The entire purpose of CPR is to get some oxygenated blood through the brain so that there is someone worth saving when help arrives.
CPR is often not performed in time, or well enough, and is likely not a 100% direct replacement for normal breathing; so permanent brain damage is likely even if the person is revived. I don't know if the de-emphasis on rescue breathing makes a difference.
The de-emphasis on rescue breathing was the biggest advance in CPR since it began.
No non-anesthesiologist can do this effectively (even in Advanced Life Support recertification classes, anesthesiologists — including me — struggled to achieve adequate air exchange with rescue breathing on a mannequin, which is far easier than on an unconscious person).
Full energy and attention and effort keeping up deep regular chest compressions at witnessed or just-occurred out of hospital cardiac arrest/loss of consciousness events stands the best chance of a good outcome.
Critical care paramedic. Even when we arrive on scene, airway management and ventilation is a "distant" priority behind defibrillation and effective compressions.
> No non-anesthesiologist can do this effectively (even in Advanced Life Support recertification classes, anesthesiologists — including me — struggled to achieve adequate air exchange with rescue breathing on a mannequin, which is far easier than on an unconscious person).
Hah, and I guarantee your mannequins are far nicer than ours - we do have some Sim-Men for our ALS providers, but BLS providers etc. are practicing on "cheap" mannequins that you either need to artificially hyper-rotate the head back to get air exchange into the 'lungs'.
The citizen CPR classes I teach (well, to providers, too) - the rough rule of thumb is that "for each minute of arrest, the chance of survival goes down 10%", which roughly correlates with my understanding that our blood is generally sufficiently oxygenated for about 7-8 minutes of compressions.
> In-hospital arrests are almost universally fatal.
As are out-of-hospital traumatic arrests.
Other random facts, comments, etc.:
- Start compressions, have someone call 911 (if alone, call and go on speaker, put it down beside you). As soon as you have a defib available, use it, zero delay.
- Contrary to TV and the movies, defibrillation is not like jump starting a car. If the battery is dead, so to speak, that doesn't work. The best analogy for tech people is this: the heart is malfunctioning. If your computer is malfunctioning, you'd ultimately hit Ctrl-Alt-Delete, reboot, and see what happens. That's defibrillation - apply sufficient energy to cause the various nodes of the heart (I'm not being precise here, but trying to explain more easily) to 'failsafe' and reboot, and try to bring about an organized electric current to flow through those nodes to get a coordinated muscle contraction that makes up a pulse.
- You are generally not breaking ribs. You're separating cartilage from the sternum. This is "not a concern".
- Compressions are 1/3 to 1/2 the depth of the chest. If you're not sure, or worried, go deeper (unless it's a little old lady who weighs 80lb, it's pretty difficult to go "too deep").
- If the person is unresponsive, to vigorous stimuli, start CPR. Don't try looking for a pulse. It is difficult to describe to a lay person over the phone where to find the carotids (and do not rely on TV shows to be of any assistance). Contrary to popular belief, doing CPR on someone who actually still has a pulse is -not- a problem. In fact, EMS will continue chest compressions after getting ROSC (return of spontaneous circulation) for a CPR cycle to "support" circulation.
- Once you start CPR, don't stop. Yes, it's hard work. We rotate compressors every two minutes because quality declines. But if you're alone, yeah, it's going to suck, but keep going. It takes about a minute and a half of compressions to build up effective blood pressure for perfusion (because you pushing through the chest wall is obviously less effective than the squeeze of the left ventricle), and only about 8 seconds of no CPR to lose that work. -Even when EMS arrives- they'll tell you to continue CPR until we are literally ready to switch in beside you.
- In adults - realize that we're not "fixing" anything. ROSC is a good "outcome", especially in the field. But we didn't clear the blood vessels of plaque. The fixes for arrest happen in the cath lab or theater. It is entirely possible (and really, the default) that the person will re-arrest while we're packaging or transporting the patient.
- In children, there are two major causes of cardiac arrest: 1) congenital heart defect (known or unknown), or 2) FBAO (foreign body airway obstruction) and similar things, like near-drowning events. For number 2, the merciful aspect is that if the root problem is solved, re-arrest is unlikely. If something is blocking the airway, and is subsequently vomited up, or dislodged by compressions, the problem "goes away".
- Work to the side of your patient. Don't lean over their face or head. That's a good way to get sometimes fairly forceful bloody vomit in your direction. Expect potential incontinence of bladder or even bowel (to quote a gruff instructor I had, "they can't control the function of their heart, what makes you think the muscle tone of the bladder is a higher priority for the body?").
Also, on a personal note, I am very appreciative to the anesthesiologists I know who have been instrumental in my initial and ongoing education for your assistance and teachings as we learn and practiced tube placement in theater.
> doing CPR on someone who actually still has a pulse is -not- a problem
Unless they wake up and say "Ow! Quit doing that." This is very unlikely but it happened to me once when we had a patient who had OD'd on something (we didn't know what) so we gave him Narcan and boom! He's wide awake and complaining that his ribs hurt.
Narcan is extremely potent. While our LE and EMTs carry IN (nasal) Narcan, our Medical Director actually prefers us to gently titrate IV Narcan while providing airway management and ventilation. His perspective is that 1) that makes life a lot easier for everyone involved, because sometimes those patients "come up swinging", and 2) there's a hope that if even a few per cent of those patients are gently roused by the time they get to the ER, they may be more willing to consider addiction help.
But, funny story on what you said: a call for some teens in a park drinking, one is now unconscious. "We think he's had a heart attack!" Dispatcher: "are you sure, not just black out drunk?" (not a good thing, but still). "No, we can't find a pulse...". Dispatcher starts walking them through phone CPR while dispatching us. A few minutes later, some commotion on the phone. "What's happening?" "We're having a really hard time giving him CPR!" "Why?" "He keeps pushing us away and telling us to leave him alone but you said we cannot stop no matter what!"
And on a more serious note, you can have situations where a patient is (mildly) conscious through CPR. We had a patient who had internal bleeding that we were attempting to stabilize to get to theater. He was able to squeeze his wife's hand when she talked to him through our compressions.
> Narcan is extremely potent. While our LE and EMTs carry IN (nasal) Narcan, our Medical Director actually prefers us to gently titrate IV Narcan while providing airway management and ventilation. His perspective is that 1) that makes life a lot easier for everyone involved, because sometimes those patients "come up swinging", and 2) there's a hope that if even a few per cent of those patients are gently roused by the time they get to the ER, they may be more willing to consider addiction help.
Sorry, can you explain this a bit more? Why would a patient who wakes up more gently be more willing to consider addiction help?
Probably not because it's more gentle in itself. More that the experience isn't immediately "antagonistic" with law enforcement presence, the sudden rush of being brought out of the narcotic stupor (well, respiratory depression), in a often less-than-ideal environment.
To be very real, most people that we get to the ER and they take over bringing up the Narcan until that respiratory drive kicks back in (kinda a sleepy morning wakeup feeling), will still AMA and leave. But some may consider or talk about it a bit. And maybe there's a more positive longer term outcome.
Completely agree about the wisdom of Narcan titration when you are able to do it. If you give them too much they can wake up swinging fists because you just ruined the heroin/fentanyl/whatever high they paid $20 for. And in that moment they won't be especially receptive to platitudes like "Dude, you died and I just brought you back to life."
And then 20 minutes later the Narcan will wear off and they can crash again, and you're back to square one.
That's hilarious about the teens. Teens don't have heart attacks. And you can never count on people having common sense.
I love our dispatchers. They work as hard as we do.
I'm not a doctor, but I watch some on YouTube and that practically makes me an expert right? I'd heard that the chest compressions only is preferred now with the exception of potential drowning victims because you're much less certain about the existing oxygen supply in the blood. Is that the case?
