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Three Part Question

In [infants in cardiac arrest] is [two thumb CPR better than two finger CPR] at [delivering effective chest compressions]?

Clinical Scenario

You are put on standby by the paramedic emergency service for a cardiac arrest in an 8 week old baby. Whilst you are assembling your equipment in the emergency department, you recall that the APLS suggests a two thumb, hand encircling technique may be better when more than one rescuer is present, but rarely do you see this being used. You wonder whether current evidence supports this or not.

Search Strategy

Medline 1966-07/04 using the OVID interface.
[{(exp Cardiopulmonary Resuscitation OR exp Heart Arrest/ OR cardiopulmonary resuscitation.mp OR heart arrest.mp OR CPR.mp) AND (chest compression$.mp OR exp Heart Massage)}OR cardiac compression$.mp] AND (BestBETs paediatric search filter) LIMIT to English language AND human.

Search Outcome

Altogether 175 papers found of which 4 helped to answer the question posed. These are summarised in the table

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Houri et al, 1997, USA	Swine with induced cardiac arrest. CPR performed with two fingers (TF) or two thumbs (TT).	Randomised crossover trial	Diastolic blood pressure	No significant difference	Sternal compression force achieved was lower in the two fingers group when investigators tried to standardise this component
			Systolic blood pressure	25% increase with and 57% increase in two thumbs group when no foce feedback was given
Dorfsman et al, 2000, USA	21 rescuers performing CPR on adapted manikin. CPR performed with two fingers (TF) or two thumbs (TT)	Randomised crossover trial	Diastolic blood pressure	Higher in TT group (mean 17.6 v 12.5 p<0.001)	Only verbal instructions given in performing TT technique - all rescuers experienced in TF technique
			Systolic blood pressure	Higher in TT group (mean 68.9 v 44.8 p<0.001)
			Mean arterial blood pressure	Higher in TT group (mean 35.3 v 23.3 p<0.001)
			Perfusion pressure	Higher in TT group (mean 51.4 v 31.2 p<0.001)
Whitelaw et al, 2000, USA	209 subjects performing CPR on manikin. CPR performed with two fingers (TF) or two thumbs (TT)	Randomised crossover trial	Adequacy of CPR on skill guide	No significant difference - 40 participants produced adequate CPR using TT (95% CI 14-25%) and 38 using TF (95% CI 13-24%) TT produced more than 40 too shallow compressions in 40 participants compared to 15 in the TF group (p<0.005)	Heterogenous group of participants with varying levels of experience 71% of participants failed to give more than 60 adequate compressions in 2 minute period
Menegazzi et al, 1993, USA	5 rescuers performing CPR on 7 swine with induced cardiac arrest. CPR performed with two fingers (TF) or two thumbs (TT)	Randomised crossover trial	Diastolic blood pressure	Higher in TT group (21.8 v 18.5; p<0.001)	No measure of force applied during techniques Differences statistically relevant, ?not clinically
			Systolic blood pressure	Higher in TT group (59.4 v 41.6; p<0.001)
			Mean arterial blood pressure	Higher in TT group (34.2 v 26.1; p<0.001)
			Coronary perfusion pressure	Higher in TT group (15.1 v 12.2; p<0.001)

Comment(s)

In addition to these papers, the International Consensus on Science published revised guidelines in 2000, which, amongst other things advocated the use of two thumb technique where possible. Whether this leads to improvement in overall survival rates needs further evaluation.

Clinical Bottom Line

Two thumb compression CPR produces improved haemodynamic states in experimental models, and should be performed when possible in preference to the two finger technique.

References

1. Houri PK, Frank LR, Menegazzi JJ, et al. A randomized, controlled trial of two-thumb vs two-finger chest compression in a swine infant model of cardiac arrest. Prehospital Emergency Care 1997;1(2):65-7.
2. Dorfsman ML, Menegazzi JJ, Wadas RJ, et al. Two-thumb vs. two-finger chest compression in an infant model of prolonged cardiopulmonary resuscitation. Acad Emerg Med 2000;7(10):1077-82.
3. Whitelaw CC, Slywka B, Goldsmith LJ. Comparison of a two-finger versus two-thumb method for chest compressions by healthcare providers in an infant mechanical model Resuscitation 2000;43(3):213-6.
4. Menegazzi JJ, Auble TE, Nicklas KA, et al. Two-thumb versus two-finger chest compression during CRP in a swine infant model of cardiac arrest Ann Emerg Med 1993;22(2):240-3.