CPR help.

[Expatmedic]

Originally Posted by abnrgr1sg

Well. Any lifesaving attempt is heroic to me, successful or not. You can't blame the circumstances leading to the lifesaving attempt & the situation your facing.

My grandson was in the water at least 4 minutes. Not breathing, faint pulse, blue lips & eyes, all color lost. Solid white. It took me a minute & a half to get vitals I definitely had help from the Ranger in the Sky.

Thanks 1SG. It is nice to hear that it does work and it ended well.

Working up pediatric codes is always stressful.

[Soutpiel]

I had several many but two instances that stick out in my memory bank.

1. I was about 20 and on leave from the army. My girlfriend was marrying a buddy (I was away in Angola semi-permanently so I suppose somebody had to knob her) and I was sitting at a table at the wedding reception as the bridal party walked in with the photographer in front of them shuffling backwards while taking pics.... and he collapsed. right there blocking the route between the tables. So I jumped in and started doing my thing. Some loud chick jumped in, chanted repeated out my way I'm a doctor, and proceeded to do weird stuff. I remember sitting back at my table watching the chaos and thinking this guy is now fucked. Anyway, he died and I discovered later the chick was first year med student. But anyhoo.

2. In 2012 I was having a business meeting at a breakfast table on the verandah at Lake Tanganyika Hotel in Kigoma and an "african business man" looking guy came shuffling past the table dragging his feet and not looking so wonderful. Caught my attention. So I excused myself from the table and went after the guy. True as bob he collapsed in cardiac arrest before he got to reception. So I did the necessary and got him idling again. They chucked him in the back of a station wagon (that's how they roll in Africa- if you blink somebody has chucked the patient in a car and disappeared) and took him to the local hospital so I don't know the outcome but I'm chuffed in a weird way that I spotted one before it happened. A side benefit of having half decent situational awareness I suppose

[jportal50]

I am 1 for 1.

At a resort in Cabo San Lucas with a girlfriend. We were getting our food, she went first (we both got burger and fries). She was already at the table when I got mine; I sat down. I mumbled looking at my food "This is awesome" (beautiful day), no response. Said it again, no response. I looked up at her: Discolored skin tone (blue/pale), not breathing, etc. At first i thought choking. I jump up, grab her and conduct heimlich twice. No response (everyone around including staff gathering, watching and freaking). Lay her down and begin CPR, 1min she begins breathing, color coming back and then asked me what was going on. Conclusion in Mexico ($600 cash later) and in the US that she had gone into cardiac arrest. I consider myself (and her) lucky. Not sure how I would have explained to her family, etc had the outcome not been in her favor. She broke up with me about 6 mos later; ungrateful bitch. :)

[Old_Starlight]

Originally Posted by jportal50

I am 1 for 1.

At a resort in Cabo San Lucas with a girlfriend. We were getting our food, she went first (we both got burger and fries). She was already at the table when I got mine; I sat down. I mumbled looking at my food "This is awesome" (beautiful day), no response. Said it again, no response. I looked up at her: Discolored skin tone (blue/pale), not breathing, etc. At first i thought choking. I jump up, grab her and conduct heimlich twice. No response (everyone around including staff gathering, watching and freaking). Lay her down and begin CPR, 1min she begins breathing, color coming back and then asked me what was going on. Conclusion in Mexico ($600 cash later) and in the US that she had gone into cardiac arrest. I consider myself (and her) lucky. Not sure how I would have explained to her family, etc had the outcome not been in her favor. She broke up with me about 6 mos later; ungrateful bitch. :)

Sounds like a reward to me :D

It is good to see all the success stories here. Kudos one and all for getting in giving your all regardless of your outcomes.


Cheers,

[billdawg24]

Remember, the Red Cross, and MIL type CLS classes teach differently as well.
The last time I went through CLS,(JUL 2013) they said no rescue breaths, as the chest compressions are forcing the lungs to work at the same time.

[O_Pos]

Originally Posted by billdawg24

Remember, the Red Cross, and MIL type CLS classes teach differently as well.
The last time I went through CLS,(JUL 2013) they said no rescue breaths, as the chest compressions are forcing the lungs to work at the same time.

The Department of Defense supports/teaches/follows American Heart Association guidelines for CPR (BLS/ACLS).

In CLS, you are basically being taught bystander CPR (non-healthcare).

There is still debate about the amount of gaseous exchange that actually takes place at the alveolar level in the lungs simply due to the negative pressure created by chest decompression, especially without supplemental oxygen or a basic airway adjunct in place. There was some thought that the AHA recommendations would go to compression-only all of the way but the literature/science was not enough for a consensus recommendation, although some systems do this in practice.

Much of the science theory/support for initial bystander chest compression only revolves around the fact that in an adult experiencing sudden cardiac arrest, there should be residual oxygen levels in the blood supply that can sustain oxygen saturation for some number of minutes (depends on person's physiology). That combined with the small amount of gas exchange due to compressions should be enough to maintain until additional help arrives. In major systems where EMS uses compression-only CPR, it most usually includes application of high-flow O2 via mask/cannula and often insertion of a basic airway adjunct to keep airway open.

Note to the readers here, while CLS may be teaching basic CPR techniques, remember that the tenets of TCCC apply long before this type of intervention should be attempted. i.e. Return fire and seek cover, apply basic self-aid/buddy-aid to control massive hemorrhage, etc. IT IS NOT ADVISABLE NOR RECOMMENDED to attempt to resuscitate a pulseless/apneic casualty during care under fire. This also applies to tactical field care unless security has been well established and mission objectives (as well as command decision) allow for the personnel and equipment resources to be dedicated to this one casualty.

[Medic4070]

There is a growing trend in EMS towards cardiocerebral resuscitation (CCR) and traditional CPR. In my region, the responding EMS personnel have the option of choosing either option, depending on the etiology of the arrest. If the arrest appears to be primarily cardiac in nature, then we will apply passive O2 via NRB AND NC, both at 15 L/min and do only compressions for the first 6 minutes. ALS providers can work the monitor, start lines, push drugs, but are not supposed to drop advanced airways. The emphasis is on maximizing perfusion pressures within the heart via continuous compressions and not creating intrathoracic pressures with positive pressure ventilations. The dual high-flow devices are thought to wash out the upper airway and dead space with pure O2. Thus, when the compressions create changes in intrathoracic pressure, it results in some ventilation/gas exchange as well.

If the arrest has an extended downtime, appears to be respiratory in nature, or has gone on more than 6 minutes, then the crew will go to traditional CPR at 30:2 until an advanced airway is placed. Then it's our usual/traditional flogging.

[justamedic]

Originally Posted by Medic4070

There is a growing trend in EMS towards cardiocerebral resuscitation (CCR) and traditional CPR. In my region, the responding EMS personnel have the option of choosing either option, depending on the etiology of the arrest. If the arrest appears to be primarily cardiac in nature, then we will apply passive O2 via NRB AND NC, both at 15 L/min and do only compressions for the first 6 minutes. ALS providers can work the monitor, start lines, push drugs, but are not supposed to drop advanced airways. The emphasis is on maximizing perfusion pressures within the heart via continuous compressions and not creating intrathoracic pressures with positive pressure ventilations. The dual high-flow devices are thought to wash out the upper airway and dead space with pure O2. Thus, when the compressions create changes in intrathoracic pressure, it results in some ventilation/gas exchange as well.

If the arrest has an extended downtime, appears to be respiratory in nature, or has gone on more than 6 minutes, then the crew will go to traditional CPR at 30:2 until an advanced airway is placed. Then it's our usual/traditional flogging.

Is this evidence based?
It sounds good, and makes sense in my head. A lot of times I feel like we are wasting time and effort by stopping compressions. Those of us with a standard ACLS card have seen the charts regarding the coronary artery perfusion pressures, where the pause in compressions takes you back to square one.
I haven't upped my JEMS subscription, so I may have missed this. I just went through critical care training a few months ago, and I didn't hear about this there either.

[Crna]

I get called to the ED frequently to intubate codes.
I have never seen a code being worked in the hospital where the pt was not intubated.
I have been out of the ED for 15 years, have you guys ever seen a successful resuscitation where there wasn't an advanced airway in place and positive pressure ventilation being given?
Pediatrics/Witnessed arrest with immediate compressions/drug OD given Narcan does not count.

[dustyrebel]

Justamedic- Our previous Medical Director was very evidence based in her thought process in regards to protocols. We switched to this style of running codes about 4-5 years ago. Our save rates have increased. We have increased CPC scores of the patients that leave the hospital. I can send you our protocol and training materials on this Pit Crew style resuscitation if you would like.

CRNA- I can only speak of personal experience, but I don't think that there is a huge difference in survivor rates when pt are intubated, or having an OPA and good ventilations provided.

[O_Pos]

Originally Posted by justamedic

Is this evidence based?

As I mentioned above, the evidence is all over the place, which is why there was no change in the official broad-based consensus recommendation, although some EMS systems made the transition in practice.

The Resuscitation Outcomes Consortium found that "cardiopulmonary resuscitation (CPR) administered by emergency medical services (EMS) providers following sudden cardiac arrest that combines chest compressions with interruptions for ventilation resulted in longer survival times and shorter hospital stays than CPR that uses continuous chest compressions. Although compressions with pauses for ventilation lead to more hospital-free days within 30 days of the cardiac arrest, both methods achieved similar overall survival to hospital discharge."

The American Heart Association International Liaison Committee on Resuscitation stated in the newest ECC guidelines that: "For witnessed OHCA with a shockable rhythm, it may be reasonable for emergency medical service (EMS) systems with priority-based, multi-tiered response to delay positive-pressure ventilation by using a strategy of up to 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts (Class IIb, LOE C-LD). We do not recommend the routine use of passive ventilation techniques during conventional CPR for adults, because the usefulness/effectiveness of these techniques is unknown (Class IIb, LOE C-EO). However, in EMS systems that use bundles of care involving continuous chest compressions, the use of passive ventilation techniques may be considered as part of that bundle (Class IIb, LOE C-LD)."

https://roc.uwctc.org/tiki/tiki-download_file.php?fileId=20208
http://circ.ahajournals.org/content/132/18_suppl_2.toc

[justamedic]

Interesting stuff there O Pos. Thanks for the post.
The jury is still out on just what works absolutely best for viable resuscitation. Interested to see what new technologies/science will help us better understand to help others in the coming years.

Dusty, thank you. We practice pit crew style efforts during codes as well. The survival from OHCA to discharge numbers improved as well. A problem I see with many medical providers from BLS to ALS and beyond that skews the data is starting resuscitation measures on those where it is simply futile.

I was more asking about the shift to CCR vs. standard ALS/ACLS CPR, as I had not heard of that distinction with those parameters. Locally, we were to begin CPR with a BLS airway and NRB for the first two minutes prior to attempting to intubate. The only distinction in protocols was traumatic arrest vs. full arrest, not considering the cause of non-traumatic arrest until well into the ALCS Hs & Ts. And as always, the better providers tend to take things into account rather than be a cook book medic.

[MWL]

It is important not to forget that correct compression depth is just as important as compression rate.

The holy trinity in CPR is rate, depth and flow time.

I have worked in two different services. One that ran codes with 3 to 5 responders, ET tubes, drugs, IVs, etc., in addition to CPR and defibs, and one that uses KLTs with CPR and defibs, usually with only 2 responders.

We have seen our ROSC rate improve noticeably using only CPR, defib and KLTs, with the only variable being increases in compression depth, with changes in compression rate and flow time being minimal.

Our priorities are to have 1 responder provide good CPR (rate, depth, flow time) while the other runs the defib, and gets a KLT in asap. After the KLT is inserted, the 2 responders perform asynchronous CPR, and after 20 minutes with no ROSC and no shock advised, if the EtCO2 is <10mmHg, we call it.

I think I'm at about 6 for 50+.

Regards.

Mark

[1RiserSlip]

I was initially certified in CPR in 1981. Lots of small changes in procedures throughout the years. Was certified a BLS Instructor in 03 thru the AHA & ARC. Until I read this thread I was unaware of the teaching of using popular songs as a standardization for compression ratios. Very good idea with the recent changes with more emphasis on compressions.

While driving the other day listening to the radio... I heard many songs that could actually be used. I'm sure there are lots of them. But understand the need to use a standardized one for instruction.

One thing though. I still conduct a patient survey, find out as much as I can, give the 2 initial breaths to check the chest rise or fall to determine airway blockage. After using compressions as currently taught, I still use a couple breadths now & then. This works for me. Much easier w/2 man cpr

Old school I guess, but works for me.

[MWL]

It is no longer ABC (Airway, Breathing, Circulation).

It is now CAB (Circulation, Airway, Breathing).

So no more look, listen and feel for breathing.

Check for hazards.
Check for response.
If no response, call for help.
Look for signs of life for non-medical persons; or 10 second pulse check while looking for any signs of breathing for medical professionals.
Straight into chest compressions if necessary.
Continual compressions at 100 to 120 per minute (and 2 inches depth) for non-medical persons; 30 compressions at 100 to 120 per minute, followed by two breaths (just enough to see chest rise), for medical professionals .
Rinse and repeat.



Regards.

Mark

[1RiserSlip]

I find 311 "Down" works well for compression ratio.
To each his own I guess.