This case report gives us important information on the relationship between chest compression quality/technique and the attained blood pressure. A 2-thumbs encircling hands technique, usually recommended for infant resuscitation if there are two or more rescuers, did not create acceptable pressures, and was difficult to perform in a child of 2 years age. The direct sternal compression technique with the tips of two fingers, are also recommended in infants for the lone rescuer situation. In this case the two thumbs (two fingers) direct sternal compression technique resulted in rapid achievement of adequate blood pressure when compared it to the 2-thumbs encircling hands technique. Specifically, diastolic arterial pressure and exhaled CO2 were well maintained. When compressions were continued with a one-hand technique supplemented by sternal accelerometer and force transducer real-time guidance, the CPR quality was excellent, and the systolic arterial pressures were even higher. Although speculative, this could be due to the wider spread of pressure over the thoracic cage or, perhaps more likely, to the feedback signal from the defibrillator guiding CPR quality, especially the compression depth and rate and full-release. In the compression-to-compression analysis there was a significant correlation with invasive blood pressures and compression depth.
Current resuscitation guidelines for a small infant recommend a 2-thumb encircling hands or 2 finger sternal chest compression techniques. For child over one year either 1- or 2-hand technique is recommended [1–3]. The sternum should be pressed at least one third of the anterior-posterior (AP) chest diameter in all children, which means approximately 40 mm (1.5 inches) in infants and 50 mm (2 inches) in children . In this case, the increase in compression depth from 1/3 to ½ AP chest diameter created higher SAP.
During adult advanced life support the use of feedback devices during CPR are encouraged, since they improve rescuer ability to achieve correct chest compression depth, rate and chest recoil. The feedback devices also attempt to minimize no-flow time, as much as possible [5, 6]. Although the quality deficiencies are similar in adult and pediatric resuscitation attempts, the feedback devices currently available are recommended for children at least 8 years of age. In this case the quality of resuscitation attempt was controlled by invasive pressure. To achieve better pressure team wanted to check CPR quality by using the Q-CPR compression sensor, and since it seemed to result in improved invasive arterial pressures the resuscitation attempt was continued with the compression sensor in place until spontaneous circulation was returned.
The quality of the CPR and compliance with current guidelines was good in this case, at least in those later phases when it was controlled. We do not have similar data describing the quality of CPR before the Q-CPR compression sensor was deployed. Previous studies have shown that the compression depth in children is correlated to invasive pressures , but depth itself very seldom reaches the targeted level . This may have happened also in the current case before the use of compression sensor. The mean compression depth in our patient with compression sensor was 43 (6) mm.
There is evidence that the sternal accelerometer that calculated the movement of the Q-CPR sensor, even for a child on a mattress with backboard, may include some movement of the mattress. Therefore our presented depths are higher than the actual compression of the chest achieved. However, the amount of depth movement attributable to a thin, hard stretcher mattress is minimal .
In this case deployment of the feedback device improved the invasive blood pressure, and we hypothesize that this was related to improved chest compression quality since no epinephrine was given until normothermia was achieved. Future studies will be needed to further determine the relationship between quantitatively measured depths and blood pressure during actual pediatric resuscitation attempts.