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Two thumb vs two finger

Question Type:
Full Question:
In neonates receiving cardiac compressions

 (P), does does the use of a two thumb technique (I), compared with as opposed to a two finger technique (C), change  (O)?
Consensus on Science:
For the critical outcomes of time to ROSC, survival rates, or neurologic injury, we found no data. For the critical outcome of improved perfusion and gas exchange during CPR, we identified low-quality evidence from 9 randomized controlled trials (downgraded for indirectness and imprecision) (Menegazzi 1993, 240; Houri 1997, 65; Dorfsman 2000, 1077; Whitelaw 2000, 213; Udassi 2010, 712; Christman 2011, F99-F101; Martin 2013, 1125; Martin 2013, 576; Martin 2013, 666) and 6 nonrandomized controlled trials (downgraded for indirectness, imprecision, and high risk of bias) (Moya 1962, 798; Thaler 1963, 606; Todres 1975, 781; David 1988, 552; Dellimore 2013, 350; Park 2014, 1659) identifying higher blood pressure generation with the 2-thumb versus the 2-finger method. For the important outcome of compressor fatigue, we identified low-quality evidence from 4 randomized controlled trials (downgraded for indirectness and imprecision), with 2 (Dorfsman 2000, 1077; Huynh 2012, 658) identifying less fatigue with the 2-thumb versus the 2-finger technique, and 2 studies finding no difference. (Udassi 2009, 328; Udassi 2010, 712)New compression methods: Thumb and index finger (TIF) (Fakhraddin 2011, 15) compared the new method versus the 2-thumb and 2-finger methods on manikins. Cardiac compressions lasted for only 5 minutes while recording rate, hand location, depth, incomplete recoil, excessive depth, and error rate during CPR. Two-thumb and TIF had less decay in “suitable chest compressions” over the 5 minutes compared with the 2-finger method. Adhesive glove (Udassi 2009, 1158) compared using the adhesive glove with conventional CPR in 4 groups, including an infant group in a manikin model. The 2-thumb method was used as standard in the infant group versus adhesive 2-thumb method. The theory is that the glove provides active compression-decompression. Rate, compression, and decompression depth were measured. No differences in fatigue variables were found amongst groups. Results showed more active decompression with the adhesive glove group. Summary: No evidence was found supporting the new thumb and index finger technique as superior to the 2-thumb method. The adhesive glove enhanced active decompression but did not reduce fatigue.Other issues:Does the CPR technique cause fractures? Franke (Franke 2014, 1267) performed a 10-year retrospective survey to determine whether the 2-thumb technique causes rib fractures. All infants received CPR plus chest x-rays. Median age was 9 days.Summary: There was no evidence of rib fractures in any case. Best location on the sternum: Using 4 assessment methods over a wide age range of infants, (Orlowski 1986, 667) it was confirmed that the heart lies under the lower third of the sternum. In addition, blood pressure readings were higher when cardiac compressions were applied to the lower versus the middle third of the sternum. Use of the infant computed tomography (CT) scan data (mean age, 4.4 months) and adult thumb side-by-side measurements on manikins(You 2009, 1378) confirmed that the left ventricle lies mostly under the lower quarter of the sternum. No functional data were collected to confirm better outcomes if compressions focused on that area. An assumption was made that the lower third of the sternum was the best position for compressions.(Saini 2012, 690)Term and preterm babies: Correct positioning on the chest was determined to be much better with the 2-thumb method in both groups of babies, although incorrect placements were found for both techniques in infants less than 1500 g. Chest x-ray analysis of term and preterm babies(Phillips 1986, 1024) found the heart to be under the lower third of the sternum. Chest CT scans of infants (mean age, 4.7 months), compared with adult thumb measurements on a manikin, comparing the 2-thumb method side by side or superimposed,(Lee 2011, 1214) demonstrated that the side-by-side method increases the likelihood of other organs (lungs and liver) being under the points of compressions application. A manikin study looked at fatigue levels with the 2-thumb technique, comparing side-by-side or superimposed thumb position(Lim 2013, 139) demonstrated that the superimposed thumb technique generated higher simulated blood pressure and pulse pressure but had a higher fatigue-rating score. Physiologic indices of fatigue showed no difference between groups. CT scans of the chest to compare thumb (side-by-side)/fingers measurements placed on manikins were conducted to determine which method avoided compressing other structures when using the lower third of the sternum.(Lee 2013, 766) Both methods compress other structures, but the 2-thumb method(side-by-side) performs better than the two finger method. The accuracy of using the nipple line to the xiphisternum landmarks for 2-finger chest compression was examined by Clements.(Clements 2000, 43) They concluded that this method could result in abdomen and xiphisternum compression in all infants and suggested an alternate method of determining position. Summary: The lower one third of the sternum remains the best location to press over the newborn heart. Superimposed thumbs may be the better technique.
Treatment Recommendation:
We suggest that chest compressions in the newborn should be delivered by the 2-thumb, hands-encircling-the-chest method as the preferred option (weak recommendation, very-low-quality evidence). We suggest that chest compressions should be delivered over the lower third of the sternum (weak recommendation, very-low-quality evidence).Values, Preferences, and Task Force Insights None are noted.
CoSTR Attachments:
GRADE GRID - NRP 605 TT vs TF CPR_n.docx    
NRP 605 Risk of bias Table_n.xlsx    

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