Are you certain you have the order correct?

If I ever code, chest compressions only please.

We were told to do 30:2 on adults until we could intubate them, and were told to only do compressions-only if absolutely necessary.

1 – Must be an adult who collapsed on dry land.
2 – Must NOT be a child, or a drowning victim.

The airport has had a few lives saved … whoever responds does compression-only until the EMTs get there, or someone brings the AED off the wall.

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@groovydoc … my instructor made it very clear that it was more likely than not to be unsuccessful unless we were “lucky” enough to see the initial collapse and be in an area with fast emergency response times.

I recall there was an incident on an airplane where someone tried to use the AED and claimed it was faulty when in fact it was probably working fine, it just wasn’t a situation it could treat (I was probably thinking of this story http://consumerist.com/2008/02/american-airlines-disputes-empty-oxygen-tank-story.html).

AEDs that are found in public are very limited devices. The key words of the acronym are Automated and Defibrillator. You generally place pads on the patient press a button and stand back. Meanwhile the machine checks for fibrillation only if it detects such a condition (and maybe one or two other situations such as tachycardia) does it apply an appropriate shock. If it detects other rhythms it will not shock and cannot be overridden.

The inexperienced observer may have trouble distinguishing massive blood loss from minimal blood loss (a little bit might look like a lot).

Or, in the case of internal loss, even the experienced will have trouble. The most reliable indicator, as always, is when the patient acts like she’s losing blood — never mind where it’s going.

It would be interesting to investigate outcomes of CPR and AED usage on airplanes. The airline I’m familiar with has trained all Flight Attendants in CPR and equipped all airplanes with AEDs. Was it worth the expense?

Consider that none of the airlines that I know of carry enough oxygen outside of the cockpit to keep a patient supplied at 15 l/m until the plane is down and can transfer to an ambulance. So you tell me how serious they are about emergency life support.

CPR doesn’t fix cancer, copd, heart failure, or most of the other common end of life diagnoses. Yet, if I had a nickel for every time I was told “Of course I want to live,” or “do everything,” or “dad’s a fighter,” I’d own my own tropical island. Strangely, I’ve never once heard the words, “I was there when they coded mom/dad, and I want you to do that for me too.”

I think CPR courses should spend a bit more time making it clear that in most cases, death is natural, and can be approached with the goal of comfort, rather than “heroic” measures.

The risk of disease transmission is very low. There have been no cases of HIV or Hepatitis transmission due to CPR. A PDF from ILCOR can be found here on disease transmission http://www.americanheart.org/presenter.jhtml?identifier=3068747

Another analysis
http://www.americanheart.org/presenter.jhtml?identifier=3065180

States

Evidence from three studies (LOE1)[Bertrand 2006 p843], (LOE 2)[Saissy 2000 p1523], (LOE 5)[Krischer 1989 p1263],
fails to consistently show improvement in survival to hospital discharge when compression only CPR (compared to
conventional CPR) is administered by professionals to adult patients with an out-of-hospital cardiac arrest.

Evidence from eight human studies (LOE5) in which off-duty EMS professionals could have been reflected in the study
population [Bohm 2007 2908, Bosseart 1989 pS99, Holmberg 2001 511, Iwami 2007 p2900, Nagao 2007 p920, Van
Hoeyweghen 1993 p47, Waalewijn 2001 p273, Wik 1994 p195] document consistent improvement in survival to hospital
discharge when compression only bystander CPR compared to no bystander CPR is administered by trained
bystanders to patients with an out-of-hospital witnessed adult cardiac arrest.]. From these studies, there is no
consistent or statistically significant evidence to document that compression only CPR is superior to conventional CPR
for out-of-hospital witnessed adult cardiac arrest. Although not tested in a formal equivalence trial or non-inferiority trial,
the evidence does not demonstrate a statistically significant difference between compression only CPR and
conventional CPR by trained bystanders.
Evidence from thirteen mathematical/educational studies show reasonably supporting evidence favoring compression
only CPR.

Evidence from 16 animal studies documents supporting evidence for compression only CPR in the animal model, but
has methodological limitations, which limits the application to the human resuscitation condition

The evidence does not support, compression only CPR in the pediatric, asphyxiated, drowning, airway obstruction,
unwitnessed, or delayed resuscitation.

In my opinion in an emergency situation there are many difficult decisions for the rescuer to remember. It is important to make these decisions as easy as possible. One of the reasons 30:2 was chosen for all types of CPR for lay rescuers was that it eliminated having to remember whether to do 15:2 or 5:1. People would be confused and be unwilling perform CPR if they couldn’t remember the proper ratio.

The 75% must be of the 25-33% who survive to discharge? Or is it of the half who survive the initial arrest event?

Thanks for the great article. It leads to more questions about the propriety of requesting a DNR order. (Do Not Resuscitate)

When a person is elderly (over 85) with numerous medical problems, none of which are directly life threatening or terminal, but which have resulted in a greatly diminished quality of life, is CPR worth the effort when it is unlikely to work, and may result in additional complications, pain, and neurological deficits (brain damage)?

It would be interesting to investigate outcomes of CPR and AED usage on airplanes. The airline I’m familiar with has trained all Flight Attendants in CPR and equipped all airplanes with AEDs. Was it worth the expense? They show a training videos with a grateful, saved passenger, but that’s an anecdote designed to make people take the training seriously. The downside of the airplane environment is that the cabin altitude is around 7000 feet on a typical flight, meaning less oxygen available, balanced against the availability of AEDs and people trained to use them.

in the real world, what is the cost/benefit of training huge numbers of people in CPR techniques that are unlikely to work? In a class I took years ago, the instructor urged us to try very hard in cases of younger people with an obvious external reason for heart stoppage (electrical shock, drowning) but not so hard with the elderly with no external cause, who probably had heart disease and were unlikely to survive. Then there’s the question of the person doing CPR acquiring a disease; a nurse once told me that she would never give mouth-to-mouth, and would instead use a resuscitator bag. I note that despite the unlikelihood of survival, you finish by recommending that everyone be trained in CPR. Should we consider these factors when deciding whether to train people, or purchase and maintain equipment in many public places?

Meanwhile, manixter just gave a condescending reply without even addressing my question. I was clearly talking about doctors or medics running a code and not lay people administering shocks willy-nilly. I am well aware that asystole does not respond to defibrillation, as evidenced by my previous post. My point was to suggest that perhaps in some extreme case, ECG may not be reliably reading the electrical activity of the patient’s heart (which does correlate to their actual heart beats), and thus, would it be wise to administer a shock at the end of the code just in case there is a very fine, undetectable and yet shockable rhythm.

During a code, when we are running the PEA algorythm, at the end the senior resident running the code may decide to shock to see if the rhythm is actually fine afib, which can look like PEA. However, normally this is towards the end of a code and we are making sure we didn’t miss anything; about the same time people start suggesting pericardiocentesis and placing 16 ga angiocaths in the chest.

CPR and defibrilaltion is really only successful for ventricular fibrillation and pulseless ventricular tachycardia arrests. Pulseless electrical activity — PEA arrest — and asystole are dead people unless you can reverse the process that made them have PEA; e.g. volume expansion in the penetrating trauma patient, decompression of tension pneumothorax, removal of fluid from around the heart in tamponade, etc. The reversible causes are known as the T’s and H’s.

As a hospitalist I have only seen pulseless vtach once, but I have seen lots of PEA arrests. While we do get a pulse and blood pressure back on some of these patients, that does not mean they survive to discharge or do not have some degree of hypoxic brain injury if they do survive. The number we were taught in residency, taking all comers, survivial for cardiac arrest / code in the hospital is some where around 14%.

Electrical activity != heartbeat. The EKG does not detect heartbeats or any muscular activity in the heart– just electrical activity. It is possible to have electrical activity but no perceivable or effective muscular activity– that’s the definition of PEA (pulseless electrical activity). There has to be certain patterns of electrical activity to coordinate appropriate muscular activity (perfusing rhythm). Some patterns of electrical activity are not compatible with a perfusing rhythm but with the application of an external shock can be converted to electrical activity that is compatible with a perfusing rhythm– such as ventricular tachycardia and ventricular fibrillation. PEA (electrical rhythm OK but no pulse) can only be made worse with shock– treatment requires treatment of underlying causes (hypoxia, acidosis, exsanguination etc). Asystole does not respond to electric shock (it’s not like jump starting your car), so that a shock in this situation can only make things worse (damaging myocardium)– treatment again is related to correcting other conditions (hypoxia etc) so as to hopefully restore the ability of the heart to generate a perfusing rhythm or at least one that can be converted to a perfusing rhythm.
It is exceedingly unlikely (never seen even a case study) that there would be a shockable rhythm not detected by the EKG. It is remotely possible that an automated external defibrillator (AED) could misdiagnose a rhythm– this would not be a reason for a layperson to shock “just in case”. In fact, the operator must direct the AED to shock with an appropriate rhythm, since an inappropriate shock could be harmful (so likely that many bystanders might not such with a shockable rhythm). It is much more likely for a bystander to cause harm by to defibrillating inappropriately by mistake or intent (which is why they can’t be overridden to shock) than to cause harm by delaying a defibrillation.
The defibrillators in medical centers do not have such limitations since the people using them are trained to interpret an EKG, use other resuscitation modalities etc such that much more likely to have harm from being unable to give a shock rather than giving a shock inappropriately.

Short answer: No. If there is no breathing, continue rescue breaths. If there is not a pulse, continue external chest compressions. If there is not a shockable rhythm, continue not to shock the heart.

When people ask me am I scared of death, I tell them I’ve been there and back and everything now is a bonus.

Of course, this was the same instructor who didn’t bother teaching the class how to landmark for the Heimlich maneuver, so half of the students were doing abdominal thrusts way up against the lower ribcage. Most of the students who weren’t already trained to some degree walked out of that class saying they’d never feel confident to attempt CPR, despite their newly-earned certification. What a waste.

As for TV, probably the most egregious depiction of CPR I ever saw was one that was supposedly a re-enactment of a real-life rescue. The rescuer, after trying a few rounds of more-or-less realistic CPR, and getting no response, screamed in frustration, straddled the guy’s hips, and started punching him in the chest with both hands. And then he woke up, and was okay!

Ri-ight.

I think both approches should be taught.

The inexperienced observer may have trouble distinguishing massive blood loss from minimal blood loss (a little bit might look like a lot). A small percentage of cardiac arrests even in patients with what looks like significant blood loss might be due to heart attacks or vagal reflexes before the blood volume has been depleted to the point of no return. So CPR is still attempted, and may be successful.

In any event, CPR is attempted in spite of the low success rate.

In the elderly, sometimes you have to break a rib to do effective CPR.

In young adults, too. Unfortunately the patient was bleeding out faster than we could pour fluid in and had enough internal volume that although we got her heart restarted, she was pumping saline by the time she got to where there was blood available.

I do not think it could cause harm to a person that is for all intents and purposes dead. As I said, I am speculating on the possibility that they have a shockable rhythm that is undetectable by ECG. Does anyone know if this is possible?

Tim, I think the issue with bleeding is that so many people are uncomfortable with blood, just as many people are uncomfortable with mouth-to-mouth. I think it would take an aggressive campaign with PSA’s and maybe school/workplace programs to convince people to do it. The sad thing is, anyone can be trained to do CPR in a few hours, but less than half of people take the time to learn. I think a lot of people adopt the philosophy of “it’s not my job. I will just call the paramedics because its their job.” The PSAs should therefore do a good job of convincing people of the need for early CPR and early defibrillation through easy-to-use AEDs.

Tangentially, a surgeon on my campus gives every class an hour-long lecture on exsanguination in public, i.e. how not to let people bleed to death after accidents. His battle cry is that any artery, aside from the aorta itself, can be stopped with pressure applied by a single finger. He shows us story after horrible story, newspaper accounts of a child or young person bleeding to death in front of dumbfounded onlookers, any of whom count have provided a life-saving therapy. Common mistakes are putting an entire hand over the bleeding area instead of one finger, or applying pressure through layers of cloth instead of directly on the torn artery.

Does the AHA or any other group make good PSAs about dealing with bleeding injuries? Maybe less common than cardiopulmonary arrest, but seems like an easier and more effective intervention.

My heart rate is already 40 bpm without betablockers. I hope nobody gives them to me by mistake. My heart might actually stop beating altogether!
(Actually, I know there is a ventricular escape rhythm. When I was running marathons, my resting pulse rate would actually drop below the ventricular rate and the ventricular escape rhythm would take over… just as I was dropping off to sleep of course – very disconcerting)

“I never understood why they thought that pumping the chest of a man bleeding profusely from many bullet wounds would somehow revive him.”

Same at accidents where someone has died due to massive blood loss and they try to revive the vctim with CPR