Traumatic Injuries Following Mechanical versus Manual Chest Compression

Abstract

Objective:
Survival after out-of-hospital cardiac arrest (OHCA) depends on multiple factors, mostly quality of chest compressions. Studies comparing manual compression with a mechanical active compression-depression device (ACD) have yielded controversial results in terms of outcomes and injury. The aim of the present study was to determine whether out-of-hospital ACD cardiopulmonary resuscitation (CPR) use is associated with more skeletal fractures and/or internal injuries than manual compression, with similar duration of cardiopulmonary resuscitation (CPR) between the groups.

Methods:
The cohort included all patients diagnosed with out-of-hospital cardiac arrest (OHCA) at a tertiary medical center between January 2018 and June 2019 who achieved return of spontaneous circulation (ROSC). The primary outcome measure was the incidence of skeletal fractures and/or internal injuries in the two groups. Secondary outcome measures were clinical factors contributing to skeletal fracture/internal injuries and to achievement of ROSC during CPR.

Results:
Of 107 patients enrolled, 45 (42%) were resuscitated with manual chest compression and 62 (58%) with a piston-based ACD device (LUCAS). The duration of chest compression was 46.0 minutes vs. 48.5 minutes, respectively (p=0.82). There were no differences in rates of ROSC (53.2% vs.50.8%, p=0.84), cardiac etiology of OHCA (48.9% vs.43.5%, p=0.3), major complications (ribs/sternum fracture, pneumothorax, hemothorax, lung parenchymal damage, major bleeding), or any complication (20.5% vs.12.1%, p=0.28). On multivariate logistic regression analysis, factors with the highest predictive value for ROSC were cardiac etiology (OR 1.94;CI 2.00-12.94) and female sex (OR 1.94;CI 2.00-12.94). Type of arrhythmia had no significant effect. Use of the LUCAS was not associated with ROSC (OR 0.73;CI 0.34-2.1).

Conclusion:
This is the first study to compare mechanical and manual out-of-hospital chest compression of similar duration to ROSC. The LUCAS did not show added benefit in terms of ROSC rate, and its use did not lead to a higher risk of traumatic injury. ACD devices may be more useful in cases of delayed ambulance response times, or events in remote locations.

Full text

ORIGINAL RESEARCH
Traumatic Injuries Following Mechanical versus
Manual Chest Compression
Safwat Saleem
1
, Roman Sonkin
2
, Iftach Sagy
3,4
, Refael Strugo
2
, Eli Jaffe
2
, Michael Drescher
1,5
,
Shachaf Shiber
1,5
1
Emergency Department, Rabin Medical Center – Beilinson Hospital, Petach-Tikva, Israel;
2
Magen David Adom (Israel National Emergency Medical
Service), Ramat Gan, Israel;
3
Rheumatology Unit, Soroka Hospital, Be’er Sheva, Beer Sheva, Israel;
4
Faculty of Medicine, University of the Negev, Be’er
Sheva, Israel;
5
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Correspondence: Shachaf Shiber, Department of Emergency Medicine, Rabin Medical Center – Beilinson Hospital, 39 Jabotinski St, Petach Tikva,
4941492, Israel, Tel +972-54-4699750, Email sofereret@gmail.com
Objective: Survival after out-of-hospital cardiac arrest (OHCA) depends on multiple factors, mostly quality of chest compressions.
Studies comparing manual compression with a mechanical active compression-depression device (ACD) have yielded controversial
results in terms of outcomes and injury. The aim of the present study was to determine whether out-of-hospital ACD cardiopulmonary
resuscitation (CPR) use is associated with more skeletal fractures and/or internal injuries than manual compression, with similar
duration of cardiopulmonary resuscitation (CPR) between the groups.
Methods: The cohort included all patients diagnosed with out-of-hospital cardiac arrest (OHCA) at a tertiary medical center between
January 2018 and June 2019 who achieved return of spontaneous circulation (ROSC). The primary outcome measure was the
incidence of skeletal fractures and/or internal injuries in the two groups. Secondary outcome measures were clinical factors
contributing to skeletal fracture/internal injuries and to achievement of ROSC during CPR.
Results: Of 107 patients enrolled, 45 (42%) were resuscitated with manual chest compression and 62 (58%) with a piston-based ACD
device (LUCAS). The duration of chest compression was 46.0 minutes vs. 48.5 minutes, respectively (p=0.82). There were no
differences in rates of ROSC (53.2% vs.50.8%, p=0.84), cardiac etiology of OHCA (48.9% vs.43.5%, p=0.3), major complications
(ribs/sternum fracture, pneumothorax, hemothorax, lung parenchymal damage, major bleeding), or any complication (20.5% vs.12.1%,
p=0.28). On multivariate logistic regression analysis, factors with the highest predictive value for ROSC were cardiac etiology (OR
1.94;CI 2.00–12.94) and female sex (OR 1.94;CI 2.00–12.94). Type of arrhythmia had no signicant effect. Use of the LUCAS was
not associated with ROSC (OR 0.73;CI 0.34–2.1).
Conclusion: This is the rst study to compare mechanical and manual out-of-hospital chest compression of similar duration to ROSC.
The LUCAS did not show added benet in terms of ROSC rate, and its use did not lead to a higher risk of traumatic injury. ACD
devices may be more useful in cases of delayed ambulance response times, or events in remote locations.
Keywords: cardiopulmonary resuscitation, CPR, fractures, active compression-decompression device, ACD
Introduction
Survival after out-of-hospital cardiac arrest (OHCA) depends on multiple factors. One of the most important is the
quality and timing of basic life support, consisting mainly of chest compressions and early debrillation
1–4
. To ease the
difculty of effective manual compression in the prehospital/patient transport setting,
5
researchers developed the active
compression-decompression (ACD) device which allows for recoil of the chest and self-compressions during cardio-
pulmonary resuscitation (CPR) and lessens caregiver fatigue.
6
Luo et al
7
found that compared to manual chest
compression, ACD device-assisted compression was associated with higher rates of return of spontaneous cardiac
rhythm (ROSC) and survival after 24 hours, but not more hospital discharges or improvement in neurological status.
ACD devices can be categorized into auto-pulse load-distributing band (LDB) devices and mechanical piston devices
(MPD) depending on the mechanism that delivers compressions. LDB devices have been found to improve coronary
Open Access Emergency Medicine 2022:14 557–562 557
© 2022 Saleem et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.
php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the
work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For
permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
Open Access Emergency Medicine Dovepress
open access to scientific and medical research
Open Access Full Text Article
Received: 23 May 2022
Accepted: 13 September 2022
Published: 4 October 2022

perfusion during CPR.
8
Studies of the Lund University Cardiopulmonary Assist System (LUCAS), a type of MPD with
a vacuum head, reported improved perfusion to cerebral neurological systems and coronary arteries, achieving high
PCO
2
values compared to standard manual compression.
9–11
The LUCAS is also amenable for use during coronary
catheterization
12,13
and during Extracorporeal cardiopulmonary resuscitation (ECPR), a rescue strategy for nonrespon-
ders to CPR in cardiac arrest.
13
With the expanded distribution of ACD devices, investigations of their relative efcacy and safety in patients with
OHCA have increased. Hallstrom and colleagues
14
found no signicant difference between the LDB device and
manual compression in the percentage of patients who achieved ROSC; indeed, both survival rate and neurological
outcomes were lower in the LDB group. However, an important limitation of this study was that the device was
programmed to a rate of 80 compressions per minute whereas manual compressions are performed, according to the
guidelines at a rate of 100–120 per minute.
14
Smekal et al
15
compared the LUCAS to manual chest compression and
reported an increase in the number of rib and bone fractures in the LUCAS group. Additional injuries were examined,
but the results were equivocal. By contrast, Kralj and colleagues
16
found no difference in the injury rate of
resuscitated patients between the LUCAS and manual compression. None of the studies conducted so far stratied
outcomes of spontaneous pulse recurrence, hospitalization survival, and 30-day hospitalization survival by duration
of CPR.
The aim of the present study was to determine if the use of ACD devices during CPR is associated with more skeletal
fractures and/or internal injuries than manual compression, with similar duration of cardiopulmonary resuscitation (CPR)
between the groups.
Methods
Setting and Design
A retrospective study was conducted between January 2018 and June 2019. Data were collected from the electronic
database of Magen David Adom (MDA), the Israel National Emergency Medical Service, and Rabin Medical Center,
a tertiary hospital in central Israel.
MDA operates according to the American emergency medical services model, using mobile intensive care units
manned by paramedics and regular ambulances manned by medics. All mobile intensive care units have been equipped
with the LUCAS (Physio-Control Inc., Lund, Sweden), a piston-type ACD device, since January 2014.
Study Population
The cohort consisted of patients diagnosed with OHCA at Rabin Medical Center during the study period who achieved
ROSC prior to transport to the hospital. Only patients who underwent chest x-ray and point-of-care ultrasound on
emergency department admission were included to ensure that the information on skeletal fractures and/or internal
injuries was complete. Patients were divided into two groups by method of CPR: manual or mechanical (LUCAS) chest
compression. The groups were pre-matched for CPR time.
Data Collection
Demographic, clinical, treatment, and outcome data of the patients were retrospectively collected by review of the
healthcare databases of MDA and Rabin Medical Center.
Study Outcomes
The primary outcome measure was the incidence of skeletal fractures and/or internal injuries in patients resuscitated with
the LUCAS device. Secondary outcomes were clinical factors contributing to the occurrence of skeletal fractures and/or
internal injuries during CPR (for example, patient age and sex, duration of CPR) and predicting ROSC [for example,
patient age and sex, type of CPR used (manual, LUCAS), type of arrhythmia, etiology of cardiac arrest (cardiac, other)].
The skeletal and internal injuries investigated were rib fractures, ail chest, sternum fracture, pneumothorax, major
bleeding, hemothorax, and lung parenchymal damage.
https://doi.org/10.2147/OAEM.S374785
DovePress
Open Access Emergency Medicine 2022:14
558
Saleem et al Dovepress
Powered by TCPDF (www.tcpdf.org)

Statistical Analysis
Data are expressed as mean and standard deviation (SD), median and interquartile range (IQR) or number and
percentage. T-test, chi-square test, and nonparametric tests were used as appropriate to compare clinical characteristics
between groups. Due to the small number of complications, regression analysis of between-group differences for this
factor was not performed. A multivariate logistic regression model was applied to identify factors predicting ROSC. Data
were generated with SPSS, version 25.0. A p value of <0.05 was considered signicant.
Results
A total of 107 patients enrolled in the study. Their epidemiological, clinical, and radiological manifestations are listed in
Table 1. CPR was performed with manual chest compressions in 45 patients (42%) and with the LUCAS in 62 patients
(58%). The corresponding durations of chest compression to ROSC were 46.0 and 48.5 minutes, with no signicant
difference between the groups (p=0.82).
ROSC was achieved in 25 patients (53.2%) with manual chest compression and in 31 patients (50.8%) using the
LUCAS; the difference was not statistically signicant (p=0.82). OHCA was due to a cardiac etiology in the majority of
patients in both groups (n=22, 48.9% and n=27, 43.5%, respectively; p=0.3). There were no signicant between-group
differences in the rates of major complications (ribs/sternum fracture, pneumothorax, hemothorax, lung parenchymal
damage, major bleeding) or of any complication (Table 1) (20.5% vs 12.1%, respectively, p=0.28).
There were no fatal complications due to CPR in both groups.
On multivariate logistic regression analysis, factors with the strongest predictive values for ROSC were cardiac
etiology (OR 1.94; CI 2.00–12.94) and female sex (OR 1.94; CI 2.00–12.94), followed by young age (OR 1.01, 95%
CI 0.99–1.04). Use of the LUCAS was not associated with achievement of ROSC (OR 0.73; CI 0.34–2.1) (Table 2).
Table 1 Characteristics of Patients with OHCA
Variable Manual Chest
Compressions
(p=45)
LUCAS Device
(n=62)
P value
Age, yr (mean±SD) 66.6 (16.8) 65.3 (18.0) 0.72
Male (n,%) 26 (57.8) 45 (72.6) 0.11
ROSC (n,%) 25 (53.2) 31 (50.8) 0.84
CPR duration, min
(median, IQR)
46.0 (35.0–60.0) 48.5 (31.7–64.5) 0.82
Cardiac etiology (n,%) 22 (48.9) 27 (43.5) 0.3
Cardiac rhythm (n,%)
VF 15 (31.9) 17 (27.4) 0.87
Asystole 26 (55.3) 36 (58.1)
PEA 6 (12.8) 9 (14.5)
Traumatic injury (n,%)
Rib fracture 4 (9.1) 3 (5.0) 0.41
Sternum fracture 0 (0.0) 1 (1.7) 0.38
Tamponade 0 (0.0) 1 (1.7) 0.38
Flail chest 1 (2.3) 1 (1.7) 0.83
Pneumothorax 2 (4.5) 2 (3.4) 0.76
Parenchymal damage 4 (9.1) 2 (3.4) 0.22
Hemothorax 1 (2.3) 0 (0.0) 0.24
Major bleeding 0 (0.0) 1 (1.7) 0.38
Any complication (n,%) 9 (20.5) 7 (12.1) 0.28
Abbreviations: CPR, cardiopulmonary resuscitation; PEA, pulseless electrical activity; VF, ventricular
brillation; ROSC, return of spontaneous circulation.
Open Access Emergency Medicine 2022:14 https://doi.org/10.2147/OAEM.S374785
DovePress
559
Dovepress Saleem et al
Powered by TCPDF (www.tcpdf.org)

Discussion
This is the rst study, to our knowledge, to examine traumatic manifestations of prehospital chest compression with the
LUCAS compared to manual compression, both applied for a similar duration. The results show that the LUCAS was not
associated with a higher rate of traumatic complications. At the same time, it did not have any advantage in terms of
achieving ROSC over manual compression, in agreement with earlier studies.
17,18
The PARAMEDIC study from the UK by Gates et al
17
was based on data from clusters of ambulance service vehicles
that were randomly assigned to administer CPR with the LUCAS-2 or manual chest compression. Intention-to-treat
analysis showed that 30-day survival was 6.3% (104/1652) in the LUCAS-2 group and 6.8% (193/2819) in the manual
compression group (OR 0.86, 95% CI 0.64–1.15). No serious adverse events were noted. Similarly, in a prospective
registry study of 278 patients, Karasek et al
18
found no signicant difference in the rate of ROSC between the those who
underwent CPR with the LUCAS (44/144, 30.6%) and those who did not (69/278, 24.8%) (p=0.35). Use of the LUCAS
was associated with a signicantly higher rate of conversion from non-shockable to shockable rhythm (20.7% vs 10.10%;
p=0.04) and a signicantly lower rate of 30-day survival (5.07% vs 16.31%, p=0.044).
Milling et al
19
retrospectively compared the outcomes of 84 patients who underwent both manual and mechanical chest
compression with 353 patients treated with manual chest compression only. On unadjusted analysis, mechanical chest
compression as an adjunct was associated with a higher risk of injuries than manual chest compression (p <0.001, OR 3.10).
However, the difference lost signicance when the analysis was adjusted (with statistical technique) for duration of CPR.
In a 2021 meta-analysis examining the effectiveness of mechanical chest compression devices,
20
15 studies (n=18,474)
were analyzed: 6 randomized controlled trials, 2 cluster randomized controlled trials, 5 retrospective case-control studies, and
2 phased prospective cohort studies. The pooled estimate summary effect did not indicate a signicant difference in achieving
ROSC between mechanical and manual compression (Mantel-Haenszel OR 1.16, 95% CI 0.97–1.39; p=0.11, I2=0.83).
We also found that achieving ROSC was related to female sex, cardiac etiology of OHCA. These observations are supported
by previous literature.
21–23
Navab et al
21
sought to identify major factors contributing to ROSC in the prehospital setting. A total of
3214 patients were included. The overall rate of success of ROSC was 8.3%, and of hospital death, 4.1%. Factors negatively
associated with ROSC outcomes were older age, longer ambulance response time, longer CPR duration, and history of cardiac
disease. Factors positively associated with ROSC were being witnessed, bystander CPR, and initial shockable rhythm. In another
study of 1150 patients in whom CPR was attempted,
22
ROSC was achieved in 250 (27.8%). The rate of ROSC was signicantly
higher when CPR was initiated by bystanders (p <0.001). The likelihood of achieving ROSC was higher in patients with VF/VT
cardiac rhythm than with asystole (OR 2.68, 95% CI 1.86–3.85; p < 0.001), and higher (by 1.78-fold) when the event occurred in
a public place (p <0.001).
A recent study of 8115 patients (32.4% female) used logistic regression to examine the effect of sex and the
interaction of sex and age on ROSC and survival to hospital discharge.
23
Female patients had a lower proportion of
bystander-witnessed cardiac arrests and initial shockable rhythms. In concordance with our study, the likelihood of
ROSC was higher in female than male patients (OR 1.29, 95% CI 1.15–1.42, p <0.001). The ROSC advantage was
signicant in female patients with non-shockable rhythms (OR 1.48, 95% CI 1.24–1.78, p < 0.001) and female patients of
premenopausal age. However, there was no signicant difference in survival to hospital discharge between females and
males overall or by sex-age groups. Both younger females and younger males had a higher survival rate to hospital
discharge than older females and males.
Table 2 Logistic Regression Predicting ROSC in Patients with OHCA
Variable P value Odds Ratio 95% Condence Interval
Young age 0.19 1.01 0.99–1.04
Female 0.16 1.94 0.75–4.97
Cardiac origin 0.001 5.09 2.00–12.94
LUCAS 0.73 0.85 0.34–2.1
Abbreviations: ROSC, return of spontaneous circulation; OHCA, out-of-hospital cardiac arrest.
https://doi.org/10.2147/OAEM.S374785
DovePress
Open Access Emergency Medicine 2022:14
560
Saleem et al Dovepress
Powered by TCPDF (www.tcpdf.org)

Strengths and Limitations
This study was limited by its retrospective design and the reliance on data from the patients’ medical records. It is
possible that there were some errors, though it is unlikely that they would have occurred more often in a particular group.
Our main advantage of our study is that there is no statistically signicant difference in length of CPR between the
groups. Past studies had difculty understanding if there are more traumatic injuries from mechanical CPR. Naturally,
using LUCAS device happens in a longer CPR. In our study, we matched the time of CPR between the groups and we
could assess exactly that LUCAS device is not contributing to more traumatic complication than manual compressions.
Another important advantage of our study was the availability of a digital patient record system that includes data from
emergency medicine services as well as the main hospitals serving the community. We also applied strict inclusion criteria, and
excluded patients without imaging studies documenting the presence (or absence) of post-CPR traumatic injuries.
Conclusion
This study showed that the use of a mechanical compression-decompression device (LUCAS) in patients with prehospital
cardiac arrest was not associated with improved rates of ROSC compared to manual compression. It also does not pose an
elevated risk of traumatic injuries. Mechanical CRP devices may be useful when ambulance response times are delayed or too
few or untrained response teams are available, or in remote events occurring a long distance from a hospital.
Data Sharing Statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author on
reasonable request.
Ethics Statement
The Rabin Hospital Ethics Committee approved this study, and that all data accessed complied with relevant data
protection and privacy regulations – IRB – RMC – 20-477.
We conrm that the guidelines outlined in the Declaration of Helsinki were followed.
Funding
No funding was received for this study.
Disclosure
The authors report no conict of interest.
References
1. Steen S, Liao Q, Pierre L, Paskevicius A, Sjöberg T. The critical importance of minimal delay between chest compressions and subsequent
debrillation: a haemodynamic explanation. Resuscitation. 2003;58(3):249‒258. doi:10.1016/s0300-9572(03)00265-x
2. Sato Y, Weil MH, Sun S, et al. Adverse effects of interrupting precordial compression during cardiopulmonary CPR. Crit Care Med. 1997;25
(5):733‒736. doi:10.1097/00003246-199705000-00005
3. Paradis NA, Martin GB, Rivers EP, et al. Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary CPR.
JAMA. 1990;263(8):1106. doi:10.1001/jama.1990.03440080084029
4. Eftestøl T, Sunde K, Andreas Steen P. Effects of interrupting precordial compressions on the calculated probability of debrillation success during
out-of-hospital cardiac arrest. Circulation. 2002;105(19):2270‒2273. doi:10.1161/01.CIR.0000016362.42586.FE
5. Olasveengen TM, Wik L, Steen PA. Quality of cardiopulmonary CPR before and during transport in out-of-hospital cardiac arrest. Resuscitation.
2008;76(2):185‒190. doi:10.1016/j.resuscitation.2007.07.001
6. Yuksen C, Prachanukool T, Aramvanitch K, Thongwichit N, Sawanyawisuth K, Sittichanbuncha Y. Is a mechanical-assist device better than manual
chest compression? A randomized controlled trial. Open Access Emerg Med. 2017;9:63‒67. doi:10.2147/OAEM.S133074
7. Luo X, Zhang H, Chen G, Ding W, Huang L. Active compression-decompression cardiopulmonary CPR (CPR) versus standard CPR for cardiac
arrest patients: a meta-analysis. World J Emerg Med. 2013;4(4):266‒272. doi:10.5847/wjem.j.1920-8642.2013.04.004
8. Wik L, Kiil S. Use of an automatic mechanical chest compression device (LUCAS) as a bridge to establishing cardiopulmonary bypass for a patient
with hypothermic cardiac arrest. Resuscitation. 2005;66(3):391‒394. doi:10.1016/j.resuscitation.2005.03.011
9. Steen S, Liao Q, Pierre L, Paskevicius A, Sjöberg T. Evaluation of LUCAS, a new device for automatic mechanical compression and active
decompression CPR. Resuscitation. 2002;55(3):285‒299. doi:10.1016/s0300-9572(02)00271-x
Open Access Emergency Medicine 2022:14 https://doi.org/10.2147/OAEM.S374785
DovePress
561
Dovepress Saleem et al
Powered by TCPDF (www.tcpdf.org)

10. Rubertsson S, Karlsten R. Increased cortical cerebral blood ow with LUCAS; a new device for mechanical chest compressions compared to
standard external compressions during experimental cardiopulmonary CPR. Resuscitation. 2005;65(3):357‒363. doi:10.1016/j.
resuscitation.2004.12.006
11. Axelsson C, Karlsson T, Axelsson AB, Herlitz J. Mechanical active compression-decompression cardiopulmonary CPR (ACD-CPR) versus manual
CPR according to pressure of end tidal carbon dioxide (PETCO2) during CPR in out-of-hospital cardiac arrest (OHCA). Resuscitation. 2009;80
(10):1099‒1103. doi:10.1016/j.resuscitation.2009.08.006
12. Wagner H, Terkelsen CJ, Friberg H, et al. Cardiac arrest in the catheterisation laboratory: a 5-year experience of using mechanical chest
compressions to facilitate PCI during prolonged CPR efforts. Resuscitation. 2010;81(4):383‒387. doi:10.1016/j.resuscitation.2009.11.006
13. Marinacci LX, Mihatov N, D’Alessandro DA, et al. Extracorporeal cardiopulmonary resuscitation (ECPR) survival: a quaternary center analysis.
J Card Surg. 2021;36:2300–2307. doi:10.1111/jocs.15550
14. Hallstrom A, Rea TD, Sayre MR, et al. Manual chest compression vs use of an automated chest compression device during resuscitation following
out-of-hospital cardiac arrest: a randomized trial. JAMA. 2006;295(22):2620‒2628. doi:10.1001/jama.295.22.2620
15. Smekal D, Lindgren E, Sandler H, Johansson J, Rubertsson S. CPR-related injuries after manual or mechanical chest compressions with the
LUCAS™ device: a multicentre study of victims after unsuccessful resuscitation. Resuscitation. 2014;85(12):1708‒1712. doi:10.1016/j.
resuscitation.2014.09.017
16. Kralj E, Podbregar M, Kejžar N, Balažic J. Frequency and number of resuscitation related rib and sternum fractures are higher than generally
considered. Resuscitation. 2015;93:136‒141. doi:10.1016/j.resuscitation.2015.02.034
17. Gates S, Lall R, Quinn T, et al. Prehospital randomised assessment of a mechanical compression device in out-of-hospital cardiac arrest
(PARAMEDIC): a pragmatic, cluster randomised trial and economic evaluation. Health Technol Assess. 2017;21(11):1‒176. doi:10.3310/hta21110
18. Karasek J, Ostadal P, Klein F, et al. LUCAS II device for cardiopulmonary resuscitation in a nonselective out-of-hospital cardiac arrest population
leads to worse 30-day survival rate than manual chest compressions. J Emerg Med. 2020;59(5):673‒679. doi:10.1016/j.jemermed.2020.06.022
19. Milling L, Astrup BS, Mikkelsen S. Prehospital cardiopulmonary resuscitation with manual or mechanical chest compression: a study of
compression-induced injuries. Acta Anaesthesiol Scand. 2019;63(6):789‒795. doi:10.1111/aas.13347
20. Sheraton M, Columbus J, Surani S, Chopra R, Kashyap R. Effectiveness of mechanical chest compression devices over manual cardiopulmonary
CPR: a systematic review with meta-analysis and trial sequential analysis. West J Emerg Med. 2021;22(4):810–819. doi:10.5811/
westjem.2021.3.50932
21. Navab E, Esmaeili M, Poorkhorshidi N, Salimi R, Khazaei A, Moghimbeigi A. Predictors of out of hospital cardiac arrest outcomes in pre-hospital
settings; a retrospective cross-sectional study. Arch Acad Emerg Med. 2019;7(1):36.
22. Czapla M, Zielińska M, Kubica-Cielińska A, Diakowska D, Quinn T, Karniej P. Factors associated with return of spontaneous circulation after
out-of-hospital cardiac arrest in Poland: a one-year retrospective study. BMC Cardiovasc Disord. 2020;20(1):288. doi:10.1186/s12872-020-01571-5
23. Awad E, Humphries K, Grunau B, Besserer F, Christenson J. The effect of sex and age on return of spontaneous circulation and survival to hospital
discharge in patients with out of hospital cardiac arrest: a retrospective analysis of a Canadian population. Resusc Plus. 2021;5:100084.
doi:10.1016/j.resplu.2021.100084
Open Access Emergency Medicine Dovepress
Publish your work in this journal
The Open Access Emergency Medicine is an international, peer-reviewed, open access journal publishing original research, reports, editorials,
reviews and commentaries on all aspects of emergency medicine. The manuscript management system is completely online and includes a very
quick and fair peer-review system, which is all easy to use. Visit http://www.dovepress.com/testimonials.php to read real quotes from published
authors.
Submit your manuscript here: https://www.dovepress.com/open-access-emergency-medicine-journal
DovePress Open Access Emergency Medicine 2022:14
562
Saleem et al Dovepress
Powered by TCPDF (www.tcpdf.org)