Impact of elbow supports use on chest compression quality: a crossover simulation study

During chest compressions, a downward force is generated by the rescuer’s body through straightened arms to the patient’s chest. If the elbows are not straight, the depth of chest compressions could be reduced. Such a situation could occur during prolonged chest compressions or when the rescuer must wear protective equipment, such as during the coronavirus disease 2019 (COVID-19) pandemic, and can lead to reduced chest compression quality. This study aimed to compare the quality of chest compressions performed using elbow supports to limit the elbows’ range of motion with that of standard chest compression (SCC). This prospective, randomized controlled, crossover simulation trial was conducted from October to December 2018. It included 34 participants who were certified in Basic Life Support with an overall compression score of ≥80% in the preliminary evaluation. They were randomly assigned to the immediate intervention (elbow support chest compression (ESCC)) or wait-list control (SCC) groups, and were asked to perform hands-only cardiopulmonary resuscitation for 8 minutes with and without elbow supports, respectively. After 1 week, the participants were made to switch groups, and the quality of chest compressions between the two groups was compared. The study findings showed that the ESCC group had a significantly higher overall compression score than the SCC group (82.85 ± 13.73% vs. 76.11 ± 19.19%, respectively, p = 0.044). No difference was observed in the chest compression depth between men and women in the ESCC group (53.12 ± 6.14 mm vs. 49.13 ± 3.23 mm, respectively, p = 0.053), but a significant difference was observed between those of the SCC group (53.18 ± 6.58 mm vs. 47.87 ± 5.23 mm, respectively, p = 0.026). Thus, elbow supports could assist rescuers in performing more effective chest compressions, especially for females or in situations where compression quality could be affected.

Out-of-hospital cardiac arrest; Cardiopulmonary resuscitation; Cardiac massage; Elbow joint

[1] Travers AH, Rea TD, Bobrow BJ, Edelson DP, Berg RA, Sayre MR, et al. Part 4: CPR overview: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010; 122: S676–S684.

[2] Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, et al. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015; 132: S414–S435.

[3] Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, et al. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020; 142: S366–S468.

[4] Van Hoeyweghen RJ, Bossaert LL, Mullie A, Calle P, Martens P, Buylaert WA, et al. Quality and efficiency of bystander CPR. Resuscitation. 1993; 26: 47–52.

[5] Malta Hansen C, Kragholm K, Pearson DA, Tyson C, Monk L, Myers B, et al. Association of bystander and first-responder intervention with survival after out-of-hospital cardiac arrest in North Carolina, 2010–2013. The Journal of the American Medical Association. 2015; 314: 255–264.

[6] Kragholm K, Wissenberg M, Mortensen RN, Hansen SM, Malta Hansen C, Thorsteinsson K, et al. Bystander efforts and 1-year outcomes in out-of-hospital cardiac arrest. New England Journal of Medicine. 2017; 376: 1737–1747.

[7] McDonald CH, Heggie J, Jones CM, Thorne CJ, Hulme J. Rescuer fatigue under the 2010 ERC guidelines, and its effect on cardiopulmonary resuscitation (CPR) performance. Emergency Medicine Journal. 2013; 30: 623–627.

[8] Sugerman NT, Edelson DP, Leary M, Weidman EK, Herzberg DL, Vanden Hoek TL, et al. Rescuer fatigue during actual in-hospital cardiopulmonary resuscitation with audiovisual feedback: a prospective multicenter study. Resuscitation. 2009; 80: 981–984.

[9] Foo N, Chang J, Lin H, Guo H. Rescuer fatigue and cardiopulmonary resuscitation positions: a randomized controlled crossover trial. Resusci-tation. 2010; 81: 579–584.

[10] Hattori H, Akasaka K, Otsudo T, Takei K, Yamamoto M. The effects of elbow bracing on medial elbow joint space gapping associated with repetitive throwing in high school baseball players. Orthopaedic Journal of Sports Medicine. 2017; 5: 2325967117702361.

[11] Ko SY, Ro YS, Shin SD, Song KJ, Hong KJ, Kong SY. Effect of a first responder on survival outcomes after out-of-hospital cardiac arrest occurs during a period of exercise in a public place. PLoS One. 2018; 13: e0193361.

[12] Takei Y, Nishi T, Matsubara H, Hashimoto M, Inaba H. Factors associated with quality of bystander CPR: the presence of multiple rescuers and bystander-initiated CPR without instruction. Resuscitation. 2014; 85: 492–498.

[13] Shin J, Hwang SY, Lee HJ, Park CJ, Kim YJ, Son YJ, et al. Comparison of CPR quality and rescuer fatigue between standard 30:2 CPR and chest compression-only CPR: a randomized crossover manikin trial. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2014; 22: 59.

[14] Hightower D, Thomas SH, Stone CK, Dunn K, March JA. Decay in quality of closed-chest compressions over time. Annals of Emergency Medicine. 1995; 26: 300–303.

[15] Bucki B, Waniczek D, Michnik R, Karpe J, Bieniek A, Niczyporuk A, et al. The assessment of the kinematics of the rescuer in continuous chest compression during a 10-min simulation of cardiopulmonary resuscitation. European Journal of Medical Research. 2019; 24: 1–9.

[16] Kang J, Jang Y, Han K, Jung E, Yu J, Ji J, et al. “Elbow-Lock” chest compression method in the setting of single rescuer pediatric cardiopulmonary resuscitation: a crossover simulation study. Pediatric Emergency Care. 2022; 38: e583–e587.

[17] López-González Á, Sánchez-López M, Rovira-Gil E, González-García A, Ferrer-López V, Martínez-Vizcaíno V. Sex differences in the effort indicators during cardiopulmonary resuscitation manoeuvres on manikins. European Journal of Emergency Medicine. 2015; 22: 62–65.

[18] Leary M, Buckler DG, Ikeda DJ, Saraiva DA, Berg RA, Nadkarni VM, et al. The association of layperson characteristics with the quality of simulated cardiopulmonary resuscitation performance. World Journal of Emergency Medicine. 2017; 8: 12.

[19] Bucki B, Karpe J, Michnik R, Niczyporuk A, Makarska J, Waniczek D, et al. Depth and rate of chest compression in CPR simulation during10- minute continuous external cardiac compression. Annales Academiae Medicae Silesiensis. 2017; 71: 1–6.

[20] Tian Y, Tu X, Zhou X, Yu J, Luo S, Ma L, et al. Wearing a N95 mask increases rescuer’s fatigue and decreases chest compression quality in simulated cardiopulmonary resuscitation. The American Journal of Emergency Medicine. 2021; 44: 434–438.