I had a paper on it at one point. I'll see what I can find
we've had success using it in witnessed vfib arrests, but a super small N
Printable View
I had a paper on it at one point. I'll see what I can find
we've had success using it in witnessed vfib arrests, but a super small N
Profound hypothermia is a cause of PEA, electrical activity in your heart but no actualy heart beat. So if you are in arrest because of hypothermia you would need to be actively warmed. BUT, if you are just having an MI, head injury or some other cause of arrest, MILD hypothermia may be helpful. By mild I mean only a few degrees. There are a few EMS programs in the country that are trialing this now.Quote:
Originally Posted by emtnate
Are you suggesting that in the near future we could be inducing mild hypothermia as standard ems post arrest care? Or is this taking place in the hospitals. Like I said on an earlier post, I was not aware it is being researched in head injures and non-arrest MI's as well. Is this mild enough hypothermia that the patient does not need to be in an induced coma?
My system is not the most aggressive in the region, but we have low transport times to a level 2 trauma center and 2 other large hospitals with all types of specialists available around the clock. We don't stock paralytics and only have 1 sedative available. Surrounding counties allow medics to do much more, and typically stock short lasting paralytics and sedatives.
I wonder how much more they'll be expanding our scope of practice as I start my career.
There are a few reasons for the new CPR. For the lay person it was found that 1. They were reluctant to do mouth to mouth. 2. Rescue breathing is extremely hard to do well and usually done wrong. 3. They were stopping compressions way to often to check for pulses. 4. They weren't recognizing if a pulse was there or not. As a result not doing compressions when they needed to.
For the professional rescuer they found that they were stopping too often to shock and check for pulses and check the monitor. They were tunnel visioned on getting the airway secured that they weren't doing compressions effectively enough.
Heres why the changes:
30:2 or no breath CPR -You heart is a pump, like any pump it takes a second to prime itself. In your hearts case it takes maybe 8 beats. So doing 15:2 or 5:1 wasn't circulating blood well if at all in some cases. At work I instruct everyone to just do constant compressions and never stop. For advanced rescuers you'll notice that you don't stack shocks anymore. Thats for this reason that you want to minimize stopping compression. If you get a change on the monitor you keep doing compressions regardless. It also does a bunch of stuff for keep coronary pressure up and yada yada but thats for another day.
-The breath thing. I won't tell you that oxygen is bad, or that we don't need to breath. BUT, studies are now showing that people can go a lot longer without it that we thought. That is why you focus on compressions. The average person can go about 12 minutes without breathing before cellular hypoxia sets in. Now assuming the average person in an avy is below 11,000ft, healthy, and breathing hard(not to mention high altitude adjusted and flush with red blood cells) They should last a bit longer. The flip side of the coin is that people in avalanches usually asphyxiate. So yeah, the breathing is important but don't let it interfere with your compressions. Oxygen in your lungs doesn't do much good if it isn't going around and around. As I said before, rescue breathing is HARD to do right. You want to minimize inflating the stomach, that will cause lots of trouble later on. Look up the term Sellick Maneuver.
A quick note on compressions. Most of the blood flow is caused by that up stroke in the compressions and drawing blood into the chest. So be sure to let the chest rebound all the way.
If you have to every do it in the BC, and I hope you never do, do what you know. Compressions are the key.
Yup, they are doing it in the field. I'll have to look and see where they are doing it here in the US. They have been doing it in Europe a lot too. The patient would be post arrest and either comatose or in an induced coma, otherwise they would shiver and thier metabolic rate would increase.Quote:
Originally Posted by emtnate
can somebody school me on why I should carry a pocket mask?
I've taken several CPR and first responder certs, and years ago, nobody even mentioned that masks exist. Honestly, I wouldn't really think twice about kissing someone I just met, why should I worry about giving cpr mouth-to-mouth?
I feel that stressing mask usage in trainings will just cause people to be afraid to save someone else's life!
You want to use a pocket mask you don't get someone's puke in your mouth.
Also, and equally important, the masks help get a much better seal than you would get with mouth to mouth.
We're currently involved in a study that is looking at 2 new protocols. The first involves using a plunger type device to increase and decrease thoracic pressure more effective. In theory it allows the heart to refill more. The 2nd is a device to prevent air from leaving the lungs - it's essentially a strong one-way valve. By increasing lung volume during compressions, it increases thoracic pressure. In theory, it allows compressions to empty the heart more completely.
Neither of these have much hope of becoming bystander protocols, but may make into the pre-hospital care setting.
And yes, controlled cooling has been documented to increase post code recovery.
NYC is one place. But not in the field I don't think.Quote:
Originally Posted by mtnmedic
http://www.nytimes.com/2008/12/04/ny...cardiac&st=cse
Cooling will be the standard of care here in Portland hospitals by the end of 2009.
Hep C is one good reason.Quote:
Originally Posted by jondrums
Just get a pocket faceshield and attach it to your key ring, problem solved.
And keep a real pocket mask and oral airway in your pack when in the BC.
I think the next big thing in CPR with be abdominal comressions. A second rescuer with perform upward compressions over the belly button opposite the person doing chest compressions. It would be a see-saw type pattern to flush blood out of the abdomen into the chest and also to "pump" the aorta and vena cava just like the heart.
Heres a pre hospital example of the hypothermic therapy.
http://pressherald.mainetoday.com/st...39021&ac=PHnws
While we are on this topic, can someone please make it illegal for "rescuers" on TV and in movies to find someone unconscious, breathless and pulseless, give them a rescue breath or two and a handful of fake compressions and have them wake right up and thank them for saving their life? That shit pisses me off to no end.
what's interesting about the 2005 guidelines is that they recommend stopping ventilations for bvm but not tube airways.Quote:
Originally Posted by mtnmedic
http://circ.ahajournals.org/cgi/cont...24_suppl/IV-19
I can't say I'm around alot of bagged arrests, but I've never seen that in practice.
incidentally that same paper also says "This 30:2 ratio is based on a consensus of experts rather than clear evidence."
the only evidence are two pig experiments and a mathematical model.
also interesting is they mention cric pressure. I think that's new
I've been told that once they're tubed, the risk of gastic inflation is lower, so you don't need to stop compressions. Obviously you can still bag them too hard with a tube in place and cause bad things to happen.
Cric pressure helps keep the esophagus closed during ventilations, in addition to helping visualize the airway during intubation. I've read studies on this, but have noticed it myself in the field.
huh interesting. what's the mechanism?Quote:
Originally Posted by grrrr
pretty sure the starling curve argues otherwise. increased intrathoracic pressure decreases venous return and cardiac output
and a little light reading for emtnate
http://content.nejm.org/cgi/reprint/346/8/549.pdf
http://content.nejm.org/cgi/reprint/346/8/557.pdf
http://circ.ahajournals.org/cgi/reprint/108/1/118
I'm not aware any Denver systems start it in the field
That is interesting, you may be right. I do seem to recall reading some studies that the new protocols were based on though. I will have to do some digging at work and see if I can't find them.Quote:
Originally Posted by spicy cha cha
The reason we use constant compressions at work is my patients are intubated and I can do any other procedures around the compressions. Its just easier to say "go and don't stop", and the benefit of constant compressions is obvious.
One area of concern with CPR and avy victims is where the victim has severe hypothermia. After speaking to some of the patrollers involved in the Snowbird incident earlier this year I started to wonder whether CPR is always helpful. I found a couple of papers (which are at home, so I can't cite them here) which suggest that you should wait at least a minute to check for a pulse before starting CPR on a hypothermic victim, because they could have a pulse as slow as 2-3 beats per minute, and CPR could send them into defibrulation (sp.?). If there is a pulse, even one as weak and slow as this, no CPR is indicated.
I am not sure how this works in the field, where conditions may not be condusive to finding a pulse as slow as 2-3 beats a minute. Fortunately, I have not been in that position.
On the topic of getting CPR training, the standard first aid/cpr course should be taken by everyone. For me WFR was a real eye-opener. My wife and I took it after both of our kids did it. My motivation was off-shore sailboat racing, but it has given me confidence in shoreside settings, as well.
I did my paramedic clinicals in Phoenix. When I was there in Jan/Feb 06 they were doing 200 compressions check for pulse and then another 200 compressions. No breathing was done and all they did was put in an OPA. The other medics there told me they were getting a lot better results with this than they did before.Quote:
Originally Posted by mtnmedic
All skiers and outdoors folks should take as much first aid as they can...knowledge you can use! Props to all the voly ems and patrolers and the paid pros too! Saving your bacon in times of need!
Thanks for the links to those articles. I actually got to ski today, so I'll read them when I'm less tired.
So they are doing compressions minus ventilations in Phoenix. My medical director told me this will be the standard within the next few years. Just using an OPA does not surprises me either. The last ACLS class I took was in October, and they are teaching to use a BVM with OPA / NPA as long as you are getting good ventilations. Then drop an King LT or Combitube. They want an ETT to be a last resort to secure the airway.