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O R I G I N A L R E S E A R C H Open Access
Comparison of different mechanical chest
compression devices in the alpine rescue
setting: a randomized triple crossover
experiment
Egger Alexander
1,2
, Tscherny Katharina
2,3
, Fuhrmann Verena
3
, Grafeneder Jürgen
3,4
, Niederer Maximilian
1,3
,
Kienbacher Calvin
3
, Schachner Andreas
2
, Schreiber Wolfgang
3
, Herkner Harald
3
and Roth Dominik
3*
Abstract
Background: Cardiopulmonary resuscitation in mountain environment is challenging. Continuous chest
compressions during transport or hoist rescue are almost impossible without mechanical chest compression
devices. Current evidence is predominantly based on studies conducted by urbane ambulance service. Therefore,
we aimed to investigate the feasibility of continuous mechanical chest compression during alpine terrestrial
transport using three different devices.
Methods: Randomized triple crossover prospective study in an alpine environment. Nineteen teams of the Austrian
Mountain Rescue Service trained according to current ERC guidelines performed three runs each of a standardised
alpine rescue-scenario, using three different devices for mechanical chest compression. Quality of CPR, hands-off-
time and displacement of devices were measured.
Results: The primary outcome of performed work (defined as number of chest compressions x compression depth)
was 66,062 mm (2832) with Corpuls CPR, 65,877 mm (6163) with Physio-Control LUCAS 3 and 40,177 mm (4396)
with Schiller Easy Pulse. The difference both between LUCAS 3 and Easy Pulse (Δ25,700; 95% confidence interval
21,118 –30,282) and between Corpuls CPR and Easy Pulse (Δ25,885; 23,590 –28,181) was significant. No relevant
differences were found regarding secondary outcomes.
Conclusion: Mechanical chest compression devices provide a viable option in the alpine setting. For two out of
three devices (Corpuls CPR and LUCAS 3) we found adequate quality of CPR. Those devices also maintained a
correct placement of the piston even during challenging terrestrial transport. Adequate hands-off-times and correct
placement could be achieved even by less trained personnel.
Keywords: Mechanical chest compression, Alpine rescue mission, Out-of-hospital cardiac arrest, Hypothermic
cardiac arrest
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* Correspondence: dominik.roth@meduniwien.ac.at
3
Department of Emergency Medicine, Medical University of Vienna,
Spitalgasse 23, 1090 Wien, Austria
Full list of author information is available at the end of the article
Alexander et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
(2021) 29:84
https://doi.org/10.1186/s13049-021-00899-x
Background
In 2020, 261 people died in the Austrian alps. Contrary
to popular believe, only about 4 % of them died because
of avalanche burial, whereas 22% died due to non-
traumatic cardiac arrest. The majority of patients with
non-traumatic cardiac arrest were aged between 50 and
80 years [1], reflecting an increasingly older population
visiting the mountain environment.
High-quality chest compressions and early defibrilla-
tions are the cornerstones of successful cardiopulmonary
resuscitation (CPR). This is true both in urban and
mountain environment. Transportation under continu-
ous chest compressions is generally recommended in
case of potentially reversible causes that can only be ad-
equately treated in a hospital. This is true for myocardial
infarction, but also for special circumstances often en-
countered in the alpine environment, such as
hypothermia [2].
However, transportation under continuous chest com-
pression is a special challenge for terrestrial and helicop-
ter rescue crews [3]. Continuous manual chest
compression is impossible during a fixed rope rescue or
hoist rescue operation in helicopter emergency medical
service (HEMS). In other cases, continuous manual chest
compression could not be performed in high quality
without severe risk for rescue personnel, like in challen-
ging terrain with potential falling hazard. Unacceptable
risk to rescuer or rescuer exhaustion are reasons for ter-
mination of resuscitation, even if there is a potentially
reversible underlying cause of cardiac arrest [4]. Further-
more, recent literature shows a significant decrease in
quality of manual chest compression of experienced sub-
jects after physical strain in high altitude [5]. There is
also an increase in the rigidity of the thorax in case of
profound hypothermia (core body temperature below
20 °C) [6]. This could further aggravate the exhaustion
of rescuers.
Current available devices for mechanical chest com-
pression might also be suitable for the alpine rescue mis-
sion. The mountain environment imposes many
challenges which are not present in the settings of in-
hospital emergency medicine and emergency medical
service (EMS).
The need for manual transportation to scene, prolonged
transportation time without any possibility of recharging
and lack of continuous control of correct piston place-
ment as well as extreme climatic conditions are some of
these special circumstances. The usage of mechanical
chest compression devices nevertheless offers alpine res-
cue crews’new possibilities in high quality CPR.
Most of the research on mechanical chest compression
devices has been performed in the urban or flat rural
setting. Whereas Havel et al. [7] did not find significant
differences in quality of manual chest compressions
during transportation in an ambulance vehicle or heli-
copter transport compared to on scene, Putzer et al. [8]
were able to detect a significant superiority of mechan-
ical chest compression during helicopter transport. This
finding was also supported by a study of Gaessler et al.
[9] in 2015.
A few case reports support the practicability and pos-
sible good neurological outcome after continuous chest
compressions in an alpine rescue setting, or transporta-
tion of deep hypothermic patients [2,10,11]. Mechan-
ical CPR was however only performed on site in one of
them [10], and was started at the hospital in another
[11]. There is currently only one controlled study on
modes of CPR during transportation in the alpine envir-
onment. Thomassen et al. [12] could demonstrate that it
was possible to maintain high-quality chest compression
both manual and mechanical in such a setting. The ap-
plicability of these findings is however limited by the set-
ting of transportation in a sledge attached to a
snowmobile on a very flat slope with a descent of only
18%. A sledge in combination with a snowmobile is a
preferred option of transport in snow covered moderate
steep area, like the polar cap, some ski-slopes or glaciers.
It offers fast transport by a two-man rescue team. In
many regions, e.g. the Alps of Central Europe, the ma-
jority of alpine rescue missions however takes place on
steep hiking trails, where transportation using alpine
stretchers is necessary. Sledges cannot be used here.
This results in longer duration of transport and need for
more manpower. Most importantly, the mechanical im-
pact of a transport on a stretcher over rough terrain is
usually much higher than the rather smooth ride on a
sledge.
We hence aimed to investigate feasibility and quality
of mechanical chest compression under real alpine
conditions.
Methods
This is a randomized triple crossover prospective study
in an alpine environment. Two-person teams completed
a standardized alpine rescue scenario three times, using
three different battery-powered mechanical chest com-
pression devices in a randomized order. The study was
approved by the ethical review board of the Lower Aus-
trian government (GS1-EK-1/197–2020).
Study subjects
A total of 38 members of the Austrian mountain rescue
service at least 18 years old participated in the study.
Participants were randomized into 19 two-person teams.
Each team consisted of one trained emergency medical
technician (EMT) and one team member with regular
training in Basic Life Support (BLS) according to the
current ESC guidelines. This reflects the real-life
Alexander et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:84 Page 2 of 8
composition of mountain rescue service teams, where
only a limited number of team members have EMT
training.
Study setting
This study was performed in alpine environment (Gam-
ing, Lower Austria, Austria). The starting point was at
770 m above sea level, the arrival point at 630 m above
sea level, the total distance was 490 m, the average de-
cline was 22%, the maximum decline 38%. The study
scenario track was situated on a hiking trail in rough ter-
rain (see Fig. 1).
Intervention and measurement
After informed consent, participants received two hours
of hands-on instructions on the use of the three different
chest devices (see below), two weeks before the study
day.
Training focused on correct placement of the device
and minimizing hands-of-time.
Fig. 1 Map of hiking trail
Alexander et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:84 Page 3 of 8
On the study day, participants performed three runs of
a standardised alpine rescue-scenario using the three dif-
ferent devices. Order of devices was randomized for each
team.
The non-EMT in the team started manual
compression-only resuscitation on a manikin (Laerdal
Q-CPR Full Body (weight 24 kg), Laerdal Medical AS,
Stavanger, Norway), while the EMT prepared and ap-
plied the mechanical chest compression device. A mem-
ber of the study-staff marked the initial position of the
piston of the chest compression device using a felt pen.
After application and starting of the mechanical chest
compression device in continuous mode, the manikin
was transferred to a stretcher designed for alpine use
(Tyromont Gebirgstrage Light, Tyromont Alpin Technik
GmbH, Thaur, Austria), immobilised in a vacuum-
mattress (RedVac VM01, medida GmbH & Co. KG,
Stockstadt, Germany) and transport was begun. For the
sake of simplicity, no ventilation was performed as part
of the study. Average transportation time on the trail
was measured to be 8 min beforehand.
Devices
We compared Corpuls CPR (GS Elektromedizinische
Geräte G. Stemple GmbH, Kaufering, Germany), LUCAS
3 (Physio-Control, Redmond, USA) and Easy Pulse
(Schiller Medizintechnik GMBH, Feldkirchen, Germany)
devices. We also aimed to include the AutoPulse (ZOLL
Medical Corporation, Chelmsford, USA) device into our
study, but the company decided to not provide a device
for the trial because of the “unique”chest compression
technology that does not reproduce current ERC guide-
lines in the setting of manikin study.
All devices are driven by rechargeable battery. Under
normal conditions, manufacturers guarantee a working
time of 45–90 min. Each of them had a second battery
in case.
In addition to the stretcher used in the study, all de-
vices were also tested for compatibility with the “Tyro-
mont”rescuebag “Christophorus Evo”(Tyromont Alpin
Technik GmbH, Bert-Köllensperger-Str. 6, A-6065
Thaur) to prove possibility of fixed rope rescue or hoist
rescue operations in HEMS. Technical information for
all devices, including the AutoPulse, is listed in Table 1.
Depictions of all devices are shown in Fig. 2.
Corpuls CPR
This is a piston-based compression device with the op-
tion of three different back plates with different forms.
For the manikin study, we used the “Recboard”type
back plate. The manufacturer also offers a special ring,
to be placed on the patient’s thorax, for fixing the pa-
tient on the back plate. This is the only device with the
option to change both compression depth (from 2 to 6
cm) and rate (from 80 to 120 compressions per minute).
For this study we selected a compression depth of 5.5
cm, and 110 compressions per minute.
Physio-control LUCAS 3
This is also a piston-based compression device with two
arms in lateral position. These two arms are being fixed
on a universal backplate. The device uses a neckband
against cranio-caudal dislocation. There are two different
modes (30:2 or continuously with 102 +/−2 compres-
sions per minute). For the study setting, we used the
continuous mode.
Schiller easy pulse
This device is a combination between piston and com-
pression band, allowing “circulating”thorax compres-
sions. The device is placed on the patient’s thorax and
fixed with four straps on a back plate. The device uses
additional shoulder straps against cranio-caudal disloca-
tion. There are two different modes (30:2 and continu-
ously with 100 compressions per minute).
For the study setting, we used the continuous mode.
Outcomes
The primary outcome was performed work (number of
chest compression x compression depth), scaled for des-
cent time. Secondary outcomes included hands-off-time,
relative proportion of effective chest-compressions,
Table 1 Technical data of chest compression devices
Corpuls CPR Schiller Easy Pulse PhysioControl LUCAS 3 ZOLL AutoPulse
Weight (device) 5.5 kg 3.5 kg 8 kg 10.6 kg
Weight (including manikin) 29.5 kg 27.5 kg 32 kg 34.6 kg
Width 43 cm up to 40 cm 52 cm 44.7 cm
Compressions per minute 80 to 120/min 100/min 102 ± 2/min 80 ± 5/min
Battery capacity 90 min 45 min 45 min 30 min
Temperature range −20 to 45 °C -20 to 40 °C -20 to 40 °C 0 to 40 °C
Fits into Tyromont rescuebag + + + Not tested
Fits into Tyromont alpine stretcher + (with scoopboard) + + Not tested
Alexander et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:84 Page 4 of 8
mean compression depth, mean compression rate, and
deviation of the position of the piston over time. We
also asked participants to rank the devices according to
their personal preferences.
All measures of CPR-quality (see Analysis below) were
automatically measured by the manikin and exported to
Microsoft Excel (Microsoft Corp., Redmond, USA) after-
wards. At the end of the track, a member of the study-
staff measured movement of the compression piston
from the marked position using a measuring tape.
Statistical analysis
Sample size calculation were based on the primary out-
come of performed work (number of chest compression
x compression depth). Based on previous studies on
CPR in difficult settings, such as aboard an aircraft or
helicopter [8,13], we expected performed work over 8
min to be 40,000 (standard deviation SD 4800) mm. To
detect a meaningful difference of 10% between devices
for this outcome we would have needed to include 18
teams (probability for error of 1st kind 5%, power 80%).
To allow for the study design, we planned to include a
total of 20 teams. Due to one participant’s lack of avail-
ability, we finally included 19 teams into the study.
We tabulated outcomes by device and calculated abso-
lute differences with robust 95% confidence intervals
using a linear random-effects regression model with the
device as an independent variable. To verify successful
randomization, we also performed additional analysis in-
corporating randomization sequence as a factor variable.
We used Stata 16MP (Stata Corp, College Station,
USA) for all analyses. Generally, a two-sided p-value less
than 0.05 was considered statistically significant.
Results
Characteristics of study subjects
A total of 38 participants in 19 teams were included in
the study. Mean age of participants was 36 years (SD
12), mean body mass index was 26 (SD 4), they had an
average of 9 years (SD 6) of service, and three (8%) par-
ticipants were female. All subjects were able to complete
the scenarios as planned.
Main results
The average time taken for the descent was 11.8 min
(SD 2) when using Corpuls CPR, 13.0 min (SD 2.3) for
Physio-Control LUCAS 3 and 12.1 min (SD 1.9) for
Schiller Easy Pulse. Main outcome was scaled to a dur-
ation of 12 min for all devices.
The main outcome of performed work was 66,062 mm
(SD 2832) with Corpuls CPR, 65,877 mm (6163) with
LUCAS 3, and 40,177 mm (4396) with Easy Pulse, see
Fig. 3.
There was a significant difference between LUCAS 3
and Easy Pulse (25,700; 95% confidence interval 21,118
to 30,282 mm). There was also a significant difference
between Corpuls CPR and Easy Pulse (25,885; 95% CI
23,590 to 28,181 mm). There was no significant differ-
ence between LUCAS 3 and Corpuls CPR (185; 95%CI
−3346 to 3716 mm).
Secondary outcomes
There were no clinically relevant differences between de-
vices in terms of hands-off time (Corpuls CPR 2.9%
(1.1), LUCAS 3 3.7% (1.3), Easy Pulse 2.9% (0.7)), but a
minimal statistically significant difference between LU-
CAS 3 and Easy Pulse (absolute difference 0.8% (0.2 to
1.5)).
We found significant differences regarding the propor-
tion of effective compressions (Corpuls CPR 94% (7),
LUCAS 3 98% (3), Easy Pulse 7% (4)) between all
devices.
The difference between Corpuls CPR and LUCAS 3
was however minimal (−3% (−6.5 to −0.3%)), whereas
the difference between Easy Pulse and both Corpuls
CPR (87% (84 to 91%)) and LUCAS 3 (91% (89 to 92%))
was considerable. Mean compression rate of Corpuls
CPR (111 bpm; SD 1) was slightly higher than those of
LUCAS 3 (104 bpm; SD 2) and Easy Pulse (102 bpm; SD
2).
We found no significant differences between devices
for deviation of compression point. See Table 2for an
overview of all outcomes.
Noteworthy, despite the least favourable outcomes re-
garding objective measures of CPR quality, the Schiller
Fig. 2 Devices used in the study: Corpuls CPR (left), Schiller Easy Pulse (middle), PhysioControl LUCAS 3 (right)
Alexander et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:84 Page 5 of 8
Easy Pulse was ranked highest for personal preference
by participants (see Fig. 4).
Discussion
The study compared three mechanical chest compres-
sion devices showing the usability in an alpine rescue
scenario.
Regarding our primary outcome performed work as a
cumulative marker of quality of mechanical chest com-
pressions, we found distinctly better results for both
Corpuls CPR and LUCAS 3 than for Easy Pulse, with no
significant differences between the former two devices.
One reason for this could be the different compression
technologies: A simple piston versus piston/band-
combination.
Similar results were found regarding the secondary
outcome of proportion of effective chest compressions.
No significant differences in other secondary outcomes
were recorded.
Up to date, there are no published studies on clinical
outcomes of resuscitation with the Easy Pulse device in
a human collective, therefore we can only speculate
whether our findings regarding this device are just a
matter of measurement or do really correspond to de-
creased quality of CPR.
Our findings however do support the assumption that
both Corpuls CPR and LUCAS 3 are able to maintain
high quality chest compressions even in rough alpine
terrain.
We found that even during transport over steep and
rough alpine terrain, the devices performed without any
clinically relevant displacement. We nevertheless recom-
mend marking the piston position after placement, and
repeatedly control it during transportation to assure pa-
tient safety.
Our findings have severe influence on the manage-
ment of cardiac arrest in the alpine setting. This is the
first study to compare three different mechanical chest
Fig. 3 Main outcome (performed work) by device
Table 2 Primary and secondary outcomes
Outcome LUCAS
3
Corpuls
CPR
Schiller
EasyPulse
ΔLUCAS 3 vs Corpuls
CPR (mean, 95% CI)
ΔLUCAS 3 vs Schiller
EasyPulse (mean, 95% CI)
ΔCorpuls CPR vs Schiller
EasyPulse (mean, 95% CI)
Performed work, mm
(mean, SD)
65,877
(6163)
66,062
(2832)
40,177
(4396)
185 (−3346 –3716) 25,700 (21,118 –30,282) 25,885 (23,590 –28,181)
Hands-off-fraction, % (SD) 3.7 (1.3) 2.9 (1.1) 2.9 (0.7) −0.8 (−1.6–0.05) 0.8 (0.2–1.5) 0.1 (−0.6–0.7)
Deep enough
compressions, % (mean,
SD)
98 (3) 94 (7) 7 (4) −3(−6–−0.3) 90 (89–92) 87 (84–91)
Average compression
depth, mm (mean, SD)
57 (2) 52 (1) 34 (4) −5(−6–−4) 23 (21–25) 18 (17–20)
Average compression rate,
bpm (mean, SD)
104 (2) 111 (1) 102 (2) −7(−6–−7) 1 (1–2) 8 (8–9)
Dislocation compression
point, mm (mean, SD)
4 (2) 5 (3) 8 (6) 0.1 (−0.1–0.2) −0.3 (−0.7 –−0.01) −0.3 (−0.6–0.1)
CI: confidence interval, SD: standard deviation
Alexander et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:84 Page 6 of 8
compression devices in a realistic alpine rescue scenario.
Guidelines for cardiopulmonary resuscitation only per-
mit intermittent CPR in case of hypothermic cardiac ar-
rest, but these are very rare cases in alpine environment.
Cardiac arrest of all other origins requires continuous
chest compressions with minimal interruption. During
transportation in an alpine setting, this seems to be only
feasible using mechanical chest compression devices.
Feasibility of this has been shown previously in the
urban/flat rural setting [12]. The findings in our current
study suggest that high quality mechanical chest com-
pressions during an alpine rescue mission are achievable.
This warrants the provision of such devices in HEMS
and alpine rescue organizations.
Our results complement the findings of one previous
study, in which mechanical CPR in alpine terrain was in-
vestigated. Thomassen et al. [12] report high quality of
both manual and mechanical chest compressions during
transportation on a sledge. Compared to our study, the
scenario of this study was however much less represen-
tative for the reality of alpine rescue organizations, as
mentioned before. Still, the findings of our study must
be interpreted in light of the limitations of its design.
This was a manikin study, and further research is needed
to validate the applicability of findings in real patients.
Further studies should also include ventilation as part of
the scenario. Furthermore, we were not able to study
one commonly used device, the Zoll AutoPulse, as men-
tioned above. The findings of our study might however
be helpful to design and adequately power a study com-
paring the AutoPulse to the other devices. Design of
such a study should especially consider the large differ-
ences found between the EasyPulse (using a combined
piston & band system) and the other two devices, which
used a conventional piston system only.
Conclusion
Mechanical chest compression devices may provide a vi-
able option for CPR in the alpine setting. Even if the use
of such devices is expected to be generally rare in this
setting, we found that short hand-off times and correct
placement can be achieved, even by less trained
personnel.
We could show that the Corpuls CPR and LUCAS 3
devices provided high quality chest compressions
throughout the rescue scenarios. These devices also
maintained correct placement of the piston even during
challenging terrestrial transport. Further studies on the
use of the Easy Pulse device are needed.
Abbreviations
BLS: Basic Life Support; CI: confidence interval; CPR: cardiopulmonary
resuscitation; EMS: emergency medical service; EMT: emergency medical
technician; SD: standard deviation
Acknowledgements
We would like to thank Koloszar Medizintechnik, Austria for providing the
manikin and the PysioControl LUCAS 3 device; Schiller Handels GesmbH,
Austria for providing the Schiller Easy Pulse device; and Sanitas GmbH,
Austria for providing the Corpuls CPR device.
Authors’contributions
AE participated in conceptualization, methodology, validation, formal
analysis, investigation, resources, data curation, writing (original draft),
visualization and project administration. KT participated in conceptualization,
methodology, investigation, resources, data curation and critical and writing
(review & editing). VF, JG, MN, and CK participated in investigation, data
curation and writing (review & editing). AS participated in investigation and
writing (review & editing). WS and HH participated in validation,
investigation and writing (review & editing). DR participated in
conceptualization, methodology, software, validation, formal analysis,
investigation, resources, data curation, writing (original draft), visualization,
supervision and project administration. All authors read and approved the
final manuscript.
Funding
We received no external funding for this publication.
Fig. 4 Personal ranking of devices
Alexander et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:84 Page 7 of 8
Availability of data and materials
The dataset used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Declarations
Conflict of interest
None.
Ethics approval and consent to participate
The study was approval by the ethical review board of the Lower Austrian
government (GS1-EK-1/197–2020). All participants provided written informed
consent to participate.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Mountain Rescue Service Austria, Schelleingasse 26/2/2, 1040 Wien, Austria.
2
Department of Anaesthesiology and Intensive Care Medicine, Hospital
Scheibbs, Eisenwurzenstraße 26, 3270, Scheibbs, Austria.
3
Department of
Emergency Medicine, Medical University of Vienna, Spitalgasse 23, 1090
Wien, Austria.
4
Department of Clinical Pharmacology, Medical University of
Vienna, Spitalgasse 23, 1090 Wien, Austria.
Received: 17 March 2021 Accepted: 11 June 2021
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