Dallas 2015

TFQO: Myra Wyckoff #COIEVREV 1: Myra Wyckoff #COIEVREV 2: Lindsay Mildenhall #107Taskforce: NRP

NRP: 605Two thumb verses two finger

Dallas 2015COI Disclosure (specific to this systematic review)

EVREV 1 COI#Commercial/industry• Nil

Potential intellectual conflicts• Nil

EVREV 2 COI #107Commercial/industry• Nil

Potential intellectual conflicts• Nil

Dallas 20152010 CoSTR

Chest compressions in the newborn should be delivered by the 2 thumb–encircling hands method as the preferred option.

Compressions should be centered over the lower third of the sternum and should compress the chest one third the anterior-posterior diameter.

Any chest compressions should be performed in combination with adequate inflation breaths.

Dallas 2015C2015 PICO

Population: Neonates receiving cardiaccompressions

Intervention: Does the use of a Two thumb technique

Comparison: As opposed to a Two finger technique

Outcomes: 9-Critical decrease time to ROSC9-Critical improve neurological outcomes9-Critical increase survival rates8-Critical improve perfusion/gas exchange6-Important decreased compressor fatigue

Dallas 2015Inclusion/Exclusion& Articles Found

InclusionsNeonatal / Infants / Animal / ManikinsRCT, Observational

Exclusions: Adult, V-Fib, Abstracts, Editorials

Number of Articles initially identified 80

Finally Included in Evidence Profile tables

RCTs 13non-RCTs 15Excluded52

Dallas 20152015 Proposed Treatment Recommendations

We suggest that chest compressions in the newborn should be delivered by the two thumb, hands encircling the chest method as the preferred option

(weak recommendation, very low quality of evidence).

Compressions should be delivered over the lower 1/3 of sternum.

Dallas 2015 Risk of Bias in studies

Dallas 2015 Risk of Bias in studies

Dallas 2015 Key data from key studies

Reference: Case Hx: David, 1988; Moya, 1962; Thaler, 1963; Todres, 1975

P: Neonates receiving chest compressionsI: TTC: TFO:

David 1988, 552 Todres 1975, 781

Dallas 2015 Key data from key studies

Reference: Menegazzi 1993; Houri 1997 P: Piglets receiving chest compressionsI: TTC: TFO:

Houri 1997, 65 Menegazzi 1993, 240

Dallas 2015Evidence profile table(s)

Population: Neonates needing cardiac compressions Intervention: Two thumbComparison: Two fingerOutcome: Decrease time to ROSC

Decrease time to ROSC

No data

CRITICAL-9

Outcome No of studiesAuthor Year 1st page

Study Design

Risk of bias

Inconsist-ency

Indirect-ness

Imprecision Other (including publication bias)

Quality of evidence for outcome

Importance

Population: Neonates needing cardiac compressions Intervention: Two thumbComparison: Two fingerOutcome: Improve neurologic outcomes

Outcome No of studiesAuthor Year 1st page

Study Design

Risk of bias

Inconsist-ency

Indirect-ness

Imprecision Other (including publication bias)

Quality of evidence for outcome

Importance

Improve neurologic outcomes

No data

CRITICAL-9

Dallas 2015Evidence profile table(s)

Population: Neonates needing cardiac compressions Intervention: Two thumbComparison: Two fingerOutcome: Increase survival rates

Outcome No of studiesAuthor Year 1st page

Study Design

Risk of bias

Inconsist-ency

Indirect-ness

Imprecision Other (including publication bias)

Quality of evidence for outcome

Importance

Increase survival rates

No data

CRITICAL-9

Dallas 2015Evidence profile table(s)

Population: Neonates needing cardiac compressions Intervention: Two thumbComparison: Two fingerOutcome: Improved perfusion and gas exchange during CPR

Outcome No of studiesAuthor Year 1st page

Study Design

Risk of bias

Inconsist-ency

Indirect-ness

Imprecision Other (including publication bias)

Quality of evidence for outcome

Importance

Improved perfusion and gas exchange during CPR

15 Studies

Christman, 2010, 99Dorfsman, 2000, 1077Houri, 1993, 65Martin, 2013, 576Martin, 2013, 666Martin, 2013, 1125Menegazzi, 1993, 240Udassi, 2010, 712Whitelaw, 2000, 213

David, 1988, 552Moya, 1962, 798Thaler, 1963, 606Todres, 1975, 781

Dellimore , 2013, 350Park, 2014, 1659

RCT

Non-RCT

Serious Not Serious

Serious(manikins or swine model)

Human case reports

Manikins

Serious Not Serious

VeryLow

CRITICAL-8

Dallas 2015Evidence profile table(s)

Population: Neonates needing cardiac compressions Intervention: Two thumbComparison: Two fingerOutcome: Decrease Compressor fatigue

Outcome No of studiesAuthor Year 1st page

Study Design

Risk of bias

Inconsist-ency

Indirect-ness

Imprecision Other (including publication bias)

Quality of evidence for outcome

Importance

DecreasedCompressor fatigue

4 Studies

Dorfsman, 2000, 1077Huynh, 2012, 658Udassi, 2009, 328Udassi, 2010,712

RCT

Serious Not Serious

Serious(manikins only)

Serious Not Serious

VeryLow

IMPORTANT-6

Dallas 2015Proposed Consensus on Science statements

For the critical outcome of Time to ROSC, we found

no data.  

For the critical outcome of Survival Rates, we found no data  

For the critical outcome of Neurologic Injury, we found no data.  

Dallas 2015Proposed Consensus on Science statements

For the critical outcome of “improved perfusion and gas

exchange during CPR” we identified low quality evidence from 9

RCT’s (7 manikin and 2 piglet down graded for indirectness and

imprecision) and

6 Non-RCT’s (4 human and 2 manikin down graded for

indirectness, imprecision and high risk of bias)

Summary: Higher BP (force) generation identified with the two thumb method verses the two finger.

Dallas 2015Proposed Consensus on Science statements

For the important outcome of “compressor fatigue” we identified

low quality evidence from 4 RCT’s using manikins (downgraded for

indirectness and imprecision):

2 identifying less fatigue with the two thumb technique and 2

finding no difference.

Dallas 2015Proposed Consensus on Science statements

New Compression Methods:  

Fakhraddin, 2011, 15:  New method (Thumb and index finger-TIF) compared with TT and TF on manikins.   

Udassi, 2009, 1158: Manikin study using adhesive glove compared with standard CPR in 4 groups including infant group.

  Summary: No evidence that the new thumb and index finger technique is superior to two thumb method. Adhesive glove enhanced active decompression but did not reduce fatigue.

Dallas 2015Proposed Consensus on Science statements

Best Location on the Sternum:   8 non-RCT’s

Infants: Phillips, 1986; Orlowski, 1986; Clements, 2000; Saini, 2012; supporting chest compressions best performed over lower third of the sternum plus further support for TT over TF

Infant CT scan / manikin measurements: You, 2009; Lee, 2011; Lim, 2012; Lee, 2013; LV mostly under lower third of sternum. TT and superimposed thumbs method less likely to compress other structures

Summary: Lower one third of sternum remains the best location to compress the newborn heart. Superimposed thumbs maybe the better technique.

Dallas 20152015 Draft Treatment Recommendations

We suggest that chest compressions in the newborn should be delivered by the two thumb, hands encircling the chest method as the preferred option

(weak recommendation, very low quality of evidence).

Compressions should be delivered over the lower 1/3 of sternum.

Dallas 2015Knowledge Gaps

No studies of any kind available regarding the most critical outcomes

No data from good transitional models

Very limited human neonatal data

Dallas 2015Next Steps

This slide will be completed during Task Force Discussion (not EvRev) and should include:

Consideration of interim statementPerson responsibleDue date

Essential slide (one slide only). Estimated time <30 sec