Call 911 and start compressions

[IJ]

"Compressions only is ok for the average uninformed person, but every little bit helps."

True, every little bit helps, but the question is whether we need a little bit more compressions (no separate breaths and no time wasted switching) or a little bit more air. The rate limiting step here is circulation, not ventilation.

[Bill Glasheen]

Can anyone say Nosocomial infection?

If at all possible, don't stay in a hospital. Any bug you pick up there is likely to be resistant to most antibiotics known to man.

It could be worse... In 1993 I spent 10 days in Russia and Estonia. Just before leaving, a native Russian friend of mine who was a visiting Prof at Medical College of Virginia said "Don't get sick!" He wasn't kidding. We take so much for granted here. Typical community hospitals there have no A/C so they leave the windows open where flies can come in and crawl on your wounds. Nurses don't use gloves. Syringes are washed and reused. Etc., etc.

- Bill

[Bill Glasheen]

"Compressions only is ok for the average uninformed person, but every little bit helps."

True, every little bit helps, but the question is whether we need a little bit more compressions (no separate breaths and no time wasted switching) or a little bit more air. The rate limiting step here is circulation, not ventilation.

Ian

I get the impression from the direct research I observed and this expert quoted here that one size does not fit all. With some populations, the breaths are more important than others.

It's also important to note that you ARE breathing the person (passively) when you compress. The real question then comes to one of numbers. How much do you need of this, how much of that, with how much "juice", and under what conditions?

Technique is important. When i took my first CPR class and started working on the dummy, the instructor worried that I was going to break it. Meanwhile, others might not put enough caffeine into the compressions. Then you get into the issue of the elderly and their bone mineral density. Yes, bones will be broken. But it's better to have broken ribs and a working heart than a better-looking corpse.

Babies? Another set of techniques altogether. They are easier to break in a nonrecoverable way.

Your overarching point though is well taken.

- Bill

[IJ]

There are definitely tradeoffs. But we don't tend to see 2 breaths per 15 compressions making sense anymore. Look at this animal data from 2005 guidelines, suggests that 2 breaths per 100 compressions might make more sense AFTER 4 minutes. Writing in hurry and generalizing here...

It is important to acknowledge that during cardiac arrest
without lung inflation and ventilation, there is a continuous
decrement of blood oxygen saturation. At some point in time,
the possible hemodynamic advantage conferred by continuous
chest compressions (without ventilations) will be offset
by this reduction in oxygen saturation, and the ultimate result
will be a compromise in oxygen delivery. One porcine
cardiac arrest study18 (3 minutes of untreated ventricular
fibrillation, then 12 minutes of CPR) suggests that after 4
minutes of continuous chest compressions without rescue
breathing, the delivery of 2 rescue breaths every 100 compressions
provides a survival advantage over chest compressions
alone (LOE 6*).

See the link to Circulation 2005 in http://depts.washington.edu/learncpr/

As for broken ribs--they're good! If you're not doing it hard you might as well not bother. Something for people to think about when they sign living wills.

[Jason Rees]

They tell you you're only supposed to go a certain depth on the compressions... but I don't think that's taking into consideration the size of some of the people needing this these days.

[Van Canna]

Maloney and Bridget are in town...tonight we met and it turns out Maloney is certified in CPR...I saw the card.

He said the latest instructions were to only compress and not ventilate.

[Bill Glasheen]

Maloney and Bridget are in town...tonight we met and it turns out Maloney is certified in CPR...I saw the card.

He said the latest instructions were to only compress and not ventilate.

I know, Van. They can't make up their minds.

To sum it up... The compressions are the most important part. You serendipitously ventilate someone to some extent with the compressions. (This point keeps getting missed in this discussion.) IF YOU PRACTICE, then throwing in some breaths will help. But you either do it right or don't do it at all.

You can't be squeamish about the mouth-to-mouth. If you find yourself hesitating, just forget about it and do the compressions. In our germaphobia world with the fancy devices being invented to put in-between mouths when doing this as an EMT, it gets a bit absurd. You can see the leaders of the field getting frustrated and deciding that it's better to do something than to hesitate and have somebody die with folks standing around watching and looking for a damn breathing apparatus.

- Bill

[Jason Rees]

Heh. Maybe they have completely flipped over for this outside the healthcare setting. My classes have always been for healthcare providers, and I just recertified a month ago.

[Van Canna]

Good points Bill...I agree. And as you said...Maloney pointed out that even with CPR the victim only has a 10..20% chance...better than nothing...right?

[Bill Glasheen]

Maybe they have completely flipped over for this outside the healthcare setting. My classes have always been for healthcare providers, and I just recertified a month ago.

That could be, Jason. The less experienced you are, the more the breathing trips up the rhythm. You're a professional and know your stuff. Not so much with people outside the healthcare field.

Good points Bill...I agree. And as you said...Maloney pointed out that even with CPR the victim only has a 10..20% chance...better than nothing...right?

Something's better than nothing.

As for the odds... It depends on the patient (how bad the heart problem), it depends upon the amount of time receiving compressions before being defibrillated, and it depends upon the skill of the CPR giver.

On a side note... I have problems with one of my students breathing right in his karate. He's retired, and has made it very clear he's a DNR if he drops. Just to mess with him, I told him that if he messes up his breathing and it causes him to have a heart attack, I'd get the most junior student to practice CPR on him and he just might have to live with the results. And of course there would be nothing he could do to stop us.

Morbid humor works.

FWIW, we have an automatic defibrillator in our gym about 30 feet from the training room. All gyms should have one.

- Bill

[Jason Rees]

FWIW, we have an automatic defibrillator in our gym about 30 feet from the training room. All gyms should have one.

- Bill

Agreed.

[IJ]

At the last SHM national meeting, there was an excellent review of CPR physiology and recommendations for healthcare professionals and THERE the focus is still, prime the pump and spare the air. At this point, they're not saying don't ventilate the patient; there's multiple pairs of hands to help, O2 right there, bag mask equipment. But they are saying we ventilate too much, too often, and at the expense of compressions, and as for those, they're too shallow, too slow, and too often interrupted. In some cases survival goes DOWN with AEDs in paramedics toolkits because the compressions cease while people play with the box for minutes. Even when defibrillation can be lifesaving, it matters whether the heart is primed to return to function by a minute or two of CPR (unless shock can be administered almost immediately) before the shock is given ("prime the pump").

I think I now have video access to the talk, I'll see if I can distribute it or at least review it. He's a funny speaker too.

[Jason Rees]

At ACLS the focus was definitely on the chest compressions, and if you stopped chest compressions to do things like place the pads, you failed. Breaths too, but the chest compressions were pounded relentlessly. They tested us on that the first day, because without that, all the medications and questions in the world wouldn't save them.

[Bruise Lee]

I can remember taking a cardiology for first responders class in 2006 when I was near graduating medical school - and they were telling us that the guidelines would go from CPR to CCR (continuous chest compressions) largely because of research from U of A. Most such emergencies are not pulmonary arrest (such as drowing or choking on a olive) but cardiac arrest - in which getting the heart moving blood is the thing.

Plus the research showed that when compressing the chest, it caused some air to move in and out of the lungs anyway - the lungs are next to the heart inside the rib cage.

Keeping blood flowing to the brain was the key point, and when you stop to do respirations you have stopped blood from flowing to the brain from compressions. THe research also showed that it took several compressions to get blood moving enough to push it from the heart to the brain, so even after you had begun compressions again it was still longer before you actually pushed fresh oxygenated blood into the brain. But the circulation stopped immediately when compressions were stopped.

Other studies showed many would not do ANY CPR in a real emergency because so many people puke when unconscious - or they just hated mouth to mouth contact. This is remembering statistics from 3 years ago, but something like only 45% of trained health professionals in this country would actually do CPR without a face mask in an emergency, something like 25% of civilians said they would. In Japan the numbers were worse - only something like 13% of the health care providers would do it.

With CCR its also hoped that more people would stop and help since all they have to do is chest compressions. One study in China showed thoracic compressions worked even if the person was prone (face down) - compressing between the shoulder blades still compressed the thorax (chest) enough. Plus if they (when they) vomited they were less likely to aspirate. I am not recommending this - and I am speaking from memory from 3 years ago

Anyone who can do mouth to mouth on a foamy person having a seizure deserves a medal.

[Bruise Lee]

Oh, in June my ACLS, PALS, BLS certification expires.