Cardiovascular Engineering and Technology

, Volume 8, Issue 2, pp 229–235 | Cite as

Computer-Based CPR Simulation Towards Validation of AHA/ERC Guidelines

  • Alka Rachel John
  • M. ManivannanEmail author
  • T. V. Ramakrishnan


As per the AHA 2015 and ERC 2015 guidelines for resuscitation, chest compression depth should be between 5 and 6 cm with a rate of 100–120 compressions per minute. Theoretical validation of these guidelines is still elusive. We developed a computer model of the cardiopulmonary resuscitation (CPR) system to validate these guidelines. A lumped element computer model of the cardiovascular system was developed to simulate cardiac arrest and CPR. Cardiac output was compared for a range of compression pressures and frequencies. It was observed from our investigation that there is an optimum compression pressure and rate. The maximum cardiac output occurred at 100 mmHg, which is approximately 5.7 cm, and in the range of 100 to 120 compressions per minute with an optimum value at 110 compressions per minute, validating the guidelines. Increasing the pressure or the depth of compression beyond the optimum, limits the blood flow by depleting the volume in the cardiac chambers and not allowing for an effective stroke volume. Similarly increasing the compression rate beyond the optimum degrades the ability of the chambers to pump blood. The results also bring out the importance of complete recoil of the chest after each compression with more than 400% increase in cardiac output from 90% recoil to 100% recoil. Our simulation predicts that the recommendation to compress harder and faster is not the best counsel as there is an optimum compression pressure and rate for high-quality CPR.


Cardiac arrest Cardiopulmonary resuscitation Computer modeling Cardiac output Compression depth Compression rate Recoil 


Conflict of interest

Alka Rachel John declares that she has no conflict of interest. M. Manivanan declares that he has no conflict of interest. T.V. Ramakrishnan declares that he has no conflict of interest.

Human and Animal Rights

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    American Heart Association. (2015). Highlights of the 2015 American Heart Association guidelines update for CPR and ECC.Google Scholar
  2. 2.
    Babbs, C. F. Relative effectiveness of interposed abdominal compression CPR: sensitivity analysis and recommended compression rates. Resuscitation 66(3):347–355, 2005.CrossRefGoogle Scholar
  3. 3.
    Babbs, C. F., and K. Thelander. Theoretically optimal duty cycles for chest and abdominal compression during external cardiopulmonary resuscitation. Acad. Emerg. Med. 2(8):698–707, 1995.CrossRefGoogle Scholar
  4. 4.
    Beck, C. S., and D. S. Leighninger. Death after a clean bill of health: so-called fatal heart attacks and treatment with resuscitation techniques. JAMA 174(2):133–135, 1960.CrossRefGoogle Scholar
  5. 5.
    Beyar, R., Y. Kishon, E. Kimmel, H. Neufeld, and U. Dinnar. Intrathoracic and abdominal pressure variations as an efficient method for cardiopulmonary resuscitation: studies in dogs compared with computer model results. Cardiovasc. Res. 19(6):335–342, 1985.CrossRefGoogle Scholar
  6. 6.
    Haas, T., W. G. Voelckel, V. Wenzel, H. Antretter, A. Dessl, and K. H. Lindner. Revisiting the cardiac versus thoracic pump mechanism during cardiopulmonary resuscitation. Resuscitation 58(1):113–116, 2003.CrossRefGoogle Scholar
  7. 7.
    Halperin, H. R., J. E. Tsitlik, A. D. Guerci, et al. Determinants of blood flow to vital organs during cardiopulmonary resuscitation in dogs. Circulation 73(3):539–550, 1986.CrossRefGoogle Scholar
  8. 8.
    Hemalatha, K., and M. Manivannan. Valsalva maneuver for the analysis of interaction hemodynamic model study. In: 2010 International Conference on Recent Trends in Information, Telecommunication and Computing (ITC), IEEE, pp. 28–32, 2010.Google Scholar
  9. 9.
    Hemalatha, K., and M. Manivannan. A study of cardiopulmonary interaction haemodynamics with detailed lumped parameter model. Int. J. Biomed. Eng. Technol. 6(3):251–271, 2011.CrossRefGoogle Scholar
  10. 10.
    Higano, S. T., J. K. Oh, G. A. Ewy, and J. B. Seward. The mechanism of blood flow during closed chest cardiac massage in humans: transesophageal echocardiography observations. Mayo Clinic Proc. 65(11):1432–1440, 1990.CrossRefGoogle Scholar
  11. 11.
    Huemer, G., N. Kolev, and M. Zimpfer. Transoesophageal echocardiographic assessment of mitral and aortic valve function during cardiopulmonary resuscitation. Eur. J. Anaesthesiol. 13(6):622–626, 1996.CrossRefGoogle Scholar
  12. 12.
    Kim, H., S. O. Hwang, C. C. Lee, et al. Direction of blood flow from the left ventricle during cardiopulmonary resuscitation in humans—its implications for mechanism of blood flow. Am. Heart J. 156(6):1222-e1, 2008.CrossRefGoogle Scholar
  13. 13.
    Koeken, Y., P. Aelen, G. J. Noordergraaf, I. Paulussen, P. Woerlee, and A. Noordergraaf. The influence of nonlinear intra-thoracic vascular behaviour and compression characteristics on cardiac output during CPR. Resuscitation 82(5):538–544, 2011.CrossRefGoogle Scholar
  14. 14.
    Kouwenhoven, W. B., J. R. Jude, and G. G. Knickerbocker. Closed-chest cardiac massage. JAMA 173(10):1064–1067, 1960.CrossRefGoogle Scholar
  15. 15.
    Kühn, C., R. Juchems, and W. Frese. Evidence for the ‘cardiac pump theory’ in cardiopulmonary resuscitation in man by transesophageal echocardiography. Resuscitation 22(3):275–282, 1991.CrossRefGoogle Scholar
  16. 16.
    Liu, P., Y. Gao, X. Fu, et al. Pump models assessed by transesophageal echocardiography during cardiopulmonary resuscitation. Chin. Med. J. 115(3):359–363, 2002.Google Scholar
  17. 17.
    Luo, J., X. Wu, H. Zeng, and H. Yuan. Computer simulations of hemodynamic effects of EECP during AEI-CPR. In: 2010 4th International Conference on Bioinformatics and Biomedical Engineering (iCBBE), IEEE, pp. 1–3, 2010Google Scholar
  18. 18.
    Mair, P., E. Kornberger, B. Schwarz, M. Baubin, and C. Hoermann. Forward blood flow during cardiopulmonary resuscitation in patients with severe accidental hypothermia: an echocardiographic study. Acta Anaesthesiol. Scand. 42(10):1139–1144, 1998.CrossRefGoogle Scholar
  19. 19.
    Michael, J. R., A. D. Guerci, R. C. Koehler, et al. Mechanisms by which epinephrine augments cerebral and myocardial perfusion during cardiopulmonary resuscitation in dogs. Circulation 69(4):822–835, 1984.CrossRefGoogle Scholar
  20. 20.
    Noordergraaf, G. J., T. J. Dijkema, W. J. Kortsmit, W. H. Schilders, G. J. Scheffer, and A. Noordergraaf. Modeling in cardiopulmonary resuscitation: pumping the heart. Cardiovasc. Eng. 5(3):105–118, 2005.CrossRefGoogle Scholar
  21. 21.
    Noordergraaf, G. J., J. T. Ottesen, W. J. Kortsmit, W. H. Schilders, G. J. Scheffer, and A. Noordergraaf. The donders model of the circulation in normo-and pathophysiology. Cardiovasc. Eng. 6(2):51–70, 2006.CrossRefGoogle Scholar
  22. 22.
    Perkins, G. D., A. J. Handley, R. W. Koster, et al. European Resuscitation Council Guidelines for Resuscitation 2015. Section 2. Adult basic life support and automated external defibrillation. Resuscitation 95:81–99, 2015.CrossRefGoogle Scholar
  23. 23.
    Ralston, S. H., W. D. Voorhees, and C. F. Babbs. Intrapulmonary epinephrine during prolonged cardiopulmonary resuscitation: improved regional blood flow and resuscitation in dogs. Ann. Emerg. Med. 13(2):79–86, 1984.CrossRefGoogle Scholar
  24. 24.
    Redberg, R. F., K. J. Tucker, T. J. Cohen, J. P. Dutton, M. L. Callaham, and N. B. Schiller. Physiology of blood flow during cardiopulmonary resuscitation. A transesophageal echocardiographic study. Circulation 88(2):534–542, 1993.CrossRefGoogle Scholar
  25. 25.
    Rich, S., H. L. Wix, and E. P. Shapiro. Clinical assessment of heart chamber size and valve motion during cardiopulmonary resuscitation by two-dimensional echocardiography. Am. Heart J. 102(3):368–373, 1981.CrossRefGoogle Scholar
  26. 26.
    Rudikoff, M. T., W. L. Maughan, M. A. R. K. Effron, P. A. U. L. Freund, and M. Weisfeldt. Mechanisms of blood flow during cardiopulmonary resuscitation. Circulation 61(2):345–352, 1980.CrossRefGoogle Scholar
  27. 27.
    Sun, Y., M. Beshara, R. J. Lucariello, and S. A. Chiaramida. A comprehensive model for right-left heart interaction under the influence of pericardium and baroreflex. Am. J. Physiol. 272(3 Pt 2):H1499–H1515, 1997.Google Scholar
  28. 28.
    Tomaszewski, C. A., and S. A. Meador. Theoretical effects of fluid infusions during cardiopulmonary resuscitation as demonstrated in a computer model of the circulation. Resuscitation 15(2):97–112, 1987.CrossRefGoogle Scholar
  29. 29.
    Tomlinson, A. E., J. Nysaether, J. Kramer-Johansen, P. A. Steen, and E. Dorph. Compression force–depth relationship during out-of-hospital cardiopulmonary resuscitation. Resuscitation 72(3):364–370, 2007.CrossRefGoogle Scholar
  30. 30.
    Turner, I., S. Turner, and V. Armstrong. Does the compression to ventilation ratio affect the quality of CPR: a simulation study. Resuscitation 52(1):55–62, 2002.CrossRefGoogle Scholar
  31. 31.
    Werner, J. A., H. L. Greene, C. L. Janko, and L. A. Cobb. Visualization of cardiac valve motion in man during external chest compression using two-dimensional echocardiography. Implications regarding the mechanism of blood flow. Circulation 63(6):1417–1421, 1981.CrossRefGoogle Scholar
  32. 32.
    Zhang, Y. (2013). Computer Models in Bedside Physiology.Google Scholar
  33. 33.
    Zhang, Y., and J. M. Karemaker. Abdominal counter pressure in CPR: what about the lungs? An in silico study. Resuscitation 83(10):1271–1276, 2012.CrossRefGoogle Scholar

Copyright information

© Biomedical Engineering Society 2017

Authors and Affiliations

  • Alka Rachel John
    • 1
  • M. Manivannan
    • 1
    Email author
  • T. V. Ramakrishnan
    • 2
  1. 1.Touch Lab, Biomedical Research Group, Department of Applied MechanicsIIT MadrasChennaiIndia
  2. 2.SRMC & RIChennaiIndia

Personalised recommendations