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Fırat University Medical Journal of Health Sciences
2020, Cilt 34, Sayı 3, Sayfa(lar) 193-197
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Gerçek Şehir Trafiğinde Mekanik Göğüs Kompresyonu ile Manuel Göğüs Kompresyonu Arasında Etkinlik Karşılaştırması
Süha SERİN, Bahadır ÇAĞLAR
University of Balıkesir, Faculty of Medicine, Department of Emergency Medicine, Balıkesir, TURKEY
Anahtar Kelimeler: Acil tıbbi servisler, cankurtaranlar, canlandırma, hastaların hareket ettirilmesi ve kaldırılması
Özet
Amaç: Hastane dışı ani kardiyak arrest vakalarında sağkalım oranını artıran en önemli faktör, erken başlatılan ve etkin bir şekilde uygulanan kardiyopulmoner resüsitasyondur. Bu çalışma, gerçek şehir trafiğinde hareket eden bir ambulansta, sağlık çalışanları tarafından uygulanan manuel göğüs kompresyonlarının etkinliğini ile mekanik bir göğüs kompresyon cihazının etkinliği ile karşılaştırmayı amaçlamaktadır.

Gereç ve Yöntem: Otuz Sağlık çalışanından ambulanstaki mankene farklı göğüs duvarı sertliklerinde 2 dakikalık göğüs kompresyonları yapmaları istendi. Göğüs kompresyonları sırasında, ambulans gerçek şehir trafiğinde sürekli hareket halindeydi. Ardından manken üzerine mekanik bir göğüs kompresyon cihazı yerleştirilip aynı şartlarda göğüs kompresyonları yaptırıldı. Her döngüye ait göğüs kompresyonlarının ortalama hız ve derinlikleri bilgisayar programı ile kaydedildi.

Bulgular: Sağlık çalışanı grubu ve mekanik göğüs kompresyon cihazı grubunun ortanca göğüs kompresyon derinlikleri sırasıyla; 6 nm göğüs duvarı sertliğinde 52 mm ve 55 mm ve 11 nm göğüs duvarı sertliğinde 42 mm ve 51 mm ölçüldü. Dakikadaki sıkıştırma sayısıları incelendiğinde, her iki grupta 6 nm göğüs duvarı sertliğinde 102 /dk, 11 nm göğüs duvarı sertliğinde 85 /dk ve 101 /dk idi.

Sonuç: Sonuç olarak, mekanik göğüs kompresyon cihazları taşıma sırasında sağlık çalışanlarına kıyasla daha etkili göğüs kompresyonu sağlar. Yüksek vücut kitle indeksi olan hastalarda mekanik göğüs kompresyon cihazının etkinliği daha fazladır.

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    Out of hospital sudden cardiac arrest is one of the leading causes of death in the world. Today, the survival rate of out-of-hospital sudden cardiac arrest is relatively low 1,2. Neurological sequelae are observed in 90-95% of surviving patients 3. The most significant factor that increases the survival rate in out-of-hospital sudden cardiac arrest cases is cardiopulmonary resuscitation (CPR), which is started early and performed effectively. Because the continuity of perfusion of vital organs can only be achieved by effective resuscitation 2,4,5. The crucial point in effective CPR is to perform chest compression at a sufficient number (100-120/min) and depth (50-60 mm) 6-9. Due to the limited availability of healthcare workers and adverse environmental conditions, effectiveness is generally low in CPRs during transport or out-of-hospital cases 10,11.

    Effective chest compression can be performed for the desired duration with mechanical chest compression devices (MCCD). Transport conditions such as carrying on a stretcher or with an ambulance affect the number and depth of chest compression applied to the patient. These devices are thought to allow for effective chest compressions during transport. Chest compression with an MCCD is uninterrupted because it does not require a replacement of the rescuer 12. MCCD is theoretically more effective because it is independent of the rescuer 12. Mechanical chest compression devices are also safer for the transport team, who operate in a moving ambulance.

    This study aims to compare chest compressions performed by healthcare professionals with chest compressions performed by an MCCD. Both compressions are performed in an ambulance on the move in real city traffic.

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    Our study was conducted in an ambulance on the move at a crowded city (İzmir) with approximately 4.5 m population at Western Turkey. As the route, the main streets of the city, which are about 10 km long were chosen at the rush hour period. Local ethics committee permission (from Izmir Bozyaka Training and Research Hospital Clinical Research Ethics Committee at 05.07.2017/5) and other necessary permissions were obtained before the study.

    The study was carried out with 30 paramedics who attended the training organized by the ministry of health and had a minimum of 5 years of experience. Paramedics were asked to perform chest compression on the computer-assisted resuscitation manikin (Ambu Man Manikin, Ambu, USA), in accordance with the guidelines, which was placed on the trauma board in the ambulance (Transit, Ford, 2015). The manikin had adjustable chest stiffness. 6 N/mm chest stiffness was chosen to represent patients with low body mass and/or young, and 11 N/mm for patients with high body mass and/or elder. In the first round, the manikin's chest stiffness was adjusted to 6 N/mm, and each paramedic applied chest compression for 2 minutes. In the second round, its chest stiffness was adjusted to 11 N/mm, and each paramedic applied chest compression for 2 minutes. To exclude the fatigue effect, paramedics applied chest compressions in the same order. After every 2 minutes of the cycle, the average speed and depth of the compressions of that cycle were recorded on the computer. During the compresses, the ambulance continued to move on the predetermined city route.

    Then, while the ambulance was moving on the same route, a mechanical chest compression device (LUCAS 2, Jolife AB, Sweden) was placed on the manikin. 30 cycles were taken at each hardness level for 6 N/mm and 11 N/mm, respectively (each cycle were 2 minutes). Average speeds and depths of compressions for each cycle were recorded.

    SPSS 25.0 (IBM Corporation, Armonk, New York, United States) and PAST 3 (Hammer, Ø., Harper, D.A.T., Ryan, P.D. 2001. Paleontological statistics) were used in the analysis of variables. While the distribution of univariate data was evaluated by the Shapiro-Wilk test, Mardia (Dornik and Hansen omnibus) test was used to test the normality of multivariate data. To compare the depth/mm and rate/minute variables of the MCCD and Paramedic groups based on the 6 N/mm and 11 N/mm data, Mann-Whitney U test, which is one of the nonparametric tests, was used together with Monte Carlo results. Wilcoxon Signed Ranks Test was used with Monte Carlo results to compare the 6 N/mm and 11 N/mm measurements of the depth/mm and rate/minute variables. Quantitative variables are shown as median (Minimum/Maximum) in the tables. Variables were examined at a 95% confidence level, and the p-value was taken as <0.05.

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    The compression depth median value in the paramedic group was 52 mm for the 6 N/mm chest stiffness level. However, ineffective cycles (<50 mm) with a minimum of 46 mm were detected in the paramedic group. In the MCCD group, the effective depth value (50-60 mm) was measured in all cycles with a median value of 55 mm.

    When the chest wall stiffness was set as 11 N/mm, the compression depth median value in the paramedic group was measured as 42 mm. In the MCCD group, effective depth value (50-60 mm) were detected in all cycles with 51 mm depth median value.

    As for the number of compression per minute, the median value of the compression number in paramedic and MCCD group at 6 N/mm stiffness level was 102/min. However, ineffective cycles (<100/min) with a minimum of 95/min were detected in the paramedic group.

    When the chest wall stiffness level is set to 11 N/mm, the median value of compression in the paramedic group was 85/min while it was 101/min in the MCCD group (Table 1, Figure 1-2).


    Büyütmek İçin Tıklayın
    Table 1: Chest wall depth and compression rate per minute by groups


    Büyütmek İçin Tıklayın
    Figure 1: Chest wall depth by groups


    Büyütmek İçin Tıklayın
    Figure 2: Chest compression rate per minute by groups

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    Central nervous system perfusion is important for better neurological results in patients with return of spontaneous circulation. The desired perfusion can be achieved with quality chest compressions during CPR 13-17. The features of chest compressions are highlighted in detail in each new resuscitation guide 18. In the literature, there are studies comparing MCCD with manual compression. In the present study, MCCD is found more effective than manual compression in situations where physical conditions such as transportation are more difficult, and the workforce is limited. Gyory and et al. 19 put, “the machine does not get tired like a human and the quality of chest compressions does not decrease over time”.

    Although paramedics performed chest compressions for only 2 minutes, ineffective chest compressions were measured at both chest stiffness levels. We think that the reason for this is the difficulty of the physical conditions (linear-angular acceleration, vibration, shake etc.) caused by the constant movement of the ambulance 20-23. The effort made by paramedics to keep their balance in the moving ambulance negatively affects their CPR performance24. Paramedics described doing compression in a moving ambulance as “potentially unsafe” 25. Studies have shown that the conditions such as acceleration, vibration, and shaking caused by the ambulance movement trigger reflexive movements of paramedics. These reflexive movements pose a danger to the paramedics and the patients. The use of MCCD will mitigate this danger 20,26-29.

    The patient's body mass index or thorax flexibility affects the power to be applied for effective chest compression. In the literature, there are not enough studies examining the quality of chest compressions according to the physical characteristics of the patient, such as body mass and age. Although its importance is emphasised in guidelines, we think that chest compression cannot be applied effectively (100-120/min and 50-60 mm) to patients during transport in real life. In the present study, we measured effective number and depth chest compressions in the MCCD group at both chest wall stiffness levels. There was a significant difference in median values of compression depth between the paramedic and MCCD groups for the 6 N/mm chest wall stiffness. However, in this stiffness level, ineffective number of compression and ineffective depth of compression were measured the paramedic group. In 11 N/mm chest wall stiffness, the ineffective compression difference between the groups increased significantly.

    In summary, CPR quality decreases during the patient's transport 21. In such cases, it can be said that MCCD usage becomes crucial. Because when MCCD is used during transportation, the quality of the compressions can be achieved as suggested in the guidelines 13.

    The strengths of our study are the experienced paramedics and the ambulance moving in real city traffic.

    In limitations, the clinical effect of the compressions that we interpret as an ineffective compression (<100/min, <5mm) was not be examined since we used a manikin. The effect of fatigue on CPR was not evaluated since the paramedics performed chest compression for only 2 minutes. A manikin was used in the study, and this manikin had two chest stiffness levels. Therefore, chest compression was not evaluated in patients with different physical features (infant, child, morbid obesity, etc.). In the study, assembly time of the MCCD to the patient was not evaluated. Assembly time that affects the onset of CPR may prolong in patients with high body mass index.

    As a result, MCCD provides more effective chest compression during transport when compared to manual compression. The effectiveness of MCCD increases in patients with high body mass index.

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    1) Benjamin EJ, Virani SS, Callaway CW, et al. American heart association council on epidemiology and prevention statistics committee and stroke statistics subcommittee. Heart disease and stroke statistics-2018 update: A report from the American Heart Association. Circulation 2018; 137: e67-e492.

    2) Perkins GD, Handley AJ, Koster RW, et al. Adult basic life support and automated external defibrillation section Collaborators. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation 2015; 95: 81-99.

    3) Biondi-Zoccai G, Landoni G, Zangrillo A, et al. Use of the LUCAS mechanical chest compression device for percutaneous coronary intervention during cardiac arrest: Is it really a game changer? HSR Proc Intensive Care Cardiovasc Anesth 2011; 3: 203-205.

    4) Ristagno G, Tang W, Chang YT, et al. The quality of chest compressions during cardiopulmonary resuscitation overrides importance of timing of defibrillation. Chest 2007; 132: 70-75.

    5) Klouche K, Weil MH, Sun S, et al. Stroke volumes generated by precordial compression during cardiac resuscitation. Crit Care Med 2002; 30: 2626-2631.

    6) Kramer-Johansen J, Myklebust H, Wik L, et al. Quality of out of hospital cardiopulmonary resuscitation with real time automated feedback: A prospective interventional study. Resuscitation 2006; 71: 283-292.

    7) Edelson DP, Litzinger B, Arora V, et al. Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Arch Intern Med 2008; 168: 1063-1069.

    8) Hoek TL, Becker LB, Abella BS. Rescuer fatigue during actual inhospital cardiopulmonary resuscitation with audiovisual feedback: A prospective multicenter study. Resuscitation 2009; 80: 981-984.

    9) Manders S, Geijsel FE. Alternating providers during continuous chest compressions for cardiac arrest: Every minute or every two minutes? Resuscitation 2009; 80: 1015-1018.

    10) Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation during out of hospital cardiac arrest. JAMA 2005; 293: 299-304.

    11) Gates S, Quinn T, Deakin CD, Blair L, et al. Mechanical chest compression for out of hospital cardiac arrest: Systematic review and meta analysis. Resuscitation 2015; 94: 91-97. 12. Ong ME, Mackey KE, Zhang ZC, et al. Mechanical CPR devices compared to manual CPR during out of hospital cardiac arrest and ambulance transport: A systematic review. Scandinavian journal of trauma, resuscitation and emergency medicine 2012; 20: 39.

    13) Maule Y. The aid of mechanical CPR. better compressions, but more importantly more compressions. Urgence Pratique 2011; 106: 47-48.

    14) Wang HC, Chiang WC, Chen SY, et al. Video recording and timemotion analyses of manual versus mechanical cardiopulmonary resuscitation during ambulance transport. Resuscitation 2007; 74: 453-460.

    15) Saussy J, Elder J, Flores C, et al. Optimization of cardiopulmonary resuscitation with an impedance threshold device, automated compression cardiopulmonary resuscitation and post resuscitation in the field hypothermia improved short term outcomes following cardiac arrest. Circulation 2010; 122: A256.

    16) Maule Y. Mechanical external chest compression: A new adjuvant technology in cardiopulmonary resuscitation. Urgences and Accueil 2007; 29: 4-7.

    17) Bonnemeier H, Olivecron G, Simonis G. Automated continuous chest compression for in hospital cardiopulmonary resuscitation of patients with pulseless electrical activity: A report of five cases. Int J Card 2009; 136: e39-50.

    18) Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: Adult basic life support and cardiopulmonary resuscitation quality: 2015 American heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015; 132: S414-S435.

    19) Gyory RA, Buchle SE, Rodgers D, Lubin JS. The efficacy of LUCAS in prehospital cardiac arrest scenarios: A crossover mannequin study. West J Emerg Med. 2017; 18: 437-445.

    20) Callaway CW, Soar J, Aibiki M, et al. Advanced life support chapter collaborators. Part 4: Advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2015; 132: S84-S145.

    21) Russi CS, Myers LA, Kolb LJ, et al. Comparison of chest compression quality delivered during on scene and ground transport cardiopulmonary resuscitation. West J Emerg Med 2016; 17: 634-639.

    22) Olasveengen TM, Wik L, Steen PA. Quality of cardiopulmonary resuscitation before and during transport in out of hospital cardiac arrest. Resuscitation 2008; 76: 185-190.

    23) Sunde K, Wik L, Steen PA. Quality of mechanical, manual standard and active compression decompression CPR on the arrest site and during transport in a manikin model. Resuscitation 1997; 34: 235-242.

    24) Hung SC, Mou CY, Hung HC, et al. Chest compression fraction in ambulance while transporting patients with out-of-hospital cardiac arrest to the hospital in rural Taiwan. Emerg Med J 2017; 34: 398-401.

    25) Magliocca A, Olivari D, De Giorgio D, et al. LUCAS Versus manual chest compression during ambulance transport: A hemodynamic study in a porcine model of cardiac arrest. Journal of the American Heart Association 2019; 8: e011189.

    26) Gässler H, Ventzke MM, Lampl L, Helm M. Transport with ongoing resuscitation: A comparison between manual and mechanical compression. Emerg Med J 2013; 30: 589-592

    27) Chung TN, Kim SW, Cho YS, et al. Effect of vehicle speed on the quality of closed chest compression during ambulance transport. Resuscitation 2010; 81: 841-847.

    28) Roosa JR, Vadeboncoeur TF, Dommer PB, et al. CPR variability during ground ambulance transport of patients in cardiac arrest. Resuscitation 2013; 84: 592-595.

    29) Stapleton ER. Comparing CPR during ambulance transport: manual vs. mechanical methods. JEMS 1991; 16: 63-64.

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