Two-Thumb Encircling Technique Over the Head of Patients in the Setting of Lone Rescuer Infant CPR Occurred During Ambulance Transfer: A Crossover Simulation Study.

OBJECTIVE: The purpose of this study was to determine if the over-the-head 2-thumb encircling technique (OTTT) provides better overall quality of cardiopulmonary resuscitation compared with conventional 2-finger technique (TFT) for a lone rescuer in the setting of infant cardiac arrest in ambulance. METHODS: Fifty medical emergency service students were voluntarily recruited to perform lone rescuer infant cardiopulmonary resuscitation for 2 minutes on a manikin simulating a 3-month-old baby in an ambulance. Participants who performed OTTT sat over the head of manikins to compress the chest using a 2-thumb encircling technique and provide bag-valve mask ventilations, whereas those who performed TFT sat at the side of the manikins to compress using 2-fingers and provide pocket-mask ventilations. RESULTS: Mean hands-off time was not significantly different between OTTT and TFT (7.6 ± 1.1 seconds vs 7.9 ± 1.3 seconds, P = 0.885). Over-the-head 2-thumb encircling technique resulted in greater depth of compression (42.6 ± 1.4 mm vs 41.0 ± 1.4 mm, P < 0.001) and faster rate of compressions (114.4 ± 8.0 per minute vs 112.2 ± 8.2 per minute, P = 0.019) than TFT. Over-the-head 2-thumb encircling technique resulted in a smaller fatigue score than TFT (1.7 ± 1.5 vs 2.5 ± 1.6, P < 0.001). In addition, subjects reported that compression, ventilation, and changing compression to ventilation were easier in OTTT than in TFT. CONCLUSIONS: The use of OTTT may be a suitable alternative to TFT in the setting of cardiac arrest of infants during ambulance transfer.

Modified carotid sinus massage using an ultrasonography for maximizing vagal tone: a crossover simulation study.

INTRODUCTION: The aim of this study was to ascertain if a modified carotid sinus massage (CSM) using ultrasonography is superior to the conventional CSM for vagal tone generation. METHODS: This was a prospective, crossover, clinical trial including 30 subjects with sinus rhythm. Participants were paired, and they performed 2 types of CSM to each other. To perform the conventional technique, pressure was exerted at the point where the maximal impulse of the carotid pulse was palpated. In the modified technique, participants localized the point of maximal diameter just above the bifurcation of the common carotid artery using ultrasonography and applied pressure to that point. Mean differences between premaneuver and postmaneuver R-R intervals and heart rates were compared. The distance from the midline of the neck (x distance) to the angle of the mandible (y distance) was measured, and the mean distance between the 2 techniques was compared. RESULTS: The baseline mean premaneuver R-R interval and heart rate did not differ significantly between the 2 techniques. The postmaneuver R-R interval and heart rate as well as the mean R-R interval and heart rate differences were significantly greater in the modified CSM. The mean location determined using the modified CSM was located 0.8 cm lateral and 0.8 cm superior to the mean location of the conventional CSM. CONCLUSION: The modified CSM using ultrasonography might be more useful than the conventional CSM in reverting episodes of paroxysmal supraventricular tachycardia and may be a suitable alternative for treating the same in the emergency department.

Rescuer-limited cardiopulmonary resuscitation as an alternative to 2-min switched CPR in the setting of inhospital cardiac arrest: a randomised cross-over study.

BACKGROUND: The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) recommend that chest compression be rotated every 2 min to prevent rescuer fatigue. However, the quality of chest compression using 2-min switched CPR tends to decrease rapidly due to rescuer fatigue. We aimed to compare the effectiveness of use of 2-min switched CPR and rescuer-limited CPR (the person performing compressions is allowed to switch with another rescuer prior to 2 min if feeling fatigued) in the setting of inhospital cardiac arrest. METHODS: Using a randomised cross-over trial design, 90 medical students were grouped into pairs to perform four cycles of 2-min switched CPR and rescuer-limited CPR (495 s per technique). During each trial, the total number of compressions performed, mean depth of compression and proportion of effective compressions performed (compression depth >5 mm) were recorded for identification of significant differences and changes in pulse rate and RR were measured to determine the extent of exhaustion. RESULTS: Compared with 2-min switched CPR, the mean compression was deeper (51 vs 47 mm, p<0.001), total number of compressions greater (476 vs 397, p=0.003) and proportion of effective compressions greater (56% vs 47%, p=0.004) during rescuer-limited CPR. Subgroup analysis by 30-s unit showed more consistent compression quality during rescuer-limited CPR. No significant differences in change in pulse rate and RR were found between the two techniques. CONCLUSIONS: Rescuer-limited CPR yields a greater number of effective compressions and more consistent quality of CPR than 2-min switched CPR. Rescuer-limited CPR might be a suitable alternative for treating inhospital cardiac arrest.

Over-the-head two-thumb encircling technique as an alternative to the two-finger technique in the in-hospital infant cardiac arrest setting: a randomised crossover simulation study.

OBJECTIVE: To determine if the over-the-head two-thumb encircling technique (OTTT) provides better quality cardiopulmonary resuscitation (CPR) than the conventional two-finger technique (TFT) when performed by a lone rescuer in an in-hospital infant cardiac arrest setting. METHODS: This prospective, randomised crossover design study recruited 50 nurses who voluntarily performed lone rescuer infant CPR for 2 min on a manikin. Participants who performed OTTT stood at the head of the manikin to compress the chest and provide bag-valve mask ventilations, whereas those who performed TFT stood by the side of the manikin to compress the chest and provide pocket-mask ventilations. Mean hands-off time, mean compression depths and rates, proportion of effective compressions and complete recoil, and fatigue score changes were assessed during the test, and a survey on the ease of use of the techniques was conducted after the test. RESULTS: Hands-off time, total ventilation volume and number of ventilations were not significantly different between the two techniques. OTTT resulted in greater depth of compressions (p<0.001), greater proportion of effective compressions (p<0.001), smaller proportion of complete recoil (p=0.001), and smaller fatigue score change (p=0.003) than TFT. In addition, subjects reported that compression, ventilation and changing compression to ventilation were easier using OTTT than TFT. CONCLUSIONS: OTTT performed by a lone rescuer in an in-hospital infant cardiac arrest setting resulted in greater compression depth, with no increase in hands-off time, compared with TFT. OTTT may therefore be a suitable alternative to TFT in the in-hospital infant cardiac arrest setting.

Endotracheal tube-assisted orogastric tube insertion in intubated patients in an ED.

BACKGROUND AND AIMS: Inserting a nasogastric tube (NGT) in intubated patients may be difficult because they cannot follow swallowing instructions, resulting in a high rate of first-attempt failure. We introduce a simple technique for inserting an orogastric tube in an emergency department (ED). METHODS: Fifty-six patients in the ED, who were intubated and required NGT insertion, were randomly allocated to 2 groups. We inserted the NGT using a conventional technique from the nostril (control group) and an endotracheal tube (ET)-assisted technique from the mouth (ET group). The procedures' success rate, insertion duration, and complications were compared between the groups. RESULTS: There was a significantly higher overall success rate in the ET group than the control group (100% vs 64%, P<.001). Endotracheal tube group showed 100% first-attempt success rate, but 50% of the control group failed at first attempt. Mean duration of the first trial was not significantly different between the ET and control groups (58.0±16.9 vs 57.3±29.5 seconds, P=.903), but total time for successful insertion was longer in the control group than the ET group (58.0±16.9 vs 111.7±74.5 seconds, P<.001). There was less NGT kinking and more mucosal bleeding in the ET group than in the control group (0% vs 16%, P=.019; 16% vs 7%, P=.225, respectively). CONCLUSION: Endotracheal tube-assisted orogastric tube insertion technique showed a higher rate of successful insertion and shorter total duration. With this result, ET-assisted orogastric tube insertion would be useful in ED.

The importance of victim chest exposure during cardiopulmonary resuscitation: a simulation study.

BACKGROUND: During cardiopulmonary resuscitation (CPR), inaccurate positioning of the rescuer's hand might damage internal organs due to compression around the xiphoid process. OBJECTIVE: This study aimed to determine whether exposing the victim's chest during CPR would help adequate positioning of a rescuer's hand on the chest. METHODS: This simulation study included 187 participants. We gave them four photographs each of exposed chests and unexposed chests. Participants were then asked to mark a cross at the center of the chest (CoC) and at the inter-nipple line (INL), and we measured the width of participants' palms to estimate the range of hand contact with the victim's chest. Finally, we compared the position and distribution of the CoC and INL markings and analyzed whether the hand contact range on the victim's chest involved the xiphoid process. RESULTS: The participants' CoC markings were similar regardless of whether the pictures showed an exposed or unexposed chest (p = 0.638). However, the level of INL marking was significantly lower in pictures of an exposed chest (p < 0.001). When exposing the chest, the distribution of markings was narrower for both CoC (p = 0.001) and INL (p < 0.001). The proportion of CoC markings involving the xiphoid process were lower when the chest was exposed (10.7%) than when was clothed (12.3%) (p < 0.001). Similarly, INL markings involving the xiphoid process followed the same trend in exposed vs. unexposed chest images (0% vs. 1.6%, respectively). CONCLUSIONS: Exposing the chest during CPR can improve the rescuer's ability to recognize the CoC and INL, leading to more intense chest compression and reducing the risk of inaccurate compression.