title: Expert clinical assessment of thorax stiffness of infants and children during chest compressions.
abstract: BACKGROUND
  High-fidelity manikins have been shown to be useful in teaching appropriate cardiopulmonary resuscitation (CPR) techniques. Similarity of manikin chest compression characteristics to real children is desirable. Little data exists on thorax stiffness in infants and children to guide manikin construction.
  
  
  OBJECTIVE
  To determine a 'consensus clinical-expert assessment' of the pediatric chest stiffness for two specific age groups-infants and 5-year-olds.
  
  
  METHODS
  Four manikins in each of two sizes (5-year child, 6-month infant) were identically constructed, except for thorax downstroke spring stiffness. Health care providers with pediatric CPR experience provided chest compressions to each manikin in random order, masked to thoracic stiffness. Each health care provider was instructed to identify the manikin with downstroke thoracic stiffness most similar to children on whom they have performed chest compressions. Duplicate assessment of a randomly selected, previously assessed manikin was performed to assess health care provider consistency using the kappa statistic. Subject inter-rater agreement on which manikin best approximated a child of that age was assessed by calculating the percentage of subjects who identified that manikin as the best approximation of an actual child.
  
  
  RESULTS
  A convenience sample of 63 international experts was obtained: 52 from Critical Care, 3 from Emergency Medicine, 4 from Pediatrics, and 4 from other specialties. There were 6 and 8 experts whose assessments were inconsistent for the infant manikins and child manikins, respectively. Approximately half of the subjects agreed on a single manikin as the best approximation of the human for both the infant (46%) and child manikins (43%). Excluding assessments of stiffness "out of range", the percentage of experts who agreed on a single manikin as the best approximation for the human increased to approximately 90% for each manikin size.
  
  
  CONCLUSIONS
  Experienced health care providers consistently identified and agreed on the manikin thorax stiffness which they felt best approximated downstroke chest compression stiffness of children and infants. Expert opinion can be used to create manikins with realistic spring stiffness for CPR training. Further study is needed to evaluate whether enhanced manikin biofidelity will improve CPR performance.
authors.affiliation: Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA. arbogast@email.chop.edu
authors.forename: Kristy B
authors.initials: KB
authors.lastname: Arbogast
authors.forename: Akira
authors.initials: A
authors.lastname: Nishisaki
authors.forename: Sriram
authors.initials: S
authors.lastname: Balasubramanian
authors.forename: Jon
authors.initials: J
authors.lastname: Nysaether
authors.forename: Dana
authors.initials: D
authors.lastname: Niles
authors.forename: Robert M
authors.initials: RM
authors.lastname: Sutton
authors.forename: Kathryn E
authors.initials: KE
authors.lastname: Roberts
authors.forename: Lauren
authors.initials: L
authors.lastname: Nadkarni
authors.forename: John
authors.initials: J
authors.lastname: Boulet
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Maltese
authors.forename: Vinay M
authors.initials: VM
authors.lastname: Nadkarni
mesh_terms: D016887:Cardiopulmonary Resuscitation; D002675:Child, Preschool; D002983:Clinical Competence; D004548:Elasticity; D006801:Humans; D007223:Infant; D008348:Manikins; D008511:Medicine; D013909:Thorax / Q000502:physiology*