New Life saving technique

[gmattson]

Continuous chest compressing - Worth checking out!

http://www.youtube.com/v/E5huVSebZpM&hl=en_US&fs=1

[Van Canna]

This is excellent.

I now have another use for the 'Bob' striking dummy at the dojo.

Just roll it on the ground and practice.

[Bill Glasheen]

Hey, George!

I'm frankly scratching my head about this new trend. Part of me wonders if ditching the breaths is related to a reluctance on the part of the administrator to do mouth-to-mouth for fear of "cooties."

For 5 to 10 minutes? OK. Longer? Gonna need either a breath bag or the lip lock. Otherwise forgetaboutit.

- Bill

[Van Canna]

Sarver Heart Center researchers discovered years ago that overwhelming numbers of people will not perform bystander resuscitation (CPR) because they do not want to do mouth-to-mouth breathing.

More recent research has found that stopping continuous chest compressions for any reason, including so called, “rescue breathing” is actually detrimental. They found that the time it takes to deliver the two 2005 Guidelines recommend two breaths interrupted chest compressions for an average of 16 seconds.

This interruption of chest compression was found to be lethal. For during chest compressions for cardiac arrest the forward blood flow generated is so marginal that any interruption, including that for ventilation is harmful.

The guidelines changed in 2005 from recommended 2 ventilations for every 15 chest compressions to 30 chest compressions for every 2 ventilations.

While this approach provided more chest compression, the research at the Sarver Heart Center has shown that chest compression only resuscitation still results in better neurological survival.

Chest compression only bystander is only the lay component of Cardiocerebral Resuscitation, an entirely new approach to out-of hospital cardiac arrest that has been shown in two separate observational studies to increase survival of witnessed cardiac arrest with a shockable rhythm on arrival of the paramedic/firefighters by over 300%.

???

[Jason Rees]

Continuous chest compressions helps the untrained, unwilling, or otherwise compromised layperson to perform the bare minimum.

Nothing will change for healthcare providers.

[IJ]

There are many reasonable sounding interventions that do not work well in practice. It turns out that physicians cannot reliably determine if someone has a pulse or not (eg, is on cardiac bypass) when blinded to pulse presence in controlled settings in the OR when they are allowed sufficient time. Accuracy during a cardiac arrest? Fuhgeddaboudit.

We also know that air moves because of pressure changes. When you compress someone's chest 1.5-2 inches, that creates pressure; that's the whole point, to drive blood out. It only moves net in the right direction because of valves, which is handy. It doesn't work too well. Thus you don't need THAT much oxygen to oxygenate the blood you move. And it is more important to move some blood than to make oxygenated blood that sits in the lungs. And the on/off pressure from compressions does move a fair amount of air. If you've seen an premie ventilated with rapid oscillatory ventilation, you know that just turbulence mixes O2 to the lungs decently; these babies make tremble a bit but the chest doesn't move in and out.

When people stop for breaths EVEN IN THE HOSPITAL with trained staff, then the compressions stop and no blood moves. Even during compressions there is a time resetting to resume and we go too slow and shallow. It makes plenty of sense for me to make this recommendation. Once people have trained providers with mask-bag then endotracheal ventilation, they STILL need to chillax with the ventilations because overventilation reduces blood flow by taking up space in the chest, even if they don't need to stop compressions to breathe anymore. "Prime the pump SPARE THE AIR" is the cutting edge IN HOSPITAL strategy--it's a definite with bystanders.

[Bill Glasheen]

I'm with Jason here. For the life of me, I can't figure out how it's taking "16 seconds" to do two breaths. Bunch of spazzes.

But then I've seen the average beginner in a karate class....

Good point about turbulent air flow, Ian. That's the only intelligent argument made so far. The rest is total bullschit. I should know, as we did this research in the cardiology dog lab (both with dogs and pigs).

I wouldn't hesitate to throw in a few breaths. If you have 2 people working together, it's even easier.

And as for the mouth cooties part, well... When it comes to someone else's life, I get over that pretty quickly. But that's me.

- Bill

[Jason Rees]

I actually carry a clear plastic faceshield most of the time. It's incredibly portable.

[kyushoguy]

It's the way I was taught last year when I updated my First Aid so the new method is being taught in the uk already.

The Japs came up with it in their research.

Theyre not botthered about 'cooties' Bill whatever they are they are worried about contracting Aids.

[Bill Glasheen]

It's the way I was taught last year when I updated my First Aid so the new method is being taught in the uk already.

Yea... Here's another good public education project.

Duck and Cover

The Japs came up with it in their research

Theyre not botthered about 'cooties' Bill whatever they are they are worried about contracting Aids.

FWIW, kyushoguy, "cooties" is vernacular for viral, fungal, bacterial, or other infection.

Meanwhile...









I rest my case.

- Bill

P.S. Are you going to reveal your name, or are you going to continue to post anonymously? Fair is fair. If you want to post as an authority, references are required.

[IJ]

This is about what works, and what doesn't; things aren't "total bullschit" based on how we feel about them, but rather how they perform. One of the reasons the change came about is because people doing CPR noticed their loved ones regaining consciouness during compressions and losing it during respirations. I guess that's no surprise given the cessation of circulation and tenous assistance CPR offers anyway.

It makes sense to check a pulse in an evaluation of unresponsiveness; fat is, however, that we are inaccurate even under better circumstances. It makes sense to ventilate, but even trained people take too long switching. Two slow deep breaths and jaw positioning and moving your body means a break from circulation. The judgement of those teaching this is that the incremental oxygen isn't needed because the CPR doesn't move enough to require it and circulation of blood is primary.

With two people, it makes a bit more sense to try respirations, but at least don't let the compressor take his or her hands out of position or stop for more than a flash. Our perception of time is very poor in such circumstances.

And we all know you don't get AIDS (or HIV) from mouth to mouth unless there's visibly bloody fluid, right? Even with a needle stick IF the peson HAS HIV then the risk is ~1/200.

[Bill Glasheen]

This is about what works, and what doesn't; things aren't "total bullschit" based on how we feel about them, but rather how they perform.

So I take it that you'd believe invasive lab data done on pigs and dogs, no?

I'm calling bullschit on your calling my bullschit, Ian.

• "On March 31, 2008, the American Heart Association changed its guidelines to include hands-only CPR, a new version using chest compressions only. Hands-only CPR is intended for untrained rescuers and only for witnessed cardiac arrest." Wow... isn't that what Jason just said? Do you think Jason just made that up, Ian?
• There is a significant amount of oxygen in the bloodstream capable of sustaining brain tissue for several minutes, even without breathing. Proponents of doing CPR without rescue breathing argue that continuous chest compressions get blood flowing better than chest compressions interrupted by rescue breaths, and that blood flow is the only way oxygen can reach vital organs such as the brain.
  
  HOWEVER....
  
  "Not all cardiac arrests are from a diseased heart. Sometimes, drowning or drug overdoses cause respiratory arrest that leads to cardiac arrest. In those cases, rescue breathing is an important part of resuscitation efforts."
  
  In other words... If you haven't witnessed an actual cardiac event AND you are capable of doing chest compressions with rescue breathing, then hands-only CPR is bad medicine.
• If you expect to do CPR for more than a few minutes, then you're going to use up the residual oxygen in the blood with rescue-only breathing. Do you expect it to take at least 20 minutes before rescue personnel to arrive with a defibrillator? Then not doing rescue breathing means you are breaking ribs and busting your butt for nothing. They're going to die anyhow.

- Bill

References:

Brouhard, R. "The Demise of Rescue Breathing in CPR?" About.com Guide Apri 2008

Kellum, MJ, KW Kennedy and GA Ewy. "Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest." Am J Med. Apr 2006

Nagao, Ken, The SOS-KANTO Committee. "Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study." The Lancet. 17 Mar 2007

[kyushoguy]

Saliva transfer is minimal, but how many people have little cuts on or round their mouth?
you wanna risk it?
I bet not.

Bill chill out. Who said I was an authority I'm giving my opinion, it's allowed isn't it.

My name will mean nothing to you, as yours does to me.

[IJ]

I'm calling bullschit on your calling bullschit on me calling bullschit on you. To recap, a novel recommendation was discussed, and you said,

"I'm frankly scratching my head about this new trend. Part of me wonders if ditching the breaths is related to a reluctance on the part of the administrator to do mouth-to-mouth for fear of "cooties."" You added, "Good point about turbulent air flow, Ian. That's the only intelligent argument made so far. The rest is total bullschit. I should know, as we did this research in the cardiology dog lab (both with dogs and pigs). I wouldn't hesitate to throw in a few breaths. If you have 2 people working together, it's even easier."

and JR wrote:

"Continuous chest compressions helps the untrained, unwilling, or otherwise compromised layperson to perform the bare minimum."

So basically, you were suggesting that the change was made because bystanders would be phobic about doing better, breathing added, CPR; you suggested you would ignore the recommendations yourself. JR implied that the new protocol was just simpler, providing the bare minimum, ie that it wasn't optimal care to do just compressions. To prove your point you cite a reference, which I will include the whole abstract of:

"Findings 4068 adult patients who had out-of-hospital cardiac arrest witnessed by bystanders were included; 439 (11%) received cardiac-only resuscitation from bystanders, 712 (18%) conventional CPR, and 2917 (72%) received no bystander CPR. Any resuscitation attempt was associated with a higher proportion having favourable neurological outcomes than no resuscitation (5·0% vs 2·2%, p<0·0001). Cardiac-only resuscitation resulted in a higher proportion of patients with favourable neurological outcomes than conventional CPR in patients with apnoea (6·2% vs 3·1%; p=0·0195), with shockable rhythm (19·4% vs 11·2%, p=0·041), and with resuscitation that started within 4 min of arrest (10·1% vs 5·1%, p=0·0221). However, there was no evidence for any benefit from the addition of mouth-to-mouth ventilation in any subgroup. The adjusted odds ratio for a favourable neurological outcome after cardiac-only resuscitation was 2·2 (95% CI 1·2–4·2) in patients who received any resuscitation from bystanders. Interpretation cardiac-only resuscitation by bystanders is the preferable approach to resuscitation for adult patients with witnessed out-of-hospital cardiac arrest, especially those with apnoea, shockable rhythm, or short periods of untreated arrest. Tokyo, 101-8309, Japan
Kennagao@med.nihon-u.ac.jp"

You are fond of saying you argue best when you argue my point... this study suggests that compression only CPR is superior to CPR with rescue breaths. Interestingly, this was more the case when there was apnea (hey, isn't that what happens when people OD on opiates and have respiratory arrest--contrary to the opinion of the author you cited?), shockable rhythm (basically the people you can actually save; others have terrible prognosis) or short arrest (again, the only people you can actually save).

Your next reference leads me to this abstract:

Am J Med. 2006 Apr;119(4):335-40.
Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest.

Kellum MJ, Kennedy KW, Ewy GA.

Mercy Health System, Janesville, Wis, USA.

PURPOSE: The guidelines for cardiopulmonary resuscitation (CPR) have been in place for decades; but despite their international scope and periodic updates, there has been little improvement in survival rates in out-of-hospital cardiac arrest for patients who did not receive early defibrillation. The Emergency Medical Service directors in 2 rural Wisconsin counties initiated a new protocol for the pre-hospital management of adult cardiac arrest victims in an attempt to improve survival rates. The results observed after implementation of this protocol are presented and compared with those observed during a three-year period that preceded initiation of the project. METHODS: The protocol, based upon the principles of cardiocerebral resuscitation, was significantly different from the standard CPR protocol. A major objective was to minimize interruptions of chest compressions. Each defibrillation, including the first, was preceded by 200 uninterrupted chest compressions. Single shocks, rather than stacked shocks, were utilized. Post shock rhythm and pulse checks were eliminated, and chest compressions were resumed immediately after a shock was delivered. Initial airway management was limited to an oral pharyngeal device and supplemental oxygen. If the arrest was witnessed, assisted ventilations and intubation were delayed until either a return of spontaneous circulation or until three series of "compressions + analysis +/- shock" were completed. RESULTS: In the 3 years preceding the change in protocol, where standard CPR was utilized, there were 92 witnessed out-of-hospital adult cardiac arrests with an initially shockable rhythm. Eighteen patients survived, and 14 of 92 (15%) were neurologically intact. After implementing the new protocol in early 2004, there were 33 witnessed out-of-hospital adult cardiac arrests with an initially shockable rhythm. Nineteen survived, and 16 of 33 (48%) were neurologically normal. Differences in both total and neurologically normal survival are significant (chi-squared = 0.001). CONCLUSION: Instituting the new cardiocerebral resuscitation protocol for managing prehospital cardiac arrest improved survival of adult patients with witnessed cardiac arrest and an initially shockable rhythm.

Wow, that paper suggests that even when trained clinicians are doing the resuscitation, it's best to "prime the pump and spare the air." This is what I've beileved since impressive grand rounds on the issue at UCSD and a talk from a national resuscitation expert at SHM national last May. It does not support using breaths.

You also cite http://firstaid.about.com/od/cprbasics/ ... hcpr_2.htm which is an about.com review which details the information about how compression only CPR improves survival. Compared with giving breaths. Basically it just recaps the two articles we went over.

To answer your questions:
--invasive lab data is one of several types of information considered by guidelines creators and myself
--no, I don't think JR made anything up, but I disagree that a technique associated with improved survival is "the bare minimum."
--do I expect EMS to take 20 minutes to arrive with a defibrillator? Well, if they do, the person is dead no matter what! 2-5% of the patients made it, and I would bet the number is essentially zero if someone lacked a perfusing rhythm for 20 minutes, probably even 10ish.
[/b]

[IJ]

Further reading:

Ann Emerg Med. 2008 Sep;52(3):244-52. Epub 2008 Mar 28.
Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest.

Kellum MJ, Kennedy KW, Barney R, Keilhauer FA, Bellino M, Zuercher M, Ewy GA.

STUDY OBJECTIVE: In an effort to improve neurologically normal survival of victims of cardiac arrest, a new out-of-hospital protocol was implemented by the emergency medical system medical directors in 2 south-central rural Wisconsin counties. The project was undertaken because the existing guidelines for care of such patients, despite their international scope and periodic updates, had not substantially improved survival rates for such patients during nearly 4 decades. METHODS: The neurologic status at or shortly after discharge was documented for adult patients with a witnessed collapse and an initially shockable rhythm. Patients during two 3-year periods were compared. During the 2001 through 2003 period, in which the 2000 American Heart Association guidelines were used, data were collected retrospectively. During the mid-2004 through mid-2007 period, patients were treated according to the principles of cardiocerebral resuscitation. Data for these patients were collected prospectively. Cerebral performance category scores were used to define the neurologic status of survivors, and a score of 1 was considered as "intact" survival. RESULTS: In the 3 years preceding the change in protocol, there were 92 witnessed arrests with an initially shockable rhythm. Eighteen patients survived (20%) and 14 (15%) were neurologically intact. During the 3 years after implementation of the new protocol, there were 89 such patients. Forty-two (47%) survived and 35 (39%) were neurologically intact. CONCLUSION: In adult patients with a witnessed cardiac arrest and an initially shockable rhythm, implementation of an out-of-hospital treatment protocol based on the principles of cardiocerebral resuscitation was associated with a dramatic improvement in neurologically intact survival.

AND:

Circulation. 2009 May 19;119(19):2597-605. Epub 2009 May 4.
Improved patient survival using a modified resuscitation protocol for out-of-hospital cardiac arrest.

Garza AG, Gratton MC, Salomone JA, Lindholm D, McElroy J, Archer R.

BACKGROUND: Cardiac arrest continues to have poor survival in the United States. Recent studies have questioned current practice in resuscitation. Our emergency medical services system made significant changes to the adult cardiac arrest resuscitation protocol, including minimizing chest compression interruptions, increasing the ratio of compressions to ventilation, deemphasizing or delaying intubation, and advocating chest compressions before initial countershock. METHODS AND RESULTS: This retrospective observational cohort study reviewed all adult primary ventricular fibrillation and pulseless ventricular tachycardia cardiac arrests 36 months before and 12 months after the protocol change. Primary outcome was survival to discharge; secondary outcomes were return of spontaneous circulation and cerebral performance category. Survival of out-of-hospital arrest of presumed primary cardiac origin improved from 7.5% (82 of 1097) in the historical cohort to 13.9% (47 of 339) in the revised protocol cohort (odds ratio, 1.80; 95% confidence interval, 1.19 to 2.70). Similar increases in return of spontaneous circulation were achieved for the subset of witnessed cardiac arrest patients with initial rhythm of ventricular fibrillation from 37.8% (54 of 143) to 59.6% (34 of 57) (odds ratio, 2.44; 95% confidence interval, 1.24 to 4.80). Survival to hospital discharge also improved from an unadjusted survival rate of 22.4% (32 of 143) to 43.9% (25 of 57) (odds ratio, 2.71; 95% confidence interval, 1.34 to 1.59) with the protocol. Of the 25 survivors, 88% (n=22) had favorable cerebral performance categories on discharge. CONCLUSIONS: The changes to our prehospital protocol for adult cardiac arrest that optimized chest compressions and reduced disruptions increased the return of spontaneous circulation and survival to discharge in our patient population. These changes should be further evaluated for improving survival of out-of-hospital cardiac arrest patients.

AND

J Am Coll Cardiol. 2009 Jan 13;53(2):149-57.
Recent advances in cardiopulmonary resuscitation: cardiocerebral resuscitation.

Ewy GA, Kern KB

Cardiocerebral resuscitation (CCR) is a new approach for resuscitation of patients with cardiac arrest. It is composed of 3 components: 1) continuous chest compressions for bystander resuscitation; 2) a new emergency medical services (EMS) algorithm; and 3) aggressive post-resuscitation care. The first 2 components of CCR were first instituted in 2003 in Tucson, Arizona; in 2004 in the Rock and Walworth counties of Wisconsin; and in 2005 in the Phoenix, Arizona, metropolitan area. The CCR method has been shown to dramatically improve survival in the subset of patients most likely to survive: those with witnessed arrest and shockable rhythm on arrival of EMS. The CCR method advocates continuous chest compressions without mouth-to-mouth ventilations for witnessed cardiac arrest. It advocates either prompt or delayed defibrillation, based on the 3-phase time-sensitive model of ventricular fibrillation (VF) articulated by Weisfeldt and Becker. For bystanders with access to automated external defibrillators and EMS personnel who arrive during the electrical phase (i.e., the first 4 or 5 min of VF arrest), the delivery of prompt defibrillator shock is recommended. However, EMS personnel most often arrive after the electrical phase -- in the circulatory phase of VF arrest. During the circulatory phase of VF arrest, the fibrillating myocardium has used up much of its energy stores, and chest compressions that perfuse the heart are mandatory prior to and immediately after a defibrillator shock. Endotracheal intubation is delayed, excessive ventilations are avoided, and early-administration epinephrine is advocated.

Since you mentioned the pigs....

Circulation. 2007 Nov 27;116(22):2525-30. Epub 2007 Nov 12.
Improved neurological outcome with continuous chest compressions compared with 30:2 compressions-to-ventilations cardiopulmonary resuscitation in a realistic swine model of out-of-hospital cardiac arrest.

Ewy GA, Zuercher M, Hilwig RW, Sanders AB, Berg RA, Otto CW, Hayes MM, Kern KB.

BACKGROUND: The 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care changed the previous ventilations-to-chest-compression algorithm for bystander cardiopulmonary resuscitation (CPR) from 2 ventilations before each 15 chest compressions (2:15 CPR) to 30 chest compressions before 2 ventilations (30:2 CPR). It was acknowledged in the guidelines that the change was based on a consensus rather than clear evidence. This study was designed to compare 24-hour neurologically normal survival between the initial applications of continuous chest compressions without assisted ventilations with 30:2 CPR in a swine model of witnessed out-of-hospital ventricular fibrillation cardiac arrest. METHODS AND RESULTS: Sixty-four animals underwent 12 minutes of ventricular fibrillation before defibrillation attempts. They were divided into 4 groups, each with increasing durations (3, 4, 5, and 6 minutes, respectively) of untreated ventricular fibrillation before the initiation of bystander resuscitation consisting of either continuous chest compression or 30:2 CPR. After the various untreated ventricular durations plus bystander resuscitation durations, all animals were given the first defibrillation attempt 12 minutes after the induction of ventricular fibrillation, followed by the 2005 guideline-recommended advanced cardiac life support. Neurologically normal survival at 24 hours after resuscitation was observed in 23 of 33 (70%) of the animals in the continuous chest compression groups but in only 13 of 31 (42%) of the 30:2 CPR groups (P=0.025). CONCLUSIONS: In a realistic model of out-of-hospital ventricular fibrillation cardiac arrest, initial bystander administration of continuous chest compressions without assisted ventilations resulted in significantly better 24-hour postresuscitation neurologically normal survival than did the initial bystander administration of 2005 guideline-recommended 30:2 CPR.