An evaluation of the quality of CPR chest compressions performed on football-equipped and obese simulation manikins.

Longo JA, Lyman KJ, Hanson TA, et. al. Prehosp Emerg Care. 2023 Feb 3:1-6. doi: 10.1080/10903127.2023.2172494. Epub ahead of print.

Take-Home Message

Emergency responders offer shallower CPR chest compressions to obese manikins wearing American football chest/shoulder pads than those without equipment or obesity.


Immediate administration of high-quality CPR is a critical component of the cardiac chain of survival. Both body size and protective equipment impact the effectiveness of chest compressions. However, few investigators have examined how protective equipment (e.g., shoulder pads) on obese individuals affects the performance of chest compressions.

Study Goal

The researchers conducted a study to assess the quality of CPR chest compressions by an emergency responder during four randomized conditions that varied whether the manikin represented someone with obesity or wore American football equipment.  


The researchers recruited a convenience sample of 50 emergency responders with different levels of training (emergency medical responder to paramedic). The emergency responders then performed four trials of CPR. Each trial lasted 2 minutes, with a 3-minute break between each trial. The participants completed the trials on manikins simulating four conditions: (1) traditional manikin with no equipment, (2) traditional manikin with American football chest/shoulder pads, (3) obese manikin with American football chest/shoulder pads, and (4) obese manikin with no equipment. The researchers measured the effectiveness of the compressions using a Laerdal CPRmeter 2 device, which records compression rate, release, and depth. During trials without equipment, the emergency responders needed to remove the protective equipment before beginning chest compressions. This protocol allowed the study team to measure how long an emergency responder took to remove the protective equipment.


The depth of chest compressions suffered when the obese manikin had American football chest/shoulder pads. Emergency responders used more force during chest compressions on the obese manikin without pads than in the other three conditions. The average rate of delivery and number of compressions were similar regardless of obesity and protective equipment. Regardless of manikin or protective equipment, the emergency responders only met the recommended compression rate in 40% (obese with pads) to 51% (not-obese with pads) of compressions and the recommended depth in 7% (obese with pads) to 22% not-obese with pads) of compressions.


The recruited trained emergency responders often failed to provide effective chest compressions to simulated patients, especially if they were obese and wearing American football chest/shoulder pads. Hence, emergency responders may benefit from additional training regarding CPR on various body types with and without protective sports equipment. Further, we need more research to reproduce these results, to look at other types of equipment that may impact the quality of chest compressions, and to examine the benefit of regular training with on-field scenarios with emergency responders and athletic trainers.

Clinical Implications

Clinicians need to be mindful of the patients they treat and how equipment, body types, and other factors may impact the quality of CPR chest compressions. Clinicians may benefit from incorporating obese CPR manikins into their training.

Questions for Discussion

Do you incorporate equipment-specific scenarios or manikins that are obese into your CPR training? If not, what barriers would you encounter in working toward incorporating manikins that are obese or equipment-specific scenarios?

Written by Kyle Harris
Reviewed by Jeffrey Driban

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