PEDIATRICS II

Saint Louis University School of Medicine MMXXII

P.01D NEONATAL RESUSCITATION (PART 5): CHEST
COMPRESSION
Dr. BALUD | January 18, 2021

OUTLINE
I. Chest Compressions
II. Indications of Chest Compressions
III. Chest compression Techniques
IV. Two-thumb Technique

I. CHEST COMPRESSIONS
*When a newborn becomes hypoxic, the heart rate slows and Figure 2.
myocardial contractility decreases. As a result, there is a diminished Chest Compression showing increase in Intrathoracic Pressure
flow of blood and oxygen to the vital organs.
The decreased supply of oxygen to these tissues can lead to III.CHEST COMPRESSION TECHNIQUES
irreparable damage to the brain, heart, kidneys, and bowel. • Two-thumb technique (Preferred)
• To temporarily increase circulation to restore oxygen delivery to o The two thumbs may be side by side, or on top of the other,
the brain while the remaining fingers encircle the chest of the baby.
• Must be accompanied by ventilation o Less tiring
• Should use 100% oxygen o Better control of compression depth and more stable
• Two finger technique
II. INDICATIONS OF CHEST COMPRESSIONS o Better for small hands
• HR <60 bpm despite 30 seconds of PPV that moves chest o Two fingers of almost the same height are used to compress the
o When you have delivered 30 seconds of PPV that moves the chest, while the other hand supports the back of the baby.
chest, and the heart rate remains less than 60 bpm, then chest o Disadvantage: Fingers easily displaced and the compressor
compressions are indicated. needs to re-locate again the site of compression, before
o If alternate airway has not been placed yet, make sure to place resuming compression.
one already at this point.
o When chest compressions are indicated, the newborn probably
has very low blood oxygen levels and significant acidosis. The
myocardium is depressed and unable to contract strongly
enough to pump blood to the lungs. Chest compressions will
mechanically pump blood through the heart while ventilation
continues.

Figure 3.
(a) Two-thumb technique (b) Two-finger technique

IV. TWO-THUMB TECHNIQUE

A. STEPS / POSITIONING OF THUMBS
• Run your fingers along the subcostal margin until you locate the
xiphoid process
• Make an imaginary line between the nipples

Figure 1.
Indication of Chest Compression

NOTE:
The goal of chest compression is to simulate the continuity of
blood flow but this time to vital organs, especially the
brain.
As you compress the sternum of the baby, you attempt to
compress the heart against the spine. This will cause an increase
in intrathoracic pressure, which will then lead to cardiac output, Figure 4.
perfusing now the vital organs especially the brain, and to some Imaginary line demonstration
extent the peripheral organs.
In cases of hypoxia, there will be preferential blood flow to vital • Place your thumbs on the sternum below the imaginary inter-nipple
organs, especially the brain, heart and adrenal organs, at the line and above the xiphoid process
expense of other organ systems. This is also referred to as the • Thumbs compress the sternum
diving reflex. • Fingers support back

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 PEDIATRICS II
Saint Louis University School of Medicine MMXXII
o One compression consists of the downward stroke plus the
release.
o The actual distance compressed will depend on the size of the
newborn.
• Duration of the downward strokes shorter than the duration of the
release
o For generation of maximum cardiac output.
• Your thumbs or the tips of your fingers should remain in contact
with the chest at all times during compression and release. If you
take your thumbs or fingers off the sternum after compression, you:
o Waste time relocating the compression area.
o Lose control over the depth of compression.
o May compress the wrong area, producing trauma to the chest
or underlying organs.
Figure 5.
Demonstration of the steps above

• Apply pressure during compression on the sternum

• Release pressure to allow chest recoil and ventilation

Figure 7
Compression Pressure and Depth

C. COORDINATION AND VENTILATION

• One cycle of 3 compressions and 1 breath takes 2 seconds
• The breathing rate is 30 BPM and the compression rate is 90 per
minutes, this equals to 120 events per minute
o During chest compressions, the ventilation rate is actually 30
breaths per minute rather than the rate you previously
Figure 6.
learned for positive-pressure ventilation without compressions,
Correct and incorrect pressure on the baby’s chest
which was 40 to 60 breaths per minute.
o This lower ventilatory rate is necessitated by the need to provide
NOTE:
an adequate number of compressions, yet avoid simultaneous
o Care must be taken to not squeeze the chest (ribs) with your
compressions and ventilation. To ensure that the process can
whole hand during compression. If the chest is squeezed,
be coordinated, it is important that you practice with another
fractured ribs or a pneumothorax may result.
person and practice both roles.
o The thumb technique cannot be used effectively if the newborn
is large or your hands are small. However, you may find the
D. CADENDE OF COMPRESSION
thumb technique less tiring than the 2-finger technique if chest
• …and…1…and…2…and…3…and…breathe
compressions are required for a prolonged period.
o To be able to deliver 90 compressions and 30 ventilations for 1
o The compressor stays at the head part of the baby while the
minute, the resuscitator compresses the chest with the cadence:
ventilator positions himself at either side of the compressor. This
and one and two and three and breathe and one…
is to give space for the person who will access the umbilical cord
o The resuscitator compresses the chest during 1, 2, 3, and stops
for cannulation and delivery of medications.
during “breathe”, while the ventilator squeezes the bag during
breathe.
o Avoid compressing the chest and squeezing the bag
Instructor Tip: It’s easy for a nervous resuscitator to simultaneously during the word breath, or else, the lungs will
inadvertently squeeze the newborn’s chest or to hold not be ventilated.
on tightly during and between compressions. All o The compressor is the one who counts, loudly enough for all the
members of the team should watch each other’s team members to hear.
technique and calmly make suggestions for E. DURATION OF THE COMPRESSION
modification if necessary. Remember that parents • Chest compression should be done for a duration of 60 seconds
may be listening and trying to interpret your o Studies have shown that the myocardium is only able to
comments. Rather than saying, “Jane, you’re demonstrate response to chest compression after 60 seconds.
squeezing his chest and I can’t ventilate.” It would be Hence, the chest compression should be performed for a
better to say, “Jane, loosen your hands a little.” duration of 60 seconds, instead of the prior recommendation in
previous editions of 30 seconds.
B. COMPRESSION AND PRESSURE DEPTH
• Depress the sternum 1/3 of the antero-posterior diameter of F. COMPLICATIONS
the chest * As you perform chest compressions, you must apply enough pressure
o Controlling the pressure used in compressing the sternum is an to compress the heart between the sternum and spine without
important part of the procedure. With your fingers and hands damaging underlying organs.
correctly positioned, you should use enough pressure to depress • Laceration of liver
the sternum to a depth of approximately one third of the o Results from pressure applied over the lower tip of sternum
anterior-posterior diameter of the chest, then completely (xyphoid)
release the pressure to allow the heart to refill. • Rib fractures
o Due to its fragility

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 PEDIATRICS II
Saint Louis University School of Medicine MMXXII
G. STOPPING COMPRESSION
NOTE:
• After 60 seconds of compression and ventilation stop and check the When you are administering chest compressions and coordinating
heart rate ventilation, continue to ask yourself the following questions:
• Is chest movement adequate?
• Is supplemental oxygen being given?
• Is the depth of chest compression approximately one third
of the anterior-posterior diameter of the chest?
• Are the chest compressions and ventilation being well-
coordinated?

By this point in resuscitation, you most likely will have intubated the
trachea, giving a more reliable means of ventilating, and called for
additional personnel to record events. Because epinephrine
administration seems likely, establishment of an umbilical venous
line should be in progress.

Instructor’s Tip: A newborn who requires chest

compressions is seriously ill and needs a skilled and
coordinated team to administer interventions. This is why
we practice these skills frequently, so that all team
members feel confident and competent during a more
extensive resuscitation.

Figure 8
• After approximately 60 seconds of well-coordinated compressions
CHECKPOINT
and ventilation, stop for 6 seconds to determine the heart rate
1. What is/are the indications of chest compressions?
again. To determine heart beats per minute, count the beats in 6
2. What are the compression techniques? Which one is preferred?
seconds and multiply by 10. Announce the actual heart rate (say
3. Where is the proper position of the thumbs in chest
“the heart rate is 70” not “I count 7 beats”).
compression?
o If the heart rate is >60 bpm, discontinue chest compressions
4. What should be the depth of compression?
but continue positive-pressure ventilation at the rate of 40 to
5. What is the ventilation rate during chest compression?
60 breaths per minute
6. Chest compression should be done for how long?
o If the heart rate is >100 bpm and the newborn begins to
7. What is/are the indications to discontinue chest compression?
breathe spontaneously, slowly withdraw positive-pressure
ventilation and move the newborn to the nursery for post CPAP; If HR is >100 bpm and the newborn breathes simultaneously
resuscitation care 7. If the heart rate is >60 bpm, discontinue chest compressions but continue
o If the heart rate is <60 bpm, intubate the infant (if not already 6. 60 seconds
done), insert an umbilical venous catheter and give 5. 30 breaths per minute
epinephrine
4. 1/3 of the antero-posterior diameter of the chest
3. On the sternum below the imaginary nipple line above the xiphoid process
2. Two-thumb technique (preferred), two-finger technique
Instructor Tip: Learn to assess the heart rate quickly. 1. HR <60 bpm despite 30 seconds of PPV that moves chest
You should be able to recognize, within a few beats,
Answers:

if the heart rate is less than 60 bpm, 100 bpm, and

more than 100 bpm.

H. HR REMAINS LESS THAN 60 BPM

• Check adequacy of ventilation
Perform ventilation corrective steps
•
• Give supplemental oxygen
• Check depth of chest compression
• Coordinate ventilation and chest compression well
• Insert an umbilical catheter to give epinephrine

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