressions with the correct frequency,24 and iii) less fatigue25 and was subjectively preferred by study subjects.24

    • Dominant versus non-dominant hand during simulated infant CPR using the two-finger technique: a randomised study

      2021, Resuscitation Plus
      Citation Excerpt :

      Previous studies have investigated the quality of chest compressions based on hand dominance during CPR in the adult13–18 or older child populations.19 Others have explored the difference between the TTT and TFT for infant chest compressions,20–25 or the use of different fingers with the TFT.12 However, to date, no research has specifically compared DH and NH for iCPR performance using TFT.

    • Comparing the two-finger versus two-thumb technique for single person infant CPR: A systematic review and meta-analysis

      2020, Resuscitation
      Citation Excerpt :

      In addition to addressing our primary question examining the relationship between chest compressions and ventilations between two chest compression techniques, this review also identified noteworthy characteristics about the literature itself. Three studies, all performed by the same group of researchers, identified dramatically higher rates of compressions that reached an adequate depth with the two-thumb technique than all the other studies.24,25,27 The exact reasons for this are not clear and warrants further investigation.

    View all citing articles on Scopus
    View full text