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BLS-12-v1
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RECOVER 2.0 Worksheet
QUESTION ID: BLS-12
PICO Question: In cats and small dogs in CPA (P), do 2-handed circumferential ("2-thumb technique") chest compressions (I), compared to lateral chest compressions (C), improve ... (O)?
Outcomes:
Favorable neurologic outcome, Complications, Surrogate markers of perfusion, Survival to discharge, ROSC
Prioritized Outcomes (1= most critical; final number = least important):
- Favorable neurological outcome
- Survival to discharge
- ROSC
- Surrogate markers of perfusion
- Complications
Domain chairs: Steve Epstein, Kate Hopper; final edit by Jamie Burkitt
Evidence evaluators: Danielle Pollio, Jon Bach
Conflicts of interest: None reported
Search strategy: See attached document
Evidence Review:
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Study Design |
Reduced Quality Factors
0 = no serious, - = serious,
- - = very serious |
Positive Quality Factors
0 = none, + = one, ++ = multiple |
Dichotomous Outcome Summary |
Non-Dichotomous Outcome Summary
Brief description |
Overall Quality
High, moderate, low, |
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No of studies |
Study Type |
RoB |
Indirectness |
Imprecision |
Inconsistency |
Large Effect |
Dose-Response |
Confounder |
# Intervention with Outcome |
# Control with Outcome |
RR (95% CI) |
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Outcome: Favorable neurologic outcome, Survival to discharge, ROSC |
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0 |
N/A |
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Outcome: Surrogate markers of perfusion |
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2 |
EX |
0 |
- - |
0 |
0 |
0 |
0 |
0 |
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Two studies using a human infant manikin model found a circumferential, 2 thumb technique generates higher pressure in a simulated arterial system compared to a 2-finger technique |
Very low |
PICO Question Summary
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Introduction |
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The optimal chest compression technique in cats and small dogs is unknown. Lateral chest compression can be achieved in these small sized animals with 2-finger, 1-handed, or 2-handed techniques. Alternatively, 2 hands can be used to encircle the chest, which allows the rescuer to squeeze the thorax during compressions. The current pediatric human guidelines state there is insufficient evidence to make a recommendation regarding compression technique and suggest either a 1-handed or 2-handed technique can be used.1
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Consensus on science |
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For the most critical outcomes of FNO, Survival to discharge, and ROSC we identified no studies addressing the PICO question.
Outcome 4: Surrogate markers of perfusion
For the important outcome of surrogate markers of perfusion, we found 2 manikin-based experimental studies (very low level of evidence, downgraded for very serious indirectness).2,3 These 2 studies found that a circumferential, 2-thumb (i.e., 2-handed) technique generates higher pressure in a simulated arterial system compared to a 2-finger technique.2,3
For the less important outcome of complications, we identified no studies addressing this PICO question.
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Treatment recommendation |
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We recommend that chest compressions in cats and small dogs be performed using 1 of the following 3 methods, based on a combination of compressor preference and real-time markers of perfusion (e.g., EtCO2, direct blood pressure monitoring):
a) using a circumferential 2-thumb chest compression technique with the animal in lateral recumbency and both of the thumbs directly over the heart.(strong recommendation, very low quality of evidence)
b) using a 1-handed technique with the dominant hand wrapped around the sternum at the level of the heart performing compressions between the flat portion of the fingers and the flat portion of the thumb.(strong recommendation, expert opinion)
c) using a 1-handed technique with heel of the dominant hand compressing 1/3 to 1/2 the chest width over the area of the heart with the animal in lateral recumbency while the non-dominant hand supports the dorsal thorax.(strong recommendation, expert opinion) |
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Justification of treatment recommendation |
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Given there is very little evidence to inform a recommendation regarding ideal compression technique in cats and small dogs, the committee believes it is appropriate to provide a variety of options, integrating recommendations from multiple sources. The circumferential 2-thumb technique is recommended based on findings that suggest it may be superior in human infants while lateral recumbency is suggested based on chest conformation. The limited available evidence suggests that a circumferential 2-thumb chest compression technique may produce higher intrathoracic pressures than a 2-finger compression technique in human infants. This may translate to improvement in critical outcomes and supports methods (a) and (b), above. Additionally, anecdotal experience suggests that compression depth appears adequate in these animals when high-quality, 1-handed chest compressions are administered in lateral recumbency in cats and small dogs, which supports method (c), above. |
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Knowledge gaps |
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There are no studies of cats or small dogs or in animal models in lateral recumbency evaluating different chest compression techniques for any outcome of interest. Further studies of chest compression technique in cats and small dogs are needed. |
References:
1. Topjian AA, Raymond TT, Atkins D, et al. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S469-S523.
2. Smereka J, Szarpak L, Rodríguez-Núñez A, et al. A randomized comparison of three chest compression techniques and associated hemodynamic effect during infant CPR: A randomized manikin study. Am J Emerg Med. 2017;35(10):1420-1425.
3. Dorfsman ML, Menegazzi JJ, Wadas RJ, Auble TE. Two-thumb vs two-finger chest compression in an infant model of prolonged cardiopulmonary resuscitation. Acad Emerg Med. 2000;7(10):1077-1082.
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