The impact of the dental chair stabilization method on chest compressions

doi:10.21203/rs.3.rs-2219744/v1

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The impact of the dental chair stabilization method on chest compressions

https://doi.org/10.21203/rs.3.rs-2219744/v1

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Background

To evaluate, how the influence of different with and without a support stool, impacts chest compressions on the dental chair.

Methods

Experiments were conducted on CPR training manikin on a dental chair. A stool was placed under the backrest of a dental chair to stabilize it. Chest compressions were performed for 5 minutes with or without a stool. Six values in chest compressions and the degree of fatigue were measured.

Results

According to the analysis of the quality of chest compressions without a stool or with a stool under the dental chair. The mean chest compression depth of With (57.29 ± 6.24mm) was significantly deeper than that of Without (53.86 ± 8.48 mm; p < 0.001). The mean chest compression rate and total chest compressions of With were significantly higher than that of Without. QCPR score of With (94.28 ± 10.57) was significantly higher than that of Without (72.0 ± 46.66; p < 0.001). The rating of perceived exertion of With (6.75 ± 1.20) was significantly lower than that of Without (8.75 ± 0.66; p < 0.001). Only the chest compression fraction and the chest compression rebound rate does not reach a significant difference.

Conclusions

The use of a support stool improved the quality of chest compressions on the dental chair and reduced rescuer fatigue. To perform effective CPR on a dental chair, it is important to stabilize the chair against chest compressions.

Clinical relevance:

Effective chest compressions could be performed in dental chairs by using a stool when cardiac arrest occurs during dental treatments.

dental chair

chest compression

stool

CPR quality

rescuer fatigue

manikin

The most critical condition for a dental patient is cardiopulmonary arrest during dental treatment. Prevention is an important aspect of medical safety. However, it is difficult to completely prevent unexpected serious medical accidents during dental treatment. Therefore, when a cardiopulmonary arrest occurs, it is important to transport the patient to a hospital where specialized treatment is available as soon as possible and provide appropriate treatment. In Japan, the average time from the time the emergency medical team leaves the fire station to the arrival at the dental clinic is 8.9 minutes.¹ In transporting patients from the dental clinic to the hospital, the quality of CPR at the dental clinic while waiting for the ambulance or emergency medical technicians to arrive is very important. The American Heart Association (AHA) states that for every minute delay in the resuscitation of a patient in cardiopulmonary arrest, the patient's chance of survival decreases by 10%.² Early quality cardiopulmonary resuscitation, rapid defibrillation, and appropriate care after cardiac arrest are essential for patient survival.³ The depth of chest compressions has a significant impact on survival.^4–6 However, there were no guidelines for primary lifesaving procedures appropriate for dental clinics. Even though the dental clinic is one of the medical institutions, dental stuff have to use BLS recommended by the AHA and other organizations. However, BLS is used in everyday life, such as at train stations and on roadsides.

Generally, many treatment instruments are fixed directly to the floor, limited space, and few staff in the dental clinic. Therefore, it is difficult to move a patient in cardiopulmonary arrest to a hard floor and perform chest compressions as originally recommended. The rescuer is required to perform chest compressions on a dental chair, a situation that can affect the quality of chest compressions. Furthermore, fatigue affects the accuracy of chest compressions when waiting for emergency care for longer periods.^7,8 It is also important to reduce fatigue from prolonged chest compressions.⁹

In the efficiency of chest compressions, depth, speed, and recoil rate are especially important. Incomplete chest compressions reduce venous return to the heart and decrease mean arterial pressure and coronary and cerebral perfusion pressures. ^10–12 We previously reported on a method to reduce the vertical displacement of the dental chair during chest compressions.^13,14 This method stabilizes the dental chair by placing a stool under the backrest of the dental chair, reclining the dental chair, and bringing the stool into contact with the backrest. This method is recommended in the 2015 and 2021 European Resuscitation Council (ERC) guidelines.^15,16. Further studies have shown that the support effect depends on the position of the stool. For many types of dental chairs, we found that vertical displacement was significantly reduced by using a stool under the shoulder rather than directly under the chest compression site.¹⁷ However, the quality of chest compressions and rescuer fatigue during CPR using this method have not been studied in detail.

The purpose of this study is to compare the differences in the quality of chest compressions and rescuer fatigue with and without a stool using a manikin simulating a patient seated in a dental chair.

Study design

This study was designed as a counterbalanced crossover experiment and a single-blind method in a laboratory environment, in which well-trained dentists performed CPR manikin (Laerdal Little Anne^® QCPR Manikin; Laerdal Medical, Stavanger, Norway) to investigate the effects with and without the support of a stool to a dental chair on chest compressions quality and fatigue levels.

Ethical Statements

This was a manikin study and there were no human participants. The Institutional Review Board at Kyushu university confirmed that no ethical approvals were required.

Participants

This study recruited eight volunteer participants. They were active males and females (Men: Females = 4: 4) aged 28 to 48 who had been certified in formal BLS techniques in the AHA's provider course. They had staffed the university hospital in oral-maxillo-facial surgery and dental anesthesiology departments for over three years. All the participants were right-handed. Participants with cardiovascular disease, upper extremity impairments, spine-related disorders, and other disorders were excluded from the study, as such conditions were judged unsuitable for participation. The anthropometric characteristics of the study population are listed in Table 1.

Equipment

The Laerdal^® Little Anne QCPR Manikin equipped with a PC SkillReporter^® system (Laerdal, Stavanger, Norway) was used for measuring and recording CPR data. The monitoring screen was not visible to the participants, and no feedback was given.

The dental chair and a stool

The dental chair (SIGNO Treffert^®; MORITA, Osaka, Japan) was used in this study. The exterior of the chair has a severely curved backrest exterior. The study procedure was performed according to a previously established method: the CPR manikin was positioned on the reclined dental chair with the upper end of the manikin torso aligned with the top edge of the backrest. The stabilizing stool placed under the backrest of the dental chair for this study was round with a hard seating surface (diameter 30 cm; height 45 cm; FB-01ALLBK, Fuji Boeki Co., Ltd. Osaka, Japan). The superficial edge of the stool’s seat was set to vertically contact the backrest under the shoulders.^14,17 A cloth covered the side of the dental chair backrest so that participants could not see whether a stool is in place (with) or not (without).

CPR quality measurement

All the participants were required to complete two chest compressions quality tests in two situations (without a stool or with the stool under the backrest of the dental chair) in random order. Before the test, each participant checked the sternal compression rhythm at three different metronome rates (100, 110, and 120 ticks/min.). They followed the chest compression technique described in the 2020 AHA Guidelines⁵ (compression depth of 50-60 mm, compression rate of 100-120 times per minute, the uninterrupted, complete rebound of the chest) to perform 5 minutes of chest compressions on a manikin. Once the participant stopped performing CPR, the Borg Rating of Perceived Exertion (RPE) scale was used to inquire about the participant's level of fatigue at the moment of completing the test. The participants were required to rest for at least six hours between the tests, and no additional hard exercise or heavy work was allowed during the rest period to prevent them from muscle fatigue or feeling tired.

Data Analysis

All participants completed the tests in this study. Data from the Manikin and the RPE were exported to Microsoft Excel (Excel version 16.65 in Microsoft 365 for Macintosh). Data from the manikin were calculated using the SimPad PLUS^® device (Laerdal, Stavanger, Norway) with activated SkillReporter^® software (Laerdal, Stavanger, Norway). This study adopted chest compression quality parameters of chest compression fraction (CCF), chest compression depth (CCD), chest compression rate (CCR), total chest compressions (TCC), and chest compression rebound rate (CCRR), QCPR score (QCPR) as well as the rating of perceived exertion (RPE). The QCPR score (%) are non-binary number, measuring how close the learner is to success, calculated across all sub-skills of CPR by Laerdal’s QCPR algorithm. The overall CPR score is a simple representation of how good the CPR performance was, but the mathematics behind it can be very complex. The algorithm that makes up the QCPR score is made by Laerdal Medical in close collaboration with members of the AHA ECC Subcommittees and co-authors of the 2013 AHA Consensus Statement on CPR Quality.¹⁸

Statistical Analysis

All data are presented as means ± standard deviation (SD). This study used Paired Sample t tests to investigate differences in CPR quality with a stool or without one and calculated the percentage differences between the two tests for all CPR quality parameters. The statistical software JMP^®pro (version 16.0.0; SAS Institute Inc, NC, USA) was used for statistical analysis. The significance level was set to p < 0.05.

Table 2 shows the differences in the CPR quality of chest compressions without a stool or with a stool. The paired sample t-test was used to analyze the effects of stool support on the CCF, CCD, CCR, CCRR, TCC, QCPR, and RPE scores of chest compressions. The results indicated that the two different situations, Without or With a stool yielded significant differences in CCD (With: 57.29 ± 6.24 mm vs. Without: 53.86 ± 8.48 mm; 3.875[95% CI, 2.431 - 5.318]; p < 0.001), CCR (With: 112.43 ± 3.95beats/min vs. Without: 106.71 ± 4.90beats/min; 6.125[95% CI, 3.465 - 8.785]; p < 0.001), TCC (With: 1562.14 ± 15.60times vs. Without: 533.57 ± 17.80times; 30.625[95% CI, 17.324 - 43.926]; p = 0.0015), QCPR (With: 94.28 ± 10.57 score vs. Without: 72.0 ± 46.66 score; 21.5[95% CI, 17.63 - 25.37]; p < 0.001), and RPE (With: 6.75 ± 1.20 vs. Without: 8.75 ± 0.66; -2[95% CI, -2.632 - 1.368]; p < 0.001). CCF (With: 98.29 ± 0.57 % vs. Without: 8.75 ± 0.66%; 0.375[95% CI, -0.247 - 0.997]; p = 0.356) and CCRR (With: 97.57 ± 1.29 % vs. Without: 97.86 ± 0.48%; 0.375[95% CI, -0.057 - 0.807]; p = 0.172) does not found to have significant differences. Figure 1,2 shows the degrees of improvement in chest compressions quality without or with a stool. CCD increased by 6.37% (from 53.86 ± 8.48 mm to 57.29 ± 6.24 mm), CCR increased by 5.35% (from 06.71 ± 4.90 beat/min to 112.43 ± 3.95 beat/min), CCF and CCRR remained unchanged at 0.15% (from 98.29 ± 0.57 mm to 98.43 ± 0.57 mm) and 0.29% (from 97.57 ± 1.29 mm to 97.86 ± 0.48 mm). RPE credibly decreased by 77.42% (from 8.75 ± 0.66 to 6.75 ± 1.20).

With the global aging of the population, there is an increasing need to provide dental treatments for patients with many complications. Dentistry is a special environment where life-threatening emergencies and cardiac arrest can occur, including frequent use of adrenaline-added local anesthesia, aspiration of dental materials, asphyxiation, and the strong mental stress of dental treatment. In Japan, there are more than 80,000 dental clinics. Despite being a medical facility, the dental clinic still does not provide sufficient considerations for CPR or primary life-saving treatments. Dental clinics are often equipped with specialized treatment equipment fixed to the floor and are not designed to be large enough to perform CPR by lowering or laying patients directly on the floor. In addition to the small space and few staff in many clinics, more than 80% of medical accidents during dental treatment occurred on the dental chair.¹⁹ In these circumstances, it is very efficient to start CPR on the dental chair as soon as possible, without moving the patient to the floor. But basically, dental chairs are not effective for CPR because they lack stability against the strong external forces of chest compressions. The effectiveness of using a backboard for chest compressions on beds and stretchers has been reported in previous studies.^20-22 However, the main problem with chest compressions on a dental chair is the swaying of the whole chair. Therefore, the use of a backboard directly under the patient is not considered to be effective. It would be very effective for CPR if the dental chair could be stabilized to withstand the pressure of chest compressions and if CPR could be started and continued in the dental chair as soon as possible without moving the patient to the floor. Even in urban areas, only a few staff may need to perform chest compressions for an unexpectedly long time before an ambulance arrives at the dental clinic, due to distance, limited emergency facilities, lack of manpower, and traffic congestion.²³ If the rescuer performs chest compressions in an unstable position, fatigue increases because the unnecessary effort is required to maintain proper chest compressions. Rescuer fatigue affects the quality of chest compressions.^7-9 After initiation of chest compressions, the depth of chest compressions decreases with time due to rescuer fatigue. As the depth of chest compressions decreases, coronary perfusion pressure decreases, resulting in a decreased likelihood of restoring spontaneous circulation.^10-12 Fatigue affects the depth of chest compressions and other important parameters that are indicators of CPR quality. Previous studies have suggested that a faster chest compression rate is related to fatigue.⁷ Faster chest compression velocity worsens chest rebound and compression depth scores and leads to earlier onset of fatigue.²⁰ Higher chest compression rates were significantly correlated with initial Return Of Spontaneous Circulation (ROSC).²⁴

Our previous studies have shown that the use of a stool in the dental chair for chest compressions can significantly reduce vertical displacement. From the results of this study, it was observed that the quality of cardiac compression was significantly higher when a stool was used in conjunction with a dental chair than when without one. For example, CCD increased by 2.43%, CCR decreased by 1.64%, TCC decreased by 1.65%, and in addition, RPE, which indicates the degree of fatigue, decreased significantly by 7.27%. The changes in these indices showed the effectiveness of continuous chest compressions alone for as long as 5 minutes in the dental chair. Clinically, this stabilization method is effective for CPR.

When it is difficult to move the patient safely and easily to the floor and start chest compressions within 30 seconds, the procedure is very effective for a patient with cardiopulmonary arrest during dental treatment.

Limitations

There are several limitations to this study. First, these results were obtained on a manikin and may differ from those obtained on human subjects. Second, this study was conducted on only one type of dental chair, so the effects of different types of chairs were not considered. Third, previous studies have shown that the height at which the rescuer performs chest compressions significantly impacts CPR efficiency and rescuer fatigue.^{9, 25} In the present study, the axillary line height of the manikin uniformly placed on the dental chair was approximately 55 cm, which did not correspond to the appropriate position of each participant and may have affected efficiency and fatigue. Finally, this study did not use objective indices such as electrocardiogram, electromyography, or oxygen saturation to measure participants' physical fatigue, but only a subjective RPE scale fatigue assessment to ascertain subjects' sense of fatigue. Based on these issues, we would like to further examine the feasibility and efficiency of practical applications in the future.

When a rescuer performs chest compressions on a patient sitting in a dental chair, the use of a stool as a dental chair support device effect on improving the quality of chest compressions and reduces rescuer fatigue. This method is expected to improve the overall quality of CPR in the special environment of the dental clinic.

CPR

cardiopulmonary resuscitation

CCD

chest compression depth

CCR

chest compression rate

TCC

total chest compressions

RPE

rating of perceived exertion

CCRR

chest compression rebound rate

CCF

chest compression fraction

QCPR

QCPR score

EMS

emergency medical services

OHCA

out-of-hospital cardiac arrest

AHA

American Heart Association

ECC

emergency cardiovascular care

EMTs

emergency medical technicians

ROM

range of motion

EMG

electromyography

BMI

body mass index.

Ethics approval and consent to participate

All procedures were performed in studies performed on a manikin model. This article does not contain any studies with human participants performed by any of the authors. We consulted the IRB at Kyushu university, which confirmed that no formal written waiver for ethics approval was required, because of the design of the study. In addition, there was no written consent needed from all healthcare providers.

Consent for publication

Not applicable

Availability of data and materials

The data sets during and/or analyzed in the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare no competing interests.

Funding

Not applicable

Authors' contributions

TH: Project administration, Data curation, Writing–original draft, Conceptualization, Software, Formal analysis, Investigation, Methodology. JH: Investigation, Writing–review & editing, Supervision. KH: Data curation. MG: Data curation. MT: Writing–review & editing, Supervision. TY: Investigation, Writing–review & editing, Supervision.

Acknowledgments

Not applicable

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Tables 1 & 2 are available in the Supplementary Files section.

No competing interests reported.

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You are reading this latest preprint version

The impact of the dental chair stabilization method on chest compressions

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Clinical relevance:

Figures

Background

Methods

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1