New CPR guidelines issued

This news is a couple days old, but the International Liaison Committee on Resuscitation's new CPR guidelines are out. Various groups like the American Heart Association should start teaching the new guidelines in the near future. Probably in the spring.

The new guidelines are simpler, to aid in memory retention and to improve real world success. No more ABC check, and chest compressions to ventilation ratio is now 30:2, from infants through adults. If someone is unconcious, not moving, and not breathing (ignoring occasional agonal gasps), then start CPR. Actually, these changes have been in the works for quite a while, but now they're official.

Some experts argue that the guidelines should be simplified even more to just compression-only CPR, and there is evidence to support that technique, but I think that's too radical a change for the scientific/medical community to make all at once, since there is also evidence that shows that ventilation is also important.

Anyway, for those you who haven't gotten a CPR refresher in a long time (me included) you should consider doing it sometime early next year when the new guidelines are being taught.

If you'd like to check out the new CPR guidelines in all its scientific, medical journal glory, you can view it for free here , along with a ton of other new ILOR recommendations on issues like advanced life support, stroke treatment, etc. based on the best evidence available today.

Thanks, Arney, for pointing this out. I had not seen it.

WARNING: SARCASM AHEAD!

There seem to be many people (I work with some) who know CPR, but say they would hesitate to use it on a stranger. And the term "stranger" is defined by someone who doesn't have a dated-today HIV/AIDS blood test result pinned to his/her chest.

And this comes from people who would French-kiss everone of the opposite sex in a large, crowded nightclub if they were given the opportunity.

One guy who said this has recently fathered two children in casual relationships, so he is obviously not using any form of protection for anything. But he wouldn't give a dry-mouth kiss-of-life to any other stranger unless she was young, pretty, blond and had big boobs.

So, if you hesitate to give CPR to someone, stop and think who you're willing to kiss NOW. <img src="/images/graemlins/smirk.gif" alt="" />

Okay, finished.

Sue

Actually, the whole mouth-to-mouth issue is one of the big advantages that proponents of compression-only CPR put forth. We can't force people to be Good Samaritans, but if we can make it easier or more palatable by, say, making CPR simpler or teaching that just doing chest compressions is OK, then that's a worthwhile change to consider. Again, I say this in the context that there is evidence that compression-only CPR does have evidence backing it up but it's not conclusive yet.

Actually, there are places in the country that teach compression-only CPR. I have read that the University of Arizona and some places in Wisconsin teach it to the public. I have read that an important article on compression-only CPR will be published early next year.

I would say that if you have any hesitation about doing mouth-to-mouth on someone (and assuming the unconcious, not moving, not breathing conditions), then you'll still be doing the person a service by doing compression-only CPR. But I'm not a doctor (nor a lawyer!) and this is just my personal opinion.

Experts say most real world CPR is done incorrectly anyway, so simply pressing hard on that sternum steadily at 100 reptitions per minute until EMS arrives will do this person a world of good compared to wasting 20 seconds making "Do I have to?" faces before giving each puff of breath while doing regular CPR. Or worse, doing nothing at all, while the person dies. <img src="/images/graemlins/frown.gif" alt="" />

You also have to keep in mind that someone who requires CPR may have just vomited. I don't want to put my mouth on that, do you?

Well that's what I was about to point out... By inncorect head positioning you pump stomach full of air and than eventually all the stuff comes up... About 90% of my cardiac arrests are messy. My latest one which was a save happened to be a gentelman with stomach ultcer bleeding for days. When fireman pressed on his chest there was a fountain of half digested blood that went about 2-3 feet in the air. I dont know how hard core you are but I wouldnt recommend putting your mouth on that.

HIV doesnt worry me as much as Hep B. Well I had a shot for it but that's not somethign that typical bystander will have.

I'm all for making cpr simple for a layman. But medical professional should be thought differently.

Ugh, I was just about to have breakfast...and I just read your "...fountain of half digested blood that went about 2-3 feet in the air..." comment. <gulp> I think I'll pass on breakfast for a while. <img src="/images/graemlins/tongue.gif" alt="" />

But, having never been around anyone ever needing CPR, it's good to hear some feedback from people with experience about what we lay people may face. For a few years now, since first reading scientific evidence that shows the effectiveness of compression-only CPR, I decided that I would stick with compression-only CPR. That's around when I moved back to San Francisco for a few years and got a job downtown, where you see tons of homeless, drug addicts, and mentally ill people all the time. (Interestingly, I had just moved from Manhattan, where you see only see a fraction of what you see in SF) Most people wouldn't touch them with a ten-foot pole, and maybe when crunch time came, I wouldn't either, but hey, they're human beings, too, and I tried to mentally prepare myself to not waste time deciding and just get to doing compression-only CPR and hope EMS gets there quickly. That kind of situation is a tough call and one we can only make for ourselves.

Anyway, figured I should mentally rehearse one way for everybody instead of facing the prospect of doing nothing at all because I didn't want to do mouth-to-mouth. It shouldn't make a difference if the lady on the ground is young, pretty, blond, and has big boobs...it shouldn't...it--boy, she's a looker, aint' she?... <clunk!> Another one upside the head for Arney, perhaps from Susan. <img src="/images/graemlins/wink.gif" alt="" /> <img src="/images/graemlins/grin.gif" alt="" />

Carry a pocket CPR shield. There are even keychain-sized ones now.

QUOTE: "all the stuff comes up... About 90% of my cardiac arrests are messy."

This is the dirty little secret about CPR. I have had an interest in first-aid since being a Boy Scout. I was fortunate enough to have some "reality" discussions with a few Paramedics many years ago. Back in those days the pocket shields didn't exist to my knowledge. They said plan on getting a mouth full of vomit. They said this was especially common when the person goes “brain dead”. Later I have heard this was due to air in the stomach.

I have taken numerous CPR courses over the years and not a single time has this problem been mentioned. My wife also has taken many CPR courses with the same failure to prepare a student for a real CPR situation.

My guess is they don't want to discourage trained bystanders from helping with CPR situations. If I hadn't been warned about this vomiting issue I may have freaked out or panicked if it had surprised me during a resuscitation. I’ll take honesty over deception anytime. I feel leaving out critical information like this is doing a great disservice to the CPR student.

I appreciate Polak187’s frank discussion about this topic.

This brings up additional questions needing an experienced “hands-on” user to reply:

I am sure the pocket shields are better than nothing, but how effective are they “really” at preventing contamination of the CPR responder?

Are there any brands or models that should be avoided?

Are there any brands or models that are recommended?

Is it also common for CPR patients that have gone “brain dead” to relieve other bodily functions? (I thought I had better keep it clean for any other breakfast eaters).

Sometimes I feel that Polak187 is a bit jaded, but I respect his no holds barred candor on sensitive subjects like this.

Thank you, TR

(Going compression only for the near future).

I have one from MDI that has a one-way valve and an inflatable cushion to allow for a better fit against a face (and to adjust for altitude). It comes in a pouch that also holds gloves and a biohazard pouch. I got it from WMI when I did my WFR training for $15 or so.

The pocket/keychain ones are generally pretty minimal and often don't have the valve, but are better than nothing; I keep one in my pack/small first aid kit at all times.

(PS - whichever you use, it's still going to be messy.)

- Steve

It makes sense to add to your kit some latex gloves(not just for first aid but I use them for my bike and other dirty jobs) and a faceshield of some discription. The best type look like oxygen masks but the plastic sheet ones work as well. I have heard some stuff that says they actually improve your CPR.

"Is it also common for CPR patients that have gone “brain dead” to relieve other bodily functions?"

A dead faint can do that!

Sue

I agree that the little mouth shields with the one-way valve that you carry on a key chain are not the best choice. Had opportunity to use the "keychain" style once and it was a pain, but better than nothing, That's why I keep a large faceshield with one-way valve and oxygen port (hard shell case) in my backpack. The "keychain" style is just as a last resort.

Just a thought about EDC infection control; not a bad idea to keep a pair or two of medical exam gloves on you, or handy just in case you feel the urge to stop and help out on a wreck, deliver a baby, etc... I keep two pair in my fanny pack and they don't take up much room. Plus, they came in handy when I had to do a little parking lot repair job on my car (kept my hands from getting dirty)

peace,
samhain

Use nitrile gloves; many people are allergic to latex and it can be fatal.
B

I did CPR on a person who had stopped breathing & circulating by an overdose of prescription drugs. Real people can be easier to inflate than the training dummy. This one also vomited first. <img src="/images/graemlins/frown.gif" alt="" />

I am sure the pocket shields are better than nothing, but how effective are they ?really? at preventing contamination of the CPR responder?
Pocket shield is plastic with a hole where you place your mouth. That barrier is made out of porus paper/fabric like material. It will prevent you from aspiring fluid and matter directly but it will soak up the moisture/fluid therefore you are exposed to the other person vomit anyway.

Are there any brands or models that should be avoided?
Well if you absolutely have to do CPR anything is better than nothing. Chances may be that this particular arrest would be a clean one. That's why the pocket shield is an absolute minimum.

Are there any brands or models that are recommended?
Pocket masks with one way valve and O2 ports are excelent. It is easy to maintain the seal on them but disadvatage are that they are little too big for everyday pocket carry.


Is it also common for CPR patients that have gone ?brain dead? to relieve other bodily functions?
Depending on the reason the person in fornt of you needs cpr than they might have relieved themselves. Example:
traumatic arrest - if the spine has been compromised there may be no muscle tone to hold the bladder and colon together
seizure - urination is frequent and they may go into respiratory arrest. Plus you got foam from the mounth and possibly blood from tongue that was bitten during the seizure.
cardiac arrest - everything goes althou very rearly I've seen urination and defacation. During cardiac arrect it is mostly stomach content that comes up.

Last night at the dinner table I had a discussion with fellow medics about new guidelines for CPR. We all know that brain is the organ that is the most sensitive to lack of Oxygen. Now if you start circulating deoxygenated blood (compressions only) don't you make the brain die faster? I mean it was just a talk and we had no data at hand as far as how big oxygen consumption is in the brain tissue as opposed to other organs but one thing we all knew for sure was that brain necrosis starts much quicker than necrosis of other tissues.

Also don't forget that part of the cpr is also rescue breathing. Now if you are set on doing chest compressions only and as per new standards you throw away the ABCs, by starting the compressions you will put somebody into cardiac arrest.

Jaded Polak <img src="/images/graemlins/smile.gif" alt="" />

ps.
I will just assume as per alternate deffinition that "jaded" means "A woman regarded as disreputable or shrewish. " LOL

Hey Billy if they are in the cardiac arrest I think that their latex allergy is the least of their problem.

But I second the gloves idea. I carry two pairs with me all the time and from acctual med work to stupid stuff like engine repair, emergency water carrier, small pain job, garden work, etc, etc they are a life saver. Plus when inflated they make a great fast and temporary toy.

"I will just assume as per alternate deffinition that "jaded" means "A woman regarded as disreputable or shrewish. " LOL, Jaded Polak "

JP,

Nah, you've never struck me as shrewish. <img src="/images/graemlins/wink.gif" alt="" />

Thank you for your input and candor.

TR, (Off to shop for a better portable vomit-stopper)

Please bear with me, I have to get this off my chest.

I am also jaded when it comes to current and the new CPR guidelines. I started giving CPR back in 1968 as a Inhalation Therapist, now currently known as a Respiratory Therapist, at a well known teaching hospital in Chicago. Procedures that we used to great success are now not taught and are in fact frowned upon. It has been many years since I was a therapist but with the aging population and the accidents I have come across, my CPR techniques have been very successful.

They no longer teach nor recommend the Pre-Cardiac Thump Technique in CPR. The conclusion being that the risk of causing physical injury outweighed the benefits. I however have used it on heart fibrillation due to trauma or shock in both adults and infants. I last used this technique to revived my neighbor three times prior to the paramedics arriving. Other CPR techniques on him were not required as he resumed breathing on his own until his heart started fibrillating again. He was a long time diabetic who suffered a recent heart attack. We were lunching together at the time.

Now they only want people to use compressions and not breathing techniques. Unskilled or over excited rescuers can and do break ribs in current CPR techniques just as with the Pre-Cardiac Thump technique but the risk is worth it in one case and not the other. Strange logic! I personally think one is based on fear of legal repercussions and the other is based on fear of disease transmission.

To keep the brain or other organs healthy, oxygen is needed. Evan when a body is to used as organ donor, we kept brain dead victims oxygenated until surgery was preformed to, pardon the expression, mine the organs.

My longest time using unassisted CPR was forty five minutes but I was using an Ambu bag. Unbeknownst to me, the young girl happened to be the daughter of a work associate at my main vocation as a Communications Engineer. Even being in great shape, I do not think I would have been able to do CPR that long without a bag. I trained a bystander while I was doing this so that I could rest my wrist and we continued “Two Person CPR” until the ambulance arrived. To this day I carry a Ambu bag in each of my vehicles including my RV and in my main first aid kit. I have not been able to EDC one but I will keep trying to figure out a way.

Many of my friends are First Responders and they wonder why I don’t become certified especially after staying current in all the courses. Evan though I live in a state that has very friendly “Good Samaritan Laws,” I could no longer use the techniques I know save lives without risking legal liability. Once you become certified, you must follow the current rules or directives. I will just remain a well trained amateur.

One last comment. In all the cases where I performed CPR, not once did the patient throw up during the procedure. This was not due to any unique technique, I was just one lucky guy. All my associates suffered though vomit but I never had to. I always was ready to turn the patient’s head, clear their airway, throw up myself, and start again but I never had to.

My down fall and the eventual end of my therapist career was due to the large number of terminal pediatric patients under my care. Their innocent eyes tore up my heart and to this day I still think about them. Medical professionals who specialize on terminally ill infants are unique and face more stress than I can endure.

Turbo,

Your story was informative and touching. Thank you.

I am curious, how does a responder determine whether the heart is fibrillating or stopped? Is it important to know the difference? Or, just use the "thump" anytime a pulse is not detected?

TR

As per AHA standards... If you witness the arrest than the thump is used (at least that's how protocols go here in NYC).

Vfib and Asystole are being treated the same as far as the CPR goes. Both require compressions and ventilations. Difference comes into play when defiblirator is involved. Vfib is a shockable rythm (AED will shock) while you don'r really shock asystole (AED will not shock). Vfib shows on the screen as a really crazy zig zag line with no pattern while asystole is a straight line. There is a belief in the field that sometimes asystole may be a very fine vfib and you can shock it. Doesn't really hurt since being is asystole is as dead as you are going to get. Does it make any difference if the patient is in asystole or vfib? Not really from cpr point of view.

pizzaman,

Polak187 explained the technicalities very well and the correct logic of performing the "Thump." I am happy to see that they use common sense in NYC. When a patient is electronically monitored, it is fairly easy to learn cause and affect of different treatment techniques.

Determining fibrillation in a patient manually can be very difficult. Just getting a pulse on weak, elderly, and / or over weight patients can be a real challenge. As Polak187 stated, witnessing an arrest is the best time to perform the "Thump."

Remember that once a patient's heart has been interrupted for a short time, their electrolytes become unbalanced and they will need replenishment before normall pulses can again be stimulated. So never give up doing CPR until the Paramedics arrive or you transport the patient to an equipped medical facility.

Regarding compression-only CPR and...



The most deoxygenated blood will be the blood that just sits in the brain for a period of time without circulating. The brain is highly metabolic and will suck all the oxygen from the blood inside the brain's blood vessels very quickly. If you can establish some blood flow, then you can transport blood that is still oxygenated from the rest of the body to the brain. So you're saving the person's brain, at least for a short time. Of course, without ventilation, the blood will eventually become oxygen depleted, but us lay people hope that EMS will arrive before that happens.

But oxygenation is not the only factor. Interrupting compressions also decreases effective circulation, and if you're rusty at CPR or not-so-confident, you're likely to take more time than desired to switch from compression, to mouth-to-mouth, and then back to compressions, which can seriously compromise blood flow. In this situation, steady compression-only CPR would be more effective at maintaining circulation to the brain.



The ILOR did away with the pulse check because research has shown that checking the carotid is an inaccurate way of confirming the presence or absence of circulation (they said "circulation" not "heartbeat" so I assume it was on purpose). It's possible that someone could be unconcious, not moving, not breathing, and have a heartbeat, but if they're not breathing, the heart won't be beating much longer anyway.

I read a comment by a cardiologist that if you mistakenly start to do a CPR chest compression on someone with a heartbeat, they will reflexively react and you'll know to stop. It's the same principle when you do the motor portion of the GCS test on a potentially brain injured person. The person may be unconcious, but pinch them hard and they will react, like moving their hands to the point of pain. But you're right, there's the risk of inducing cardiac arrest if you compress a beating heart hard, but the probability of that happening is likely very small compared the chance of doing some good in the face of a real cardiac arrest.

That's a very interesting point that you raise. It's unfortunate that people who prepare to help others need to consider topics like this.

Is anyone aware of any lawsuits in connection to resuscitation attempts by lay bystanders? Personally, I thought the only real legal obligation for the lay person is that once you start administering CPR, then you must continue until the person revives (yay!), you're relieved by another trained person, too exhuasted, scene becomes unsafe, physician tells you to stop...I think I missed one or two more conditions. Ironically, you're more legally safe by doing nothing.