Another change in CPR

AdaFire38

Member
May 16, 2010
148
Lowell, MI
http://news.yahoo.com/s/ap/us_med_hands_first_cpr

DALLAS – New guidelines out Monday switch up the steps for CPR, telling rescuers to start with hard, fast chest presses before giving mouth-to-mouth.

The change puts "the simplest step first" for traditional CPR, said Dr. Michael Sayre, co-author of the guidelines issued by the American Heart Association.


In recent years, CPR guidance has been revised to put more emphasis on chest pushes for sudden cardiac arrest. In 2008, the heart group said untrained bystanders or those unwilling to do rescue breaths could do hands-only CPR until paramedics arrive or a defibrillator is used to restore a normal heart beat.


Now, the group says everyone from professionals to bystanders who use standard CPR should begin with chest compressions instead of opening the victim's airway and breathing into their mouth first.


The change ditches the old ABC training — airway-breathing-compressions. That called for rescuers to give two breaths first, then alternate with 30 presses.


Sayre said that approach took time and delayed chest presses, which keep the blood circulating.


"When the rescuer pushes hard and fast on the victim's chest, they're really acting like an artificial heart. That blood carries oxygen that helps keep the organs alive till help arrives," said Sayre, an emergency doctor at Ohio State University Medical Center.


"Put one hand on top of the other and push really hard," he said.


Sudden cardiac arrest — when the heart suddenly stops beating — can occur after a heart attack or as a result of electrocution or near-drowning. The person collapses, stops breathing normally and is unresponsive. Survival rates from cardiac arrest outside the hospital vary across the country — from 3 percent to 15 percent, according to Sayre.


Under the revised guidelines, rescuers using traditional CPR, or cardiopulmonary resuscitation, should start chest compressions immediately — 30 chest presses, then two breaths. The change applies to adults and children, but not newborns.


One CPR researcher, though, expressed disappointment with the new guidelines. Dr. Gordon Ewy of the University of Arizona Sarver Heart Center thinks everyone should be doing hands-only CPR for sudden cardiac arrest, and skipping mouth-to-mouth. He said the guidelines could note the cases where breaths should still be given, like near-drownings and drug overdoses, when breathing problems likely led to the cardiac arrest.


Ewy is one of the authors of a recently published U.S. study that showed more people survived cardiac arrest when a bystander gave them hands-only CPR, compared to CPR with breaths.


The guidelines issued Monday also say that rescuers should be pushing deeper, at least 2 inches in adults. Rescuers should pump the chest of the victim at a rate of at least 100 compressions a minute — some say a good guide is the beat of the old disco song "Stayin' Alive."


Dr. Ahamed Idris, of the University of Texas Southwestern in Dallas, said people are sometimes afraid that they'll hurt the patient. Others have a hard time judging how hard they are pressing, he said.


"We want to make sure people understand they're not going to hurt the person they're doing CPR on by pressing as hard as they can," he said.


Idris, who directs the Dallas-Fort Worth Center for Resuscitation Research, said that for the last two years, they've been advising local paramedics to start with chest compressions and keep them up with minimal interruptions. That, along with intensive training, has helped improve survival rates, he said.


He said they found paramedics hadn't been starting compressions until the patient was in the ambulance and lost time getting airway equipment together.


"The best chance was to start chest compressions in the house, immediately," he said.
 

Jarred J.

Lifetime VIP Donor
May 21, 2010
11,593
Shelbyville, TN
so soon it will be real easy to get cpr cerified, if you can press on a sturnum without breaking a rib then BOOm your certified.


Here's your card.
 

NPS Ranger

Member
May 21, 2010
1,990
Penn's Woods
American Heart is part of an international panel on CPR-ECC that develops the standards. After a year or two Red Cross and others get around to revising thair training materials.
 

dustymedic

Member
May 21, 2010
633
Columbus,OH
Let's see how long it takes Emergency Dispatch to change their protocols. "Hey everybody, you need to buy new flip cards again!"
 

pondfly

Member
May 21, 2010
307
IL
NPS Ranger said:
According to what I just read, if you're not breaking ribs you're probably not doing it right.

I've broken quite a few ribs in my day.

This.


I lost count on how many were broken in my days.
 

whatevah

Member
May 26, 2010
388
Delaware, USA
my first solo CPR was on a 300 pound 65 y/o male I dragged out of a car after passersby called 911 (happened to be a half-block away when the dispatch went out). Broke ribs on each of the first 3 compressions. Like the saying goes... "if you're not breaking ribs you're probably not doing it right."


One comment on the article, though... "Ewy is one of the authors of a recently published U.S. study that showed more people survived cardiac arrest when a bystander gave them hands-only CPR, compared to CPR with breaths." The key word there is "bystander". Most people don't know how to give a proper rescue breath (head-tilt, chin-lift, cover nose, good seal, etc) which is why the updated standard for civilian CPR is compressions only. I'd like to see study results focusing on BLS-only CPR (ie. only AED, no drugs, intubation etc). But, as a lowly EMT, I will do what the doctor says, it's his license that allows me to work!
 

NPS Ranger

Member
May 21, 2010
1,990
Penn's Woods
whatevah said:
One comment on the article, though... "Ewy is one of the authors of a recently published U.S. study that showed more people survived cardiac arrest when a bystander gave them hands-only CPR, compared to CPR with breaths." The key word there is "bystander". Most people don't know how to give a proper rescue breath (head-tilt, chin-lift, cover nose, good seal, etc) which is why the updated standard for civilian CPR is compressions only. I'd like to see study results focusing on BLS-only CPR (ie. only AED, no drugs, intubation etc).

More research is definitely needed. Rescue breathing causes increased intrathoracic pressure and therefore decreased cardiac filling between compressions, making the compressions less effective... the opposite of normal breathing which results from decreased intrathoracic pressure from your diaphragm moving downwards. Not to mention the tendency for enthusiastic (i.e. usual) rescue breathing to cause regurgitation of stomach contents which is then aspirated into the lungs, a definite negative factor in overall survival.
 

Stendec

Member
May 21, 2010
816
NPS Ranger said:
Not to mention the tendency for enthusiastic (i.e. usual) rescue breathing to cause regurgitation of stomach contents which is then aspirated into the lungs, a definite negative factor in overall survival.

In human, that means barf, right? ;)


I don't think I've ever done or witnessed CPR being done without puking involved. Sometimes it wasn't even me.
 

whatevah

Member
May 26, 2010
388
Delaware, USA
Yes, "barf" just not expelled because they're "dead".That's why ambulances usually keep the AED near a portable suction pump.
 

Stendec

Member
May 21, 2010
816
I have dim recollections of a Brit who made a "CPR machine" that was a frame that sat over the soon-to-be-deceased's chest. There was a piston attached to an eccentric wheel that was turned by a handcrank and did the compressions. Apparently it didn't take the EMS world by storm.


Why is every gurney in the world at exactly the wrong height to do good compressions on, regardless of how thick or thin the compressee is?
 

FDNY 10-75

Member
May 24, 2010
457
NY
Stendec said:
I have dim recollections of a Brit who made a "CPR machine" that was a frame that sat over the soon-to-be-deceased's chest. There was a piston attached to an eccentric wheel that was turned by a handcrank and did the compressions. Apparently it didn't take the EMS world by storm.

Why is every gurney in the world at exactly the wrong height to do good compressions on, regardless of how thick or thin the compressee is?


They did, just maybe not his. http://medgadget.com/archives/2009/06/l ... light.html


We just got these, another agency around here uses the 'thumper' which is similar but air powered.
 

kadetklapp

Member
May 21, 2010
1,568
Indiana
Stendec said:
Why is every gurney in the world at exactly the wrong height to do good compressions on, regardless of how thick or thin the compressee is?

I was told in the academy during "EMS awareness week" that if the patient is on a bed or couch, you have to get them on the floor (is a gurney considered a bed?). In the instance I referenced, the "descendant" as it turned out was on a bed. She weighed in excess of 300 pounds and was "dead" weight (no pun). No way I could get her off the bed. I was trying compressions and not getting anywhere. A bloody foam was coming out of her mouth (still warm to the touch so I started CPR). Between her weight and my 250 pounds (with gear) the bed ended up leaving the fight early and the whole thing went to the floor. At that point I was able to do much better compressions and that's when the rib breaking began....
 

charlie82

Member
May 21, 2010
353
PA / USA
kadetklapp said:
I was told in the academy during "EMS awareness week" that if the patient is on a bed or couch, you have to get them on the floor (is a gurney considered a bed?). In the instance I referenced, the "descendant" as it turned out was on a bed. She weighed in excess of 300 pounds and was "dead" weight (no pun). No way I could get her off the bed. I was trying compressions and not getting anywhere. A bloody foam was coming out of her mouth (still warm to the touch so I started CPR). Between her weight and my 250 pounds (with gear) the bed ended up leaving the fight early and the whole thing went to the floor. At that point I was able to do much better compressions and that's when the rib breaking began....

Beds and couches will absorb the compressions. Your gurney does not have a thick enough pad to absorb the compression. This should have been taught to you during CPR.
 

BigDogg795

Member
May 21, 2010
386
Long Island, NY
NPS Ranger said:
According to what I just read, if you're not breaking ribs you're probably not doing it right.

I've broken quite a few ribs in my day.


Thanks to my latest testing for my CPR certification, I now have the title "Bone Crusher" in my EMT class... ;)
 

ne33

Member
May 25, 2010
36
Winston Salem, NC
Not honestly sure how I feel about these new changes...What if your patient went down because of an airway compromise (most common in children)? You got the blood flowing, but without proper oxygenation, what's the point?
 

kadetklapp

Member
May 21, 2010
1,568
Indiana
charlie82 said:
Beds and couches will absorb the compressions. Your gurney does not have a thick enough pad to absorb the compression. This should have been taught to you during CPR.

Ya, i don't keep a gurney in my squad car...
 

dustymedic

Member
May 21, 2010
633
Columbus,OH
ne33 said:
Not honestly sure how I feel about these new changes...What if your patient went down because of an airway compromise (most common in children)? You got the blood flowing, but without proper oxygenation, what's the point?
I believe the changes are only adult, children still get rescue breathing..
 

Klein

Member
May 22, 2010
966
Texas
FDNY 10-75 said:
They did, just maybe not his. http://medgadget.com/archives/2009/06/l ... light.html


We just got these, another agency around here uses the 'thumper' which is similar but air powered.

We have used The Lucas since it came out being air powered. Now we have the new battery powered ones. Much better. Last time I saw one used, a month ago, it unfortunately caused Subcutaneous Emphysema. It had essentially popped a lung and air was trapped in the chest making it rigid. PT died, obviously.
 

surf_kat

Member
May 28, 2010
58
SE AZ
ne33 said:
Not honestly sure how I feel about these new changes...What if your patient went down because of an airway compromise (most common in children)? You got the blood flowing, but without proper oxygenation, what's the point?

I've been aware of and involved in the 'hands only' CPR since 2004. My first exposure to it had me questioning the same thing.. we need to circulate oxygen in the blood to the important cells (brain, heart, kidneys) in order to sustain life. Then I saw the research data and the theory behind 'hands only' resuscitation.


Let's talk about the heart (pump) first. The heart is stopped, no blood is moving. Your first compression sends blood downstream but it doesn't build much pressure in the circulatory system. It takes approximately 15 compressions to get the 'blood pressure' up to a point that blood is circulating AND there is enough pressure differential for the oxygen to cross the vascular walls into the cells to support cellular respiration. As soon as the compressions stop (in order to ventilate) that pressure falls back down to ZERO. The Sarver Heart Institute at University of Arizona Medical Center adopted a 100 compression per minute rate to be done for two minutes (which is the AED cycle time). This gets that pressure up and keeps it up for two minutes.


Now the oxygenation side. First cellular activity drops off greatly when someone is in cardiac arrest. Again we care about oxygenating the heart muscle, the brain and the kidneys. I've seen some numbers that suggest that during cardiac arrest there is a demand of only about 1/3 amount of oxygen versus a conscious patient. Second and this is the biggie: Consider that the lungs are connected to the inside wall of the chest (by the pleural lining and the surface tension of the pleural fluid). So when you compress the chest to squeeze the blood out of the heart, you are also compressing the chest and squeezing air out of the lungs. What happens when the pressure on the chest relaxes? The chest expands back out and air enters the lungs. Do we need to 'force' more air into the lungs? No. In fact that might be detrimental for two reasons: 1) if you over inflate the lungs you decrease the volume of blood the heart can pump and 2) excess air tends to make it's way down the esophagus into the stomach. Swallow a bunch of air and what happens... normal people belch and unconscious people (who cannot control the sphincter at the top of the stomach) vomit.


It has also been found that with bag valve mask ventilation most rescuers will not perform it at 10-12 times per minute (non-intubated) or 6-8 times per minute (intubated). Instead it is not unusual to see a rescuer doing 20-30 times per minute and forcing air into a patient. So that air becomes trapped in the lungs compressing the heart and the great vessels (consider a pneumo lets air into the chest cavity but doesn't allow it to escape doing the same thing).


Last fall doing ride time with Tucson Fire Department we did Sarver based cardiac care. It involved the 100 compressions per minute, no assisted ventilation BUT a non-rebreather was placed on the patient to increase oxygen from ambient (21%) into the 90% level, the only 'intubation' was a Combi or King in order to minimize interruption in CPR (other than one ET intubation to let me practice that skill), early peripheral access using an EZ-IO and the usual cardiac monitoring.


As far as airway compromise: What is the preferred method to clear an airway obstruction in an unconscious adult or child? Chest thrusts....


AHA did not go all the way like Sarver and the training organizations (Red Cross, ASHI) in taking respiration out of the equation. Then again they are the same folks who have kept lidocaine in as an anti-arrythmic drug although research doesn't support its effectiveness in v-fib.
 

surf_kat

Member
May 28, 2010
58
SE AZ
whatevah said:
One comment on the article, though... "Ewy is one of the authors of a recently published U.S. study that showed more people survived cardiac arrest when a bystander gave them hands-only CPR, compared to CPR with breaths." The key word there is "bystander". Most people don't know how to give a proper rescue breath (head-tilt, chin-lift, cover nose, good seal, etc) which is why the updated standard for civilian CPR is compressions only. I'd like to see study results focusing on BLS-only CPR (ie. only AED, no drugs, intubation etc). But, as a lowly EMT, I will do what the doctor says, it's his license that allows me to work!

Actually most bystanders WON'T give rescue breaths. I'm not so sure that most emergency workers really want to do non-BVM breathing even with one way valves (which open when you breath in...you just hope enough pressure keeps the bad stuff out) or the micro shields (keeping fluids from crossing the barrier). Cardio-Cerebral Resuscitation (CCR per ASHI) and AED survival rates are actually pretty good because 1) people are less prone to 'wait' so the arrest is caught in the early stages and 2) because it takes paramedics awhile to get there to start ACLS.


As a side note and not directed at you, some of the mechanical CPR devices such as the 'auto pulse' is thought to be better than a human doing compressions since it won't tire out (2 minutes at 100bpm is tiring) and it has a consistent rate and depth of 'compression'.
 

fp13-2

Member
May 20, 2010
359
Harrisburg, PA
Surf-kat is dead-on correct on this one. I couldn't have said it better myself.


Does this fly in the face of what some people were taught for decades? Yes. I, however, am not a doctor or researcher, so I trust they did their job and know better...
 

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