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Original Contribution
Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Yamaguchi 755-8505, Japan
Department of Stress and Bio-response Medicine, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
a r t i c l e
i n f o
Article history:
Received 6 October 2013
Received in revised form 1 May 2014
Accepted 5 May 2014
a b s t r a c t
Study objective: Recent guidelines have emphasized the need for uninterrupted chest compressions. The
purpose of this study was to evaluate the rescuer's tolerability of uninterrupted chest compressions.
Methods: Twenty-ve healthy subjects performed uninterrupted chest compressions for 7 minutes at a rate of
100 compressions per minute using a training manikin. The quality of chest compressions was assessed in
terms of the total number and percentage of chest compressions, compression depth, recoil distance, and duty
cycle. Correct chest compression was dened as a depth of 38 to 51 mm. Physiological and laboratory
parameters were measured before and after the procedure. Fatigue was measured using a numerical rating
scale. Data were compared before and after the procedure.
Results: The participants were 10 emergency physicians and 15 medical students. The compression rate was
nearly 100 compressions per minute. The number and percentage of correct compressions decreased gradually
after 3 minutes. The compression depth decreased signicantly after 2 minutes. The recoil distance and duty cycle
were unchanged over 7 minutes. Systolic blood pressure, pulse rate, respiratory rate, numerical rating scale,
serum lactate, adrenalin, and noradrenalin increased signicantly after the procedure. Noradrenalin levels
measured before the procedure were signicantly and negatively correlated with the total number and
percentage of correct compressions (r = 0.587, P = .004; r = 0.549, P = .008, respectively).
Conclusions: Performing uninterrupted chest compressions for 7 minutes is an arduous procedure. Higher
noradrenalin levels before the procedure might be associated with incorrect chest compressions.
2014 Elsevier Inc. All rights reserved.
1. Introduction
Recent guidelines for cardiopulmonary resuscitation (CPR) have
emphasized the need for uninterrupted chest compressions [1-3].
Several observational studies demonstrated that uninterrupted chest
compressions without ventilation (compression-only CPR) improved
survival to the time of hospital discharge [4-6]. However, the rescuers
can suffer fatigue, and the quality of chest compressions may deteriorate
during uninterrupted chest compressions [7,8]. Accordingly, recent
guidelines recommend that, if there is more than 1 rescuer, the rescuer
should be changed every 1 to 2 minutes [2,3]. However, if there is only 1
rescuer, the rescuer must continue uninterrupted chest compressions
unassisted for a much longer time. In Japan, the emergency medical
service takes an average of 7 minutes to arrive after an emergency call
This work was presented at the 39th Critical Care Congress, Miami Beach, FD,
January 9 to 13, 2010.
Financial support: The authors received no nancial support for this study.
Conict of interest statement: The authors have no conicts of interest to disclose.
Corresponding author. Tel.: +81 836 22 2343; fax: +81 836 22 2344.
E-mail address: yasutaka-ygc@umin.ac.jp (Y. Oda).
http://dx.doi.org/10.1016/j.ajem.2014.05.008
0735-6757/ 2014 Elsevier Inc. All rights reserved.
910
The subjects were asked to perform uninterrupted chest compressions for 7 minutes at a rate of 100 compressions per minute in
accordance with the 2005 guidelines for CPR [1] using a Resusci Anne
Simulator (Laerdal Medical, Stavanger, Norway) equipped with a PC
skill-reporting system. The manikin was placed on a stretcher
(Stryker; Stryker Medical, Portage, MI) at a height of 70 to 100 cm,
which was adjusted by a foot pedal. The stretcher used in this study is
the same as that used for CPR at our critical care center. The subjects
could use a 12-cm foot stool if the minimum height of the stretcher
(70 cm) was too high. The subjects were allowed to adjust the height
of the manikin, as desired, using the stretcher's foot pedal and/or the
foot stool.
2.2. Data collection
Cardiopulmonary resuscitation quality was evaluated as follows:
total number of chest compressions in 7 minutes, rate of chest
compressions per minute, total number of correct chest compressions
in 7 minutes, percentage of correct chest compressions, compression
depth, compression recoil distance, and duty cycle. Correct chest
compression was dened as a depth of 38 to 51 mm (1.5-2 in) according
to the 2005 guidelines [1]. Compression recoil distance was dened as the
decompression distance from baseline. The following physiological
parameters were measured before and after the uninterrupted chest
compressions: systolic blood pressure, pulse rate, respiratory rate,
oxygen saturation, and numerical rating scale for fatigue (range, 0-10).
Venous blood was taken before and after chest compressions to measure
serum lactate, adrenalin, and noradrenalin levels. Serum lactate levels
were measured using a blood gas analyzer (Radiometer, Copenhagen,
Denmark). Serum adrenalin and noradrenalin levels were measured
by high-performance liquid chromatography (Waters Capillary Ion
Analyzer; Millipore, Billerica, MA).
2.3. Statistical analysis
Summary values for continuous variables, which were regarded
as normally distributed, are presented as the mean SD, and those
for categorical variables are presented as the number and percentages. Serial changes in the parameters for uninterrupted chest
compressions were analyzed using 2-way analysis of variance. Paired
t tests were used to compare physiological and laboratory parameters measured before and after the uninterrupted chest compressions. Pearson correlation coefcients were calculated to examine
associations between compression related parameters and physiological/laboratory parameters. The number of subjects required for
the study was determined as follows: In the preliminary analysis of
the rst 10 subjects, the mean and SD of differences in declined depth
from 1 to 7 minutes among the individuals were 5.1 and 7.4 mm,
respectively. Assuming the detectability of 5-mm difference in the
depth of compression between 1 and 7 minutes with 90% power, the
number of subjects required for the use of paired t test was computed
as 25. Therefore, we set the number of subjects as 25. Statistical
analyses were performed using StatFlex version 6 (Artech Co, Ltd,
Osaka, Japan). P b .05 was considered statistically signicant.
3. Results
Blood samples were not obtained after the uninterrupted chest
compressions for 3 subjects because of technical problems. Therefore,
these subjects were excluded from statistical analyses of laboratory data.
The characteristics of the subjects and the quality of the chest
compressions are listed in Table 1. The subjects included 10
emergency physicians and 15 medical students, and 20 were male.
The mean age of the subjects was 28 5 years with a mean height of
169 8 cm. None of the subjects withdrew from the study. The mean
height of the stretcher from the oor or foot stool was 53 6 cm. One
Table 1
Subject characteristics and quality of uninterrupted chest compressions over 7 minutes
Variable
Value
No. of participants, n
Physicians, n (%)
Medical students, n (%)
Age (y)
Male, n (%)
Height (cm)
Height of stretcher from the oor or foot stool (cm)
Total number of compressions in 7 min
Compression rate (compressions per min)
Total number of correct compressions in 7 min
Percentage of correct compressions (%)
Compression depth (mm)
Recoil distance (mm)
Duty cycle (%)
25
10 (40)
15 (60)
28 5
20 (80)
169 8
53 6
690 50
99 7
494 173
72 25
42 5
32
48 2
subject, whose height was 185 cm, did not use a foot stool. The
compression rate was nearly 100 compressions per minute. The total
number of correct compressions over 7 minutes was 494, and the
percentage of correct compressions was 72%. The mean compression
depth, recoil distance, and duty cycle were 42 5 mm, 3 2 mm, and
48% 2%, respectively.
Table 2 shows the quality of uninterrupted chest compressions
every minute during the procedure. The compression rate remained
constant over 7 minutes, but the number and percentage of correct
compressions decreased gradually after 3 minutes. The compression
depth decreased signicantly after 2 minutes. The recoil distance and
duty cycle were unchanged during the test. Fig. 1 shows the 2 types of
incorrect chest compressions with compression depths of less than 38
mm or more than 51 mm. The number of subjects with incorrect chest
compressions of less than 38 mm increased gradually from 2 minutes
onwards, and approximately half of the subjects had incorrect chest
compressions of more than 51 mm in depth at 1 minute. As shown in
Table 2, the decreased number of correct compressions at 1 minute
was mostly due to incorrect chest compressions with a compression
depth of more than 51 mm.
The recoil distance was signicantly and positively correlated with
the total number and percentage of correct compressions (r = 0.468,
P = .018; r = 0.420, P = .036, respectively) and with compression depth
(r = 0.537, P = .006). However, there were no signicant correlations
between duty cycle and any other indices of the quality of chest
compressions. Only 4 subjects had a duty cycle of more than 50%. These
4 subjects had compression rates of more than 100 compressions per
minute (103, 107, 102, and 107 compressions per minute).
Table 3 compares the physiological and laboratory data measured
before and after the uninterrupted chest compressions for 7 minutes.
All physiological and laboratory parameters increased signicantly
after the chest compressions, except for oxygen saturation.
The mean height was not signicantly different between emergency physicians and students (172 vs 168 cm, P = .271). Although
emergency physicians performed a greater number and percentage of
correct compressions and a deeper compression than medical
students, the differences were not statistically signicant (558 vs
451 compressions in 7 minutes, P = .132; 83% vs 65%, P = .082; 44 vs
41 cm, P = .077, respectively).
Noradrenalin levels measured before the procedure were signicantly and negatively correlated with the total number and percentage
of correct compressions (r = 0.587, P = .004; r = 0.549, P = .008,
respectively) (Fig. 2). However, noradrenalin levels measured after the
procedure and the other physiological/laboratory variables were not
correlated with the quality of chest compressions, except for recoil
distance, which was signicantly and negatively correlated with pulse
rate and adrenalin levels after chest compressions. The subject's height
911
Table 2
Quality of uninterrupted chest compressions in each minute
Minute
Compressions
per minute
No. of correct
compressions per min
Percentage of correct
compressions
Compression depth
(mm)
Recoil distance
(mm)
Duty cycle
(%)
1
2
3
4
5
6
7
98
98
97
98
99
100
101
74
87
80
73
65
61
54
75
90
82
75
66
61
54
47
44
43
42
41
40
39
32
32
32
32
32
33
33
48
47
48
48
48
48
48
7
7
7
8
9
8
9
25
16
29
36
35
39
42a
26
17
30
36
35
39
43a
4
4a
5a
6a
6a
6a
7a
3
3
3
3
3
2
2
and the height of the stretcher from the oor or foot stool were not
correlated with the quality of chest compressions.
4. Discussion
600
500
400
300
200
100
0
300
Table 3
Physiological and laboratory variables measured before and after performing
uninterrupted chest compressions for 7 minutes
200
100
Variable
Before chest
compressions
(n = 25)
After chest
compressions
(n = 25)
117
73
14
98
0
1.3
64
570
128 15
101 23
23 6
98 1
6 12
3.3 1.9
77 29
689 205
.001
.030
b.001
.063
b.001
b.001
.015
.002
0
1
Time (min)
Fig. 1. Cumulative number of incorrect chest compressions in each subject over 7 minutes.
The upper graph shows incorrect chest compressions with a compression depth of less
than 38 mm. The number of subjects with incorrect chest compressions less than 38 mm
increased gradually from 2 minutes until 7 minutes, except in 12 subjects with no increase
in incorrect chest compressions over 7 minutes. The lower graph shows incorrect chest
compressions with a compression depth of greater than 51 mm. Although approximately
half of the subjects had incorrect chest compressions of greater than 51 mm at 1 minute,
the cumulative plots were at over 7 minutes in most cases.
12
11
2
1
0
0.6
22
208
Values are presented as the mean SD. Abbreviations: SpO2, oxygen saturation using
pulse oximetry; NRS, numerical rating scale.
a
Blood samples were not taken from 3 subjects.
912
1400
1200
1000
5. Conclusions
Performing uninterrupted chest compressions for 7 minutes by
trained health care providers was an arduous procedure and
adversely affected the quality of chest compressions over time.
Higher noradrenalin levels before starting chest compressions might
be associated with incorrect chest compressions.
800
600
400
200
Acknowledgments
0
100
200
300
400
500
600
700
800
The authors thank Prof Kiyoshi Ichihara for his expert advice on
the statistical analysis, Ms. Hitomi Ikemoto for excellent technical
assistance with assaying blood samples by high-performance
liquid chromatography, and Ms Masako Ueda for her valuable
graphical work.
References
[1] ECC Committee. Subcommittees and Task Forces of the American Heart
Association. Part 4: Adult Basic Life Support: 2005 American Heart Association
guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
Circulation 2005;112:IV1934.
[2] Berg RA, Hemphill R, Abella BS, et al. Part 5: adult basic life support: 2010
American Heart Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation 2010;122:S685705.
[3] Tanigawa K, Nakagawa T. Chapter 1, basic life support. In: Okada K, Marukawa S,
editors. JRC Guidelines 2010. Tokyo: Herusu Shuppan; 2011. p. 1543.
[4] Bobrow BJ, Ewy GA, Clark L, et al. Passive oxygen insufation is superior to bagvalve-mask ventilation for witnessed ventricular brillation out-of-hospital
cardiac arrest. Ann Emerg Med 2009;54:65662.
[5] Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation
by emergency medical services for out-of-hospital cardiac arrest. JAMA
2008;299:115865.
[6] Kellum MJ, Kennedy KW, Barney R, et al. Cardiocerebral resuscitation improves
neurologically intact survival of patients with out-of-hospital cardiac arrest. Ann
Emerg Med 2008;52:24452.
[7] Sugerman NT, Edelson DP, Leary M, et al. Rescuer fatigue during actual in-hospital
cardiopulmonary resuscitation with audiovisual feedback: a prospective multicenter study. Resuscitation 2009;80:9814.
[8] Manders S, Geijsel FE. Alternating providers during continuous chest compressions
for cardiac arrest: every minute or every two minutes? Resuscitation
2009;80:10158.
[9] Fire and Disaster Management Agency of the Ministry of Internal Affairs and
Communications (Japan). Rescue operations, rst aid. Tokyo, Ministry of Internal
Affairs and Communications (Japan); 2008. (Accessed 7 December 2009, at http://
www.fdma.go.jp/en/pdf/top/en_03.pdf).
[10] Ashton A, McCluskey A, Gwinnutt CL, et al. Effect of rescuer fatigue on
performance of continuous external chest compressions over 3 min. Resuscitation
2002;55:1515.
[11] Riera SQ, Gonzlez BS, Alvarez JT, et al. The physiological effect on rescuers of
doing 2 min of uninterrupted chest compressions. Resuscitation 2007;74:10812.
[12] Ochoa FJ, Ramalle-Gmara E, Lisa V, et al. The effect of rescuer fatigue on the
quality of chest compressions. Resuscitation 1998;37:14952.
[13] Hightower D, Thomas SH, Stone CK, et al. Decay in quality of closed-chest
compressions over time. Ann Emerg Med 1995;26:3003.
[14] Yannopoulos D, McKnite S, Aufderheide TP, et al. Effects of incomplete chest wall
decompression during cardiopulmonary resuscitation on coronary and cerebral
perfusion pressures in a porcine model of cardiac arrest. Resuscitation 2005;64:36372.
[15] Zuercher M, Hilwig RW, Ranger-Moore J, et al. Leaning during chest compressions
impairs cardiac output and left ventricular myocardial blood ow in piglet cardiac
arrest. Crit Care Med 2010;38:11416.
[16] Aufderheide TP, Pirrallo RG, Yannopoulos D, et al. Incomplete chest wall
decompression: a clinical evaluation of CPR performance by EMS personnel and
assessment of alternative manual chest compression-decompression techniques.
Resuscitation 2005;64:35362.
[17] Edelson DP, Call SL, Yuen TC, et al. The impact of a step stool on cardiopulmonary
resuscitation: a cross-over mannequin study. Resuscitation 2012;83:8748.
[18] Lee SH, Kim K, Lee JH, et al. Does the quality of chest compression deteriorate
when the chest compression rate is above 120/min? Emerg Med J 2013. http://dx.
doi.org/10.1136/emermed-2013-202682.
[19] Nakai T. Three fractions of catecholamines. In: Wada O, Ookubo A, Nagata N, et al,
editors. Clinical Management of Laboratory Data in Medical Practice 2001-2002.
Tokyo: Bunkodo; 2001. p. 4547.
[20] Ong ME, Ornato JP, Edwards DP, et al. Use of an automated, load-distributing band
chest compression device for out-of-hospital cardiac arrest resuscitation. JAMA
2006;295:262937.