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Mean (±SD) maximum depth with depth of compressed chest post-inadequate recoil at 1Gz, 0.38Gz and μG. (A) The 2005 ECC guidelines. (B) The 2010 ECC guidelines. The dashed line(s) depicts the effective limit(s) of depth for each respective guideline. n = 30; asterisk denotes significant difference in maximum depth to 1Gz control, p < 0.05. The plus sign denotes significant difference in recoil to 1Gz control, p < 0.05.
Source publication
Current 2010 terrestrial (1Gz) CPR guidelines have been advocated by space agencies for hypogravity and microgravity environments, but may not be feasible. The aims of this study were to (1) evaluate rescuer performance over 1.5 min of external chest compressions (ECCs) during simulated Martian hypogravity (0.38Gz) and microgravity (μG) in relation...
Contexts in source publication
Context 1
... mean (±SD) D Max of all four sets for 1G z and the simulated gravitational environments for the 2005 and 2010 ECC guidelines is presented in Figure 2A,B. All volunteers were able to abide by the 2005 and 2010 ECC guidelines at 1G z (47.1 (±3.0) and 57.0 (±2.3) mm) and simulated 0.38G z (46.2 (±3.6) and 55.1 (±3.7) mm). ...Context 2
... the considerable inter-volunteer variability ob- served questions the efficacy of the ER method, which con- curred with the findings of Rehnberg et al. [14]. Mean D Max failed to abide by the 2010 ECC guidelines, which corre- sponds with the findings of Kordi et al. [15] ( Figure 2B). Previous studies noted that volunteers were failing to consistently allow full chest recoil using the ER method during simulated μG (Figure 2) [14]. ...Context 3
... D Max failed to abide by the 2010 ECC guidelines, which corre- sponds with the findings of Kordi et al. [15] ( Figure 2B). Previous studies noted that volunteers were failing to consistently allow full chest recoil using the ER method during simulated μG (Figure 2) [14]. This can be detri- mental to the effectiveness of BLS, as incomplete de- compression decreases the change in thoracic pressure and thereby reduces perfusion to vital organs. ...Citations
... This engagement is crucial as it prevents the rescuer from being inadvertently pushed away from the victim. 18,39 A recent systematic review has underscored the potential benefits of alternative rescuer's positions during chest compressions in hypogravity conditions. 4 This review identified two alternative techniques in hypogravity, both demonstrating superior CPR quality compared to traditional methods. ...
Background: Cardiopulmonary resuscitation (CPR) is essential for saving lives during cardiac arrest, but performing CPR in extreme environments poses unique challenges. In scenarios ranging from hypogravity or microgravity to confined spaces like aeroplanes and underwater scenarios, traditional CPR techniques may be inadequate. This scoping review aims to identify alternative chest compression techniques, synthesise current knowledge, and pinpoint research gaps in resuscitation for cardiac arrest in extreme conditions. Methods: PubMed and the Cochrane Register of Controlled Trials as well as the website of ResearchGate was searched to identify relevant literature. Studies were eligible for inclusion if they evaluated alternative chest compression techniques, including manual or mixed CPR approaches, whilst assessing feasibility and effectiveness based on compression depth, rate, and/or impact on rescuer effort. Results: The database search yielded 9499 references. After screening 26 studies covering 6 different extreme environments were included (hypogravity: 2; microgravity: 9, helicopter: 1, aeroplane: 1, confined space: 11; avalanche: 2). 13 alternative chest compression techniques were identified, all of which tested using manikins to simulate cardiac arrest scenarios. Conclusion: To address the unique challenges in extreme environments, novel CPR techniques are emerging. However, evidence supporting their effectiveness remains limited.
... Diversos estudios han utilizado los sistemas de suspensión corporal para comparar las diversas técnicas de RCP en ambiente simulado de microgravedad. 12,13 Actualmente, este cúmulo de conocimientos es incorporado a los protocolos de manejo de la Estación Espacial Internacional (EEI), en caso de presentarse una contingencia médica. El denominado «Sistema de Man-tenimiento de la Salud» (Health Maintenance System) cuenta con todo lo necesario para atender a una víctima de paro cardiaco en ambiente de microgravedad. ...
... The mission of one cosmonaut was aborted due to ventricular tachycardia [7]. Although no cardiac arrest has occurred in space, several researchers have considered this possibility, conducting Cardiopulmonary Resuscitation (CPR) studies in groundbased, parabolic flight and underwater simulations of microgravity [8,9]. ...
italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">Goal
: Lessons learned from decades of human spaceflight have helped advance the delivery of healthcare in rural and remote areas of the globe. Inclusion of the public in spaceflights is not yet accompanied by technology capable of monitoring their physical and mental health, managing clinical conditions, and rapidly identifying medical emergencies. Telepharmacy is a practice prioritizing pharmacotherapeutic guidance and monitoring to help improve patient quality of life, and can potentially expand the field of space medicine. We seek to advance pharmaceutical care through telepharmacy by developing a digital platform.
Objective:
This study focuses on the development of a digital platform for teleassistance and pharmaceutical teleconsulting services that builds on lessons learned in delivering space medicine.
Methods:
The platform contains evidence-based information on various drugs grouped by medical specialty, and also records and saves patient appointments. It has specific service protocols for service standardization, including artificial intelligence, to allow agility in services and escalation. All data is protected by privacy and professional ethics guidelines.
Results:
The telepharmacy platform is ready and currently undergoing testing for ground applications through validation studies in hospitals or medical clinics.
Conclusions:
Although developed for use on Earth, this telepharmacy platform provides a good example of how terrestrial healthcare knowledge and technology can be transferred to space missions.
... All four studies had a Repeated Measures Design with volunteers being their own control group. Three trials were conducted at the Microgravity Center of the Pontifical Catholic University of Rio Grande do Sul in Brazil [17][18][19], and one in the Centre for Human and Applied Physiological Sciences of the King's College in London [20]. ...
... Two studies also simulated hypogravity on the Moon with a force of 0.17 G or 0.16 G (1 G = 9.81 m/s 2 ) [17,20]. [17][18][19], reprinted with permission from 'Extraterrestrial CPR and Its Applications in Terrestrial Medicine' [21]. 2010, Russomano T. CPR was performed on standard CPR mannequins (e.g., Resusci Anne Skill Reporter, Laerdal Medical Ltd., Orpington, UK), which were modified to allow for measurement of compression depth and rate. ...
... 2010, Russomano T. CPR was performed on standard CPR mannequins (e.g., Resusci Anne Skill Reporter, Laerdal Medical Ltd., Orpington, UK), which were modified to allow for measurement of compression depth and rate. Guidelines and CPR protocols can be seen in Table 2. Participants were given feedback on CPR quality with LED lights indicating compression depths [17][18][19], a metronome set to an advised compression rate of 100/s [17,18], or verbal feedback by study investigators [19,20]. [17][18][19], reprinted with permission from 'Extraterrestrial CPR and Its Applications in Terrestrial Medicine' [21]. ...
(1) Background: Cardiopulmonary resuscitation (CPR), as a form of basic life support, is critical for maintaining cardiac and cerebral perfusion during cardiac arrest, a medical condition with high expected mortality. Current guidelines emphasize the importance of rapid recognition and prompt initiation of high-quality CPR, including appropriate cardiac compression depth and rate. As space agencies plan missions to the Moon or even to explore Mars, the duration of missions will increase and with it the chance of life-threatening conditions requiring CPR. The objective of this review was to examine the effectiveness and feasibility of chest compressions as part of CPR following current terrestrial guidelines under hypogravity conditions such as those encountered on planetary or lunar surfaces; (2) Methods: A systematic literature search was conducted by two independent reviewers (PubMed, Cochrane Register of Controlled Trials, ResearchGate, National Aeronautics and Space Administration (NASA)). Only controlled trials conducting CPR following guidelines from 2010 and after with advised compression depths of 50 mm and above were included; (3) Results: Four different publications were identified. All studies examined CPR feasibility in 0.38 G simulating the gravitational force on Mars. Two studies also simulated hypogravity on the Moon with a force of 0.17 G/0,16 G. All CPR protocols consisted of chest compressions only without ventilation. A compression rate above 100/s could be maintained in all studies and hypogravity conditions. Two studies showed a significant reduction of compression depth in 0.38 G (−7.2 mm/−8.71 mm) and 0.17 G (−12.6 mm/−9.85 mm), respectively, with nearly similar heart rates, compared to 1 G conditions. In the other two studies, participants with higher body weight could maintain a nearly adequate mean depth while effort measured by heart rate (+23/+13.85 bpm) and VO2max (+5.4 mL·kg−1·min−1) increased significantly; (4) Conclusions: Adequate CPR quality in hypogravity can only be achieved under increased physical stress to compensate for functional weight loss. Without this extra effort, the depth of compression quickly falls below the guideline level, especially for light-weight rescuers. This means faster fatigue during resuscitation and the need for more frequent changes of the resuscitator than advised in terrestrial guidelines. Alternative techniques in the straddling position should be further investigated in hypogravity.
... Our results were better than the values obtained with the three main methods to perform manual CC in microgravity, that all performed below guidelines set standards in terms of CC depth achieved and the ability to sustain compressions [13]. The HS method resulted in a mean CC depth of 47.3 ± 1.2 mm, the RBH of 41.7 ± 6.2 mm [9] and the ER showed inconsistent results ranging from 27.1 ± 7.9 mm to 42.3 ± 5.6 mm [14,15]. The use of an ACCD allowed to continuously deliver high-quality CC. ...
Introduction
Space travel is expected to grow in the near future, which could lead to a higher burden of sudden cardiac arrest (SCA) in astronauts. Current methods to perform cardiopulmonary resuscitation in microgravity perform below earth-based standards in terms of depth achieved and the ability to sustain chest compressions (CC). We hypothesised that an automated chest compression device (ACCD) delivers high-quality CC during simulated micro-and hypergravity conditions.
Methods
Data on CC depth, rate, release and position were collected continuously during a parabolic flight with alternating conditions of normogravity (1 G), hypergravity (1.8 G) and microgravity (0 G), performed on a training manikin fixed in place utilising an ACCD. Kruskal-Wallis and Mann-Withney U test were used for comparison purpose.
Results
Mechanical CC was performed continuously during the flight; no missed compressions or pauses were recorded. Mean depth of CC showed minimal but statistically significant variations in compression depth during the different phases of the parabolic flight (microgravity 49.9 ± 0.7, normogravity 49.9 ± 0.5 and hypergravity 50.1 ± 0.6 mm, p < 0.001).
Conclusion
The use of an ACCD allows continuous delivery of high-quality CC in micro- and hypergravity as experienced in parabolic flight. The decision to bring extra load for a high impact and low likelihood event should be based on specifics of its crew's mission and health status, and the establishment of standard operating procedures.
... In the following years, several experiments were conducted during parabolic flight [29][30][31] or in simulated microgravity [32][33][34][35][36] in order to identify the ideal technique of performing chest compressions. ...
... This limits the possible techniques per se to the Handstand-method, the Reverse-Bear-Hug method and the Evetts-Russomano method. Only one controlled trial compared those three methods [33], whereas other studies concentrated on one or two of the techniques [29,30,32,36] or analyzed the effectiveness mathematically [40]. ...
... With regard to compression depth, the HS method demonstrated the highest depth (47.4 ± 2.4 mm) [33] of all the compared techniques, although it still not reached the recommended 50-60 mm of the current ERC guidelines [44]. The ER method showed inconsistent results concerning compression depth, ranging from 45.7 ± 2.4 mm [32] to 27.1 ± 7.9 mm [36]. Finally in the RBH method, compression depths with a maximum of only 41.7 ± 6.2 mm [33] were achieved. ...
Background: With the "Artemis"-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency-cardiac arrest. Methods: After the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to "MEDLINE". Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for
... In the following years, several experiments were conducted during parabolic flight [29][30][31] or in simulated microgravity [32][33][34][35][36] in order to identify the ideal technique of performing chest compressions. ...
... This limits the possible techniques per se to the Handstand-method, the Reverse-Bear-Hug method and the Evetts-Russomano method. Only one controlled trial compared those three methods [33], whereas other studies concentrated on one or two of the techniques [29,30,32,36] or analyzed the effectiveness mathematically [40]. ...
... With regard to compression depth, the HS method demonstrated the highest depth (47.4 ± 2.4 mm) [33] of all the compared techniques, although it still not reached the recommended 50-60 mm of the current ERC guidelines [44]. The ER method showed inconsistent results concerning compression depth, ranging from 45.7 ± 2.4 mm [32] to 27.1 ± 7.9 mm [36]. Finally in the RBH method, compression depths with a maximum of only 41.7 ± 6.2 mm [33] were achieved. ...
Background
With the “Artemis”-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency – cardiac arrest.
Methods
After the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to “MEDLINE”. Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for the guideline recommendations that were designed by at least 2 experts on the given field. Afterwards those recommendations were subject to a consensus finding process according to the DELPHI-methodology.
Results
We recommend a differentiated approach to CPR in microgravity with a division into basic life support (BLS) and advanced life support (ALS) similar to the Earth-based guidelines. In immediate BLS, the chest compression method of choice is the Evetts-Russomano method (ER), whereas in an ALS scenario, with the patient being restrained on the Crew Medical Restraint System, the handstand method (HS) should be applied. Airway management should only be performed if at least two rescuers are present and the patient has been restrained. A supraglottic airway device should be used for airway management where crew members untrained in tracheal intubation (TI) are involved.
Discussion
CPR in microgravity is feasible and should be applied according to the Earth-based guidelines of the AHA/ERC in relation to fundamental statements, like urgent recognition and action, focus on high-quality chest compressions, compression depth and compression-ventilation ratio. However, the special circumstances presented by microgravity and spaceflight must be considered concerning central points such as rescuer position and methods for the performance of chest compressions, airway management and defibrillation.
... Specifically, microgravity-induced cardiac arrhythmias are a major concern for national space agencies, as very prolonged periods of time in the International Space Station or in a mission to Mars or the Moon might set the stage for the development of ventricular tachycardia or ventricular fibrillation that could end up in sudden cardiac death (Anzai et al., 2014;Caiani et al., 2016). Although the probability of undergoing serious cardiac arrhythmias in the course of a space mission is low, with the estimated probability of suffering a life-threatening event being of 1% per year in short to mid-duration spaceflights (Russomano et al., 2013), currently available data are limited and more sophisticated techniques should be employed to identify potential in-flight abnormalities in the electrical activity of the heart (Convertino, 2009). ...
Ventricular arrhythmias and sudden cardiac death during long-term space missions are a major concern for space agencies. Long-duration spaceflight and its ground-based analog head-down bed rest (HDBR) have been reported to markedly alter autonomic and cardiac functioning, particularly affecting ventricular repolarization of the electrocardiogram (ECG). In this study, novel methods are developed, departing from previously published methodologies, to quantify the index of Periodic Repolarization Dynamics (PRD), an arrhythmic risk marker that characterizes sympathetically-mediated low-frequency oscillations in the T-wave vector. PRD is evaluated in ECGs from 42 volunteers at rest and during an orthostatic tilt table test recorded before and after 60-day –6° HDBR. Our results indicate that tilt test, on top of enhancing sympathetic regulation of heart rate, notably increases PRD, both before and after HDBR, thus supporting previous evidence on PRD being an indicator of sympathetic modulation of ventricular repolarization. Importantly, long-term microgravity exposure is shown to lead to significant increases in PRD, both when evaluated at rest and, even more notably, in response to tilt test. The extent of microgravity-induced changes in PRD has been associated with arrhythmic risk in prior studies. An exercise-based, but not a nutrition-based, countermeasure is able to partially reverse microgravity-induced effects on PRD. In conclusion, long-term exposure to microgravity conditions leads to elevated low-frequency oscillations of ventricular repolarization, which are potentiated following sympathetic stimulation and are related to increased risk for repolarization instabilities and arrhythmias. Tested countermeasures are only partially effective in counteracting microgravity effects.
... These studies have shown arm flexion angles up to 16°compared to 1 -2°in terrestrial CPR at 1Gz (Dalmarco et al., 2006). Other studies into hypogravity CPR have also found this (Rehnberg et al., 2014, Russomano et al., 2013. They suggest that flexing the arms is a countermeasure needed due to the reduced ability to accelerate the chest and is a way to overcome these difficulties. ...
... The electrogoniometer was calibrated for 0-90°prior to the beginning of each condition. The device was connected with a linear 10 kΩ potentiometer and powered by a 5-V power source (Rehnberg et al., 2014, Russomano et al., 2013. ...
... Elbow flexion was calculated as a range from the minimum to maximum angle of an individual ECC. The ECC depth was analyzed in two different ways: maximum depth (DMax) achieved and true depth (DT), which was calculated using the equation, with DIrecoil representing the depth of inadequate recoil (Baers et al., 2016, Russomano et al., 2013. ...
Introduction:
2015 UK resuscitation guidelines aim for 50-60 mm depth when giving external chest compressions (ECCs). This is achievable in hypogravity if the rescuer flexes and extends their arms during CPR, or using a new method trialed; the 'Mackaill-Russomano' (MR CPR) method.
Methods:
10 participants performed 3 sets of 30 ECCs in accordance with 2015 guidelines. A control was used at 1Gz, with eight further conditions using Mars and Moon simulations, with and without braces in the terrestrial position and using the MR CPR method. The MR CPR method involved straddling the mannequin, using its legs for stabilization. A body suspension device, with counterweights, simulated hypogravity environments. ECC depth, rate, angle of arm flexion and heart rate (HR) were measured.
Results:
Participants completed all conditions, and ECC rate was achieved throughout. Mean (± SD) ECC depth using the MR CPR method at 0.38Gz was 54.1 ± 0.55 mm with braces; 50.5 ± 1.7 mm without. ECCs were below 50 mm at 0.17Gz using the MR CPR method (47.5 ± 1.47 mm with braces; 47.4 ± 0.87 mm without). In the terrestrial position, ECCs were more effective without braces (49.4 ± 0.26 mm at 0.38Gz; 43.9 ± 0.87 mm at 0.17Gz) than with braces (48.5 ± 0.28 mm at 0.38Gz; 42.4 ± 0.3 mm at 0.17Gz). Flexion increased from approximately 2° - 8° with and without braces respectively. HR did not change significantly from control.
Discussion:
2015 guidelines were achieved using the MR CPR method at 0.38Gz, with no significant difference with and without braces. Participants were closer to achieving the required ECC depth in the terrestrial position without braces. ECC depth was not achieved at 0.17Gz, due to a greater reduction in effective body weight.
... A carabineer connects the steel wire to the attachment point on the back of the body harness (Fesp P100PGP). The manikin was positioned on the floor during the hypogravity simulation and +1 Gz [6,46,47]. Figure 5 presents a schematic view of CPR being performed during ground-based hypogravity simulation. ...
... Initial parabolic flight and ground-based simulation data showed the ER method as delivering an adequate rate and depth of chest compressions, although this was according to the 2005 resuscitation guidelines [5,42]. More recent data from ground-based simulations, using the updated 2010 guidelines, demonstrated that rescuers using the ER method fell slightly below par in terms of depth of compression but were able to maintain an adequate rate [45,47]. ...
... Research has shown that a natural tendency to adapt takes place, seeking to generate more force by flexing/extending the upper limbs in order to augment acceleration of the upper body [46]. In instances where traditional CPR in hypogravity is not sufficient to generate enough force to achieve the necessary depth of chest compressions, rescuers are encouraged to have a combined technique of accelerating their upper body and extending their upper limbs to generate enough force to compress the chest to 50-60 mm [45,47]. ...
