CPR

[spicy cha cha]

imo laypeople probably shouldn't get too caught up with 2005 compression:breath ratio change
the data on this stuff is not great, and simplification was probably the primary benefit

people screw up cpr because they don't push hard enough or fast enough, or they interrupt compressions.
And airway positioning is more important than you'd think if you're dealing with a fat person.

granted, all this is much easier said than done in the field.
add snow and a slope, and compressions are probably pretty ineffective

[emtnate]

^ Simplification was the big reason behind the change in the first place. For the lay person CPR is simple: Compressions fast and hard on an adult. Aim for 100 compressions a minute. Pump the chest along to "stayin alive"

In the heat of the moment if you do 15 compressions x 2 breaths, it won't hurt them, and still be much better than doing nothing. However, at our hospital the data suggests that the ACLS standards are improving patient outcomes. (This goes way beyond layperson CPR)

[spicy cha cha]

interesting.
how much improvement? what's your N and what are you comparing against?

[emtnate]

I'd have to dig through some reports dropped off at the firehouse to get the exact numbers. A large regional hospital in my city was participating in the study for the AHA. They were comparing data over the past 10 years or so, looking at post arrest survival with witnessed and non-witnessed arrests, in the field or in the hospital.

I'm not real clear what they meant by survival or how long they waiting to say it was a save. We can often get ROSC back with enough drugs and shocks, but the person still ends up dying hours later. If they call this a 'save' then the study would by flawed, in my non-doctor opinion.

Of course, you also have to consider that in the past several years, we have been working less people in the field. Therefore anyone who walks out of the hospital after a full-arrest would skew the results, because there would be proportionally smaller resuscitation attempts.

Also I mentioned ACLS standards. They were also updated recently. Like I said, this is WAY beyond CPR. The drugs and dosages that are pushed, doing CPR for 2 minutes before defib attempts, giving time to circulate meds with CPR all plays a big part in the improvement rate I mentioned.

The bottom line is good quality CPR started immediately upon recognition of cardiac arrest, and quick access to defibrillation is key to survival.

[summit]

^agree that 15:2 is better than no breaths for a avi victim, but do as you were taught. get refreshed. learn 30:2

imo laypeople probably shouldn't get too caught up with 2005 compression:breath ratio change
the data on this stuff is not great, and simplification was probably the primary benefit

people screw up cpr because they don't push hard enough or fast enough, or they interrupt compressions.
And airway positioning is more important than you'd think if you're dealing with a fat person.

I agree with the second statement, but not the first.

A BC skier should be more serious and involved in their rescue training than John Q Citizen taking lay person CPR. They should take something like ARC CPR for Professional Rescuers or AHA BLS for Healthcare Providers or AHSI's CPR for Professionals. And so some of the simplification is better, but 30:2 does make sense when looking at it overall, and there is good reasoning, theory, and testing behind it in addition to outcome based studies. This is EBM applied. Longer compression cycles do result in longer periods of beneficial MAP.

granted, all this is much easier said than done in the field.
add snow and a slope, and compressions are probably pretty ineffective

that's why we teach students to put patients on a hard surface whether its skis, pack, compact snow, whatever, or in urban land to take them off the bed and put them on the floor

[AKPogue]

I was surprised to find out that my 11 year old step-daughter was taught CPR in health class this year in 6th grade. Good the school system to teach this.

[natty dread]

BREATHLESS CPR IS NOT A GOOD PRACTICE FOR AVALANCHE VICTIMS

I couldn't hear you, could you please repeat?

[awake1563]

Please clear my airway, then pump and blow. or blow and pump if you will.

[emtnate]

I was surprised to find out that my 11 year old step-daughter was taught CPR in health class this year in 6th grade. Good the school system to teach this.

I was taught CPR in 6th grade, again in 8th, and in 9th grade PE it was a requirement to pass health class. I'm only 26, but our school is fairly progressive with things like that. They even teamed up with the hospital to offer EMT-Basic to seniors.

[AKPogue]

I was taught CPR in 6th grade, again in 8th, and in 9th grade PE it was a requirement to pass health class. I'm only 26, but our school is fairly progressive with things like that. They even teamed up with the hospital to offer EMT-Basic to seniors.

That's pretty cool. Wish they did the same when I was in school.

[moose pit]

Every two years, with practice in between.
That and skiing with medical and or rescue personal is never a bad idea.

[Phall]

I have CPR healthcare provider and am taking EMT (B) for VT next semester.
I have Avy 1 and plan on taking 2 in a year. As well as trying to get my OEC.

[Conundrum]

I don't really care about my credentials...just my ski partners' credentials. :wink

OEC, Prorescuer CPR, AED, Swiftwater I, Avy I & II. But my ski partners are mostly medics, ER nurses, and one ER doc.

[spicy cha cha]

I'm not real clear what they meant by survival or how long they waiting to say it was a save.

great point. neurologic recovery is what really matters. I haven't looked at the studies behind the 2005 changes, but I'd be surprised if it wasn't an endpoint.

^agree that 15:2 is better than no breaths for a avi victim, but do as you were taught. get refreshed. learn 30:2

yup. agree 100%. didn't mean to suggest refreshment wasn't important

my gist was when it comes to protocols and ebm, dogma often prevails over the bigger picture.


and we're in luck: therapeutic hypothermia is all the rage right now

[emtnate]

^^ Do you know of any studies about this? In the ER we induced hypothermia in one patient and warmed another up. I believe the one that was warmed arrested secondary to hypothermia, but am not positive.

Anyone know anything else about this? It's obviously not something we do on the streets.

[spicy cha cha]

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

[mtnmedic]

^^ Do you know of any studies about this? In the ER we induced hypothermia in one patient and warmed another up. I believe the one that was warmed arrested secondary to hypothermia, but am not positive.

Anyone know anything else about this? It's obviously not something we do on the streets.

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.

[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.

[mtnmedic]

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.

[mtnmedic]

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.

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.

[jondrums]

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!

[emtnate]

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.

[grrrr]

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.

[natty dread]

I'll have to look and see where they are doing it here in the US.

NYC is one place. But not in the field I don't think.
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.

[natty dread]

can somebody school me on why I should carry a pocket mask?

Hep C is one good reason.
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.