Two-thumb versus two-finger chest compression during CPR in a swine infant model of cardiac arrest

doi:10.1016/S0196-0644(05)80212-4

Annals of Emergency Medicine

Volume 22, Issue 2, February 1993, Pages 240-243

https://doi.org/10.1016/S0196-0644(05)80212-4 Get rights and content

Study objective:

To test the hypothesis that two-thumb chest compression generates higher arterial and coronary perfusion pressures than the current American Heart Association-approved two-finger method.

Design:

Randomized, crossover experimental trial.

Setting and participants:

Animal laboratory experiment with seven swine of either sex weighing 9.4 kg (SD, 0.8 kg), representing infants less than 1 year old.

Interventions:

Animals were sedated with IM ketamine/xylazine, intubated with a 6.0 Hi-Lo endotracheal tube, anesthetized with α-chloralose, and paralyzed with pancuronium. ECG was monitored continuously. Left femoral arterial and Swan-Ganz catheters were placed. Cardiac arrest was induced with an IV bolus of KCl and verified by ECG and pressure tracings. Five American Heart Association-certified basic rescuers were randomly assigned to perform external chest compressions for one minute by either the currently recommended two-finger method or the two-thumb and thorax-squeeze method. After all five completed their first trial, rescuers crossed over to the other method for a second minute of compressions. Ventilation was performed with a bag-valve device, and no drugs were given during CPR. After three complete cycles, the fourth through sixth cycles of compressions were recorded. Every compression was analyzed for arterial systolic, diastolic, mean, and coronary perfusion pressures. One thousand fifty compressions were analyzed with repeated-measures analysis of variance and Scheffé multiple comparisons.

Results:

Systolic blood pressure, diastolic blood pressure, mean arterial pressure, and coronary perfusion pressure were all significantly higher (P < .001) with the two-thumb thoracic squeeze technique: systolic blood pressure, 59.4 versus 41.6 mm Hg; diastolic blood pressure, 21.8 versus 18.5 mm Hg; mean arterial pressure, 34.2 versus 26.1 mm Hg; and coronary perfusion pressure, 15.1 versus 12.2 mm Hg.

Conclusion:

The two-thumb method of chest compression generates significantly higher arterial and coronary perfusion pressures than the two-finger method in this infant model of cardiac arrest.

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There are more references available in the full text version of this article.

Cited by (118)

A novel CPR-assist device vs. established chest compression techniques in infant CPR: A manikin study
2024, American Journal of Emergency Medicine
Guidelines for infant CPR recommend the two-thumb encircling hands technique (TTT) and the two-finger technique (TFT) for chest compression. Some devices have been designed to assist with infant CPR, but are often not readily available. Syringe plungers may serve as an alternative infant CPR assist device given their availability in most hospitals. In this study, we aimed to determine whether CPR using a syringe plunger could improve CPR quality measurements on the Resusci-Baby manikin compared with traditional methods of infant CPR.
Compression area with a diameter of 1 to 2 cm is recommended in previous infant CPR device researches. In this is a randomized crossover manikin study, we examined the efficacy of the Syringe Plunger Technique (SPT) which uses the plunger of the 20 ml syringe with a 2 cm diameter flat piston, commonly available in hospital, for infant External Chest Compressions (ECC). Participants performed TTT, TFT and SPT ECC on Resusci® Baby QCPR® according to 2020 BLS guidelines.
Sixty healthcare providers participated in this project. The median (IQR) ECC depths in the TTT, TFT and SPT in the first minute were 41 mm (40–42), 40 mm (38–41) and 40 mm (39–41), respectively, with p < 0.001. The median (IQR) ECC recoil in the TTT, TFT and SPT groups in the first minute was 15% (1–93), 64% (18–96) and 53% (8–95), respectively, with p = 0.003. The result in the second minute had similar findings. The SPT had the best QCPR score and less fatigue.
The performance of chest compression depth and re-rebound ratio was statistically different among the three groups. TTT has good ECC depth and depth accuracy but poor recoil. TFT is the complete opposite. SPT can achieve a depth close to TTT and has a good recoil performance as TFT. Regarding comprehensive performance, SPT obtains the highest QCPR score, and SPT is also less fatigued. SPT may be an effective alternative technique for infant CPR.
Chest compression by two-thumb encircling method generates higher carotid artery blood flow in swine infant model of cardiac arrest
2021, Resuscitation Plus
Citation Excerpt :
In neonates and infants, two-thumb encircling and two-finger techniques are recommended in current guidelines,1,2 largely based on manikin and two animal studies12,13 reporting blood pressure but not blood flow data. Menegazzi et al. compared TT to TF chest compression in a swine infant model and reported that TT-CPR generated higher systolic and diastolic blood pressures and coronary perfusion pressure (CPP) compared with the TF technique, but did not measure blood flows.12 In another study, Houri et al. compared standardized TT vs TF chest compression with and without feedback in a swine asphyxia model of cardiac arrest and reported higher systolic but not diastolic blood pressure.13
Two-Thumb(TT) technique provides superior quality chest compressions compared with Two-Finger(TF) in an instrumented infant manikin. Whether this translates to differences in blood flow, such as carotid arterial blood flow(CABF), has not been evaluated. We hypothesized that TT-CPR generates higher CABF and Coronary Perfusion Pressure(CPP) compared with TF-CPR in a neonatal swine cardiac arrest model.
Twelve anesthetized & ventilated piglets were randomized after 3 min of untreated VF to receive either TT-CPR or TF-CPR by PALS certified rescuers delivering a compression rate of 100/min. The primary outcome, CABF, was measured using an ultrasound transonic flow probe placed on the left carotid artery. CPP was calculated and end-tidal CO₂(ETCO₂) was measured during CPR. Data(mean ± SD) were analyzed and p-value ≤0.05 was considered statistically significant.
Carotid artery blood flow (% of baseline) was higher in TT-CPR (66.2 ± 35.4%) than in the TF-CPR (27.5 ± 10.6%) group, p = 0.013. Mean CPP (mm Hg) during three minutes of chest compression for TT-CPR was 12.5 ± 15.8 vs. 6.5 ± 6.7 in TF-CPR, p = 0.41 and ETCO₂ (mm Hg) was 29.0 ± 7.4 in TT-CPR vs. 20.7 ± 5.8 in TF-CPR group, p = 0.055.
TT-CPR achieved more than twice the CABF compared with TF-CPR in a piglet cardiac arrest model. Although CPP and ETCO₂ were higher during TT-CPR, these parameters did not reach statistical significance. This study provides direct evidence of increased blood flow in infant swine using TT-CPR and further supports that TT chest compression is the preferred method for CPR in infants.
European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth
2021, Resuscitation
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
Comparing the two-finger versus two-thumb technique for single person infant CPR: A systematic review and meta-analysis
2020, Resuscitation
Current guidelines recommend that single person cardiopulmonary resuscitation (CPR) on an infant should be performed with two-fingers just below the inter-mammillary line with the hand clenched, while two-person CPR should be performed with two-thumbs with the hands encircling the chest. Those recommendations are based on literature that demonstrates higher quality chest compressions with the two-thumb technique, with concerns that this technique may compromise ventilation parameters when performed by the single rescuer. The purpose of this study is to compare the two compression techniques’ performance during CPR using both compression and ventilation parameters.
We performed a systematic review and meta-analysis of literature identified through a search of PubMed and One-Search comparing the quality of chest compressions and ventilation parameters between the two-thumb and two-finger techniques (Prospero registration # CRD42018087672).
We identified 20 manuscripts examining single person infant CPR that met study criteria, with 16 that included data suitable for meta-analysis. All of the studies included in the analysis were performed on a standardized manikin. Overall, the two-thumb technique resulted in a mean difference of 5.61 mm greater compression depth compared to the two-finger technique, with 36.91% more compressions of adequate depth per national guidelines. Interestingly, ventilation parameters did not differ between the two techniques.
While recognizing that the results of this review may differ from actual clinical experience due to the lack of fidelity between manikins and actual human infants, this systematic review with meta-analysis demonstrates that when CPR is performed on a simulated infant manikin by a single rescuer, the two-thumb technique with hands encircling the chest improves chest compression quality and does not appear to compromise ventilation.
Circulatory emergencies in the delivery room
2019, Seminars in Fetal and Neonatal Medicine
The transition from fetal to neonatal life is a dramatic and complex process involving extensive physiologic changes, which are most obvious at the time of birth. Individuals who care for newly born infants must monitor the progress of the transition and be prepared to intervene when necessary. In the majority of births, this transition occurs without a requirement for any significant assistance. If newborns require assistance, the majority of the time respiratory support is all that is required. In some instances, however, there are circulatory emergencies that need to be rapidly identified or there may be dire consequences including death in the delivery room. This chapter will review various pathologies that are circulatory emergencies, and discuss how to assess them. We will also review new technologies which may help providers better understand the circulatory status or hemodynamic changes in the delivery room including heart rate, cardiac output, cerebral oxygenation and echocardiography.
What to do if A + B doesn't work
2018, Seminars in Fetal and Neonatal Medicine
The majority of newborn resuscitations require very little beyond simple airway management and assisted ventilation. If cardiovascular collapse is serious enough to warrant additional support, resuscitation algorithms recommend moving to chest compressions and then on to medications and possibly volume replacement if vital signs remain marginal or absent. The evidence base upon which this part of the neonatal resuscitation algorithm is structured is sparse. Chest compressions and medications are rare interventions that do not lend themselves easily to clinical trials. Slowly but surely, however, the genesis of an empirical evidence base for this part of the algorithm is beginning to appear.

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: Presented at the Society for Academic Emergency Medicine Annual Meeting in Toronto, Ontario, Canada, May 1992.

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Brief reportTwo-thumb versus two-finger chest compression during CPR in a swine infant model of cardiac arrest

Study objective:

Design:

Setting and participants:

Interventions:

Results:

Conclusion:

Ann Emerg Med

Lancet

Ann Emerg Med

Am J Emerg Med

Pediatric cardiopulmonary resuscitation

Clin Pediatr

Brief report
Two-thumb versus two-finger chest compression during CPR in a swine infant model of cardiac arrest