Fig 1 - uploaded by Lucas Rehnberg
Content may be subject to copyright.
The three microgravity CPR methods: A) Handstand; B) Evetts-Russomano; and C) Reverse Bear Hug. 

The three microgravity CPR methods: A) Handstand; B) Evetts-Russomano; and C) Reverse Bear Hug. 

Source publication
Article
Full-text available
Introduction: Cardiopulmonary resuscitation (CPR) in microgravity is challenging. There are three single-person CPR techniques that can be performed in microgravity: the Evetts-Russomano (ER), Handstand (HS), and Reverse Bear Hug (RBH). All three methods have been evaluated in parabolic flights, but only the ER method has been shown to be effectiv...

Contexts in source publication

Context 1
... simulate microgravity for the three positions, two methods of simulation were used: a body suspension device (BSD) and a trolley system ( Fig. 1 ). The BSD was used to perform the ER ( Fig. 1B ) and RBH ( Fig. 1C ) methods. ...
Context 2
... simulate microgravity for the three positions, two methods of simulation were used: a body suspension device (BSD) and a trolley system ( Fig. 1 ). The BSD was used to perform the ER ( Fig. 1B ) and RBH ( Fig. 1C ) methods. The BSD consists of a pyramidal frame with steel bars 6 3 3 cm in thickness and has a height of 200 cm with a base of 300 cm 3 226 cm. ...
Context 3
... simulate microgravity for the three positions, two methods of simulation were used: a body suspension device (BSD) and a trolley system ( Fig. 1 ). The BSD was used to perform the ER ( Fig. 1B ) and RBH ( Fig. 1C ) methods. The BSD consists of a pyramidal frame with steel bars 6 3 3 cm in thickness and has a height of 200 cm with a base of 300 cm 3 226 cm. ...
Context 4
... HS method ( Fig. 1A ) was performed on the trol- ley system. This system consisted of a padded trolley contained within fi xed tracks. ...
Context 5
... results show the RBH to be the worst technique in terms of both ECC depth and RPE (18.2 6 0.4). Interest- ingly, the RBH had the highest Borg scale value, but it had an almost identical V o 2 to terrestrial +1 G z CPR. It has been noted as a simple method to deploy with mini- mal training and it has been suggested that the RBH could be used as an alternative method to the HS if res- cuers are too short to perform the HS ( 7 ). ...

Citations

... 20 By using a full body suspension device Rehnberg et al. and Kordi et al. showed that the ER-and RBH-technique provided adequate compression rates but only the Handstand method met criteria for compression depth. 16,17 Jay et al. showed that during parabolic flight the Handstand method almost met current guidelines recommendation for compression frequency (98.3 ± 6.3 compressions per minute) and compression depth (40.01 ± 0.51 mm). 12 The Schmitz-Hinkelbein method was tested in an underwater setting, showing superiority in compression rates (100.5 ± 14.4 compressions/min) with 65 ± 23 % of correct compression depths (and overall high rates of correct thoracic release after compression). ...
Article
Full-text available
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.
... Sin embargo, ninguna de las tres técnicas cumplió totalmente con el estándar para considerar una RCP de alta calidad. 24 En 2015, Braunecker y asociados hicieron una revisión de cuatro publicaciones especializadas sobre las técnicas de RCP en ambiente de microgravedad. Las técnicas que encontraron fueron: el método lateral convencional, la maniobra a horcajadas alrededor de la cintura, la maniobra de Heimlich modificada, el método de Evetts-Russomano y el método vertical sobre las manos. ...
... Recent guidelines for CPR during spaceflight advise approaching CPR similarly to earth-based ones [8]. There are three main methods to perform chest compressions (CC) that can be used in microgravity: the Handstand (HS), the Reverse Bear Hug (RBH), and the Evetts-Russomano (ER) [9,10]. Guidelines suggest to start with the ER technique at the site of the emergency (as it allows transportation of the victim) and to shift to HS technique as soon as the victim is restrained and the surface distance allows for its application [8]. ...
... However, all tested methods perform below earth-based standards in terms of depth achieved. Even in the most optimal situation where the HS technique is used on a restrained patient, HS technique resulted in suboptimal American Journal of Emergency Medicine 53 (2022) 54-58 compression depth (44.9 ± 3.3mm), where a compression depth of between 50 and 60 mm is advised in international guidelines [8][9][10]. Manual chest compression quality deteriorates significantly within minutes even in highly trained and fit rescuers [8,11]. ...
Article
Full-text available
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.
... Methods for cardiopulmonary resuscitation (Rehnberg et al., 2014;Mackaill et al., 2018) and intubation (Beck, 2004; Warnecke et al., 2019) have been tested on parabolic flights. However, no recommendations have been published on the procedure after successful resuscitation in space (Beck, 2004;Warnecke et al., 2019). ...
Article
Despite rigorous health screenings, medical incidents during spaceflight missions cannot be avoided. With long-duration exploration flights on the rise, the likelihood of critical medical conditions with no suitable treatment on board will increase. Therapeutic hypothermia (TH) could serve as a bridge treatment in space prolonging survival and reducing neurological damage in ischemic conditions such as stroke and cardiac arrest. We conducted a review of published studies to determine the potential and challenges of TH in space based on its physiological effects, the cooling methods available, and clinical evidence on Earth. Currently, investigators have found that application of low normothermia leads to better outcomes than mild hypothermia. Data on the impact of hypothermia on a favorable neurological outcome are inconclusive due to lack of standardized protocols across hospitals and the heterogeneity of medical conditions. Adverse effects with systemic cooling are widely reported, and could be reduced through selective brain cooling and pharmacological cooling, promising techniques that currently lack clinical evidence. We hypothesize that TH has the potential for application as supportive treatment for multiple medical conditions in space and recommend further investigation of the concept in feasibility studies.
... 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. ...
... As mentioned above, the HS method has proved to deliver the highest quality manual chest compressions in microgravity [34,40]. With HS, both compression depth (44.9 ± 3.3 mm) and compression rate (115.4 ± 12.1 bpm) were superior to all the other manual chest compression techniques [40]. ...
... With HS, both compression depth (44.9 ± 3.3 mm) and compression rate (115.4 ± 12.1 bpm) were superior to all the other manual chest compression techniques [40]. Furthermore, it has been demonstrated to be the least strenuous technique, with a lower minute ventilation for the rescuer (HS 39.89 ± 2.01 l/min vs ER 58.38 ± 2.90 l/min vs RBH 48.24 ± 2.32 l/min) [34]. ...
Article
Full-text available
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. ...
... As mentioned above, the HS method has proved to deliver the highest quality manual chest compressions in microgravity [34,40]. With HS, both compression depth (44.9 ± 3.3 mm) and compression rate (115.4 ± 12.1 bpm) were superior to all the other manual chest compression techniques [40]. ...
... With HS, both compression depth (44.9 ± 3.3 mm) and compression rate (115.4 ± 12.1 bpm) were superior to all the other manual chest compression techniques [40]. Furthermore, it has been demonstrated to be the least strenuous technique, with a lower minute ventilation for the rescuer (HS 39.89 ± 2.01 l/min vs ER 58.38 ± 2.90 l/min vs RBH 48.24 ± 2.32 l/min) [34]. ...
Article
Full-text available
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.
... Seit Beginn der bemannten Raumfahrt werden deshalb verschiedene Untersuchungen zur not-fallmedizinischen Versorgung durchgeführt [3]. Dabei dienen besonders Parabelflüge als Basis für neue Erkenntnisse über die Anwendbarkeit und Effektivität von Re animationstechniken in Schwerelosigkeit [13]. ...
Article
ZUSAMMENFASSUNG Aufgrund der guten medizinischen Selektion, der guten körperlichen Konstitution und der engmaschigen, intensiven Betreuung sind relevante medizinische Probleme bei Astronauten im Weltall vergleichsweise selten. Bisher sind 5 relevante Methoden zur Durchführung von Thoraxkompressionen im Rahmen einer kardiopulmonalen Reanimation (CPR) in Schwerelosigkeit entwickelt worden. Das Ziel der vorliegenden Arbeit ist die Darstellung dieser 5 Techniken sowie das Aufzeigen von möglichen Problemen in Zusammenhang mit einer CPR im Weltall in Zukunft. Bisher liegen keine praktischen Erfahrungen zu einer Reanimation im Weltall vor. Alle bisher publizierten Studien wurden entweder im Parabelflug oder unter simulierten Bedingungen (z.B. Unterwasser oder in einem Aufhängeapparat) auf der Erde durchgeführt. Zukünftig sind, gerade für längere Raumflüge, weitere Analysen und detailliertere Vorgaben notwendig.
... The data provided by these studies focus on the mechanical aspects related to the performance of external chest compressions, including chest compression depth and rate, as well as the fatigue of the volunteer performing CPR, which seems to increase proportionally to the decrease in gravitational force simulated [8,9]. Although parabolic flights have a time restriction for the microgravity phase of each parabola, it does provide a more realistic experience because the volunteer feels a lack of body weight, just as would be encountered in a space mission. ...
... Although parabolic flights have a time restriction for the microgravity phase of each parabola, it does provide a more realistic experience because the volunteer feels a lack of body weight, just as would be encountered in a space mission. It also allows some displacement of blood and body fluids from the lower to the upper body, which is more representative of the cardiopulmonary changes that occur during actual microgravity exposure and might influence the CPR performance [9]. The use of a BSD prolongs the duration of the CPR performance, with no time restriction for its use. ...
Article
Travelling to the stars is a dream nearly as old as mankind itself. Nowadays, spaceflight is in many ways common business, becoming even accessible to space tourists. However, many problems remain to be solved before humanity can venture into deep space with an acceptable level of risk, and medical preparedness is one of them. The management of any severe medical emergency will be extremely challenging in this extreme environment, with limited resources in crew and equipment. Here, we discuss the case of a cardiac arrest occurring during spaceflight, and present challenges around the recognition, immediate management including delivering cardio-pulmonary resuscitation and secondary measures such as organ support or evacuation. Given the current treatment capabilities in space, the survivability of cardiac arrest is expected to be lower than on the ground.
... It has been found that rescuer fatigue leads to a failure to decompress the chest completely. This is a common problem across all three methods as fatigue takes effect, but it is more pronounced with the ER method, and this may be in part due to the positioning of the rescuer [48]. ...
... These studies also assessed the physiological cost of performing these methods, compared to terrestrial CPR. Using more objective measures, such as oxygen uptake (VO 2 ), these studies demonstrated that all three methods had a greater VO 2 than terrestrial CPR, with the HS being the least aerobically demanding and the RBH the most demanding [44,48]. ...
... Research examining CPR performance in simulated microgravity has shown all methods to be more fatiguing compared to terrestrial CPR [48]. CPR in hypogravity is also found to be more tiring than CPR on Earth, however, not to the same degree as in microgravity [47]. ...
... If required during spaceflight there are various methods of CPR that have been adapted to microgravity. [84][85][86] Alternatively a mechanical device could be useful when considering the effects of deconditioning on the CPR operator. 87 However, even if successful resuscitation was achieved, the complex supportive critical care generally required after a cardiac arrest is unlikely to be available or sustainable over any extended period in the space environment. ...
Article
Space medicine is fundamental to the human exploration of space. It supports survival, function and performance in this challenging and potentially lethal environment. It is international, intercultural and interdisciplinary, operating at the boundaries of exploration, science, technology and medicine. Space medicine is also the latest UK specialty to be recognized by the Royal College of Physicians in the UK and the General Medical Council. This review introduces the field of space medicine and describes the different types of spaceflight, environmental challenges, associated medical and physiological effects, and operational medical considerations. It will describe the varied roles of the space medicine doctor, including the conduct of surgery and anaesthesia, and concludes with a vision of the future for space medicine in the UK.Space medicine doctors have a responsibility to space workers and spaceflight participants. These 'flight surgeons' are key in developing mitigation strategies to ensure the safety, health and performance of space travellers in what is an extreme and hazardous environment. This includes all phases from selection, training and spaceflight itself to post-flight rehabilitation and long-term health. The recent recognition of the speciality provides a pathway to train in this fascinating field of medicine and is a key enabler for the UK Government's commercial spaceflight ambition.