OBXDIVEGUY
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H2Andy:
Doctor sparks debate over CPR
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MookieMoose
Guest
My Master's degree was CPR research - the idea of continuous chest compressions is not a new one, and really does provide better blood circulation. First off, until you have a patient intubated, you can get lung ventilation almoast as good as mouth-to-mouth just by pumping the chest - the lungs are designed to suck air into them, not to have it blown in, so pumping the chest works pretty well. As far as the circulation part is concerned, without adequite blood flow the heart muscle itself begins to go into contracture - kind of like a muscle spasm that wont let go. Eventually the heart gets so stiff that CPR can't pump any blood. This is a process that can happen fairly quickly, and has be demonstrated to be accelerated by interrupting chest compressions to deliver a breath. The bottom line is that this Dr. in arizona is probably right. You get almoast as much ventilation, and much better circulation by just pumping the chest.
Cam
Cam
H2Andy
Contributor
MookieMoose:
do you know of a movement to change the procedure nation-wide?
liberato
Guest
Even it it is not better it is better than bystanders doing nothing which seems to be the trend. 20 years ago 60% of people would be willing to do m-to-m on a stranger. Now it is only something like 20%. Most would be willing to do CCC-CPR if they thought it would be helpful, though.
The near-drowning situations we would encounter as divers are probably more complicated than the poor soul who keels over at the mall which is what they are probably talking about.
Aversion to m-to-m contact notwithstanding, I found in my CPR training that stopping the compressions to do the breaths and then repositioning to start the compressions again to be extremely exhausting while just doing compressions was not that taxing if positioned right. So, if CCC was almost as good I could do it for a much longer time.
Heart Center Recommends New CPR Guidelines
Experts Move to Resuscitate CPR
The near-drowning situations we would encounter as divers are probably more complicated than the poor soul who keels over at the mall which is what they are probably talking about.
Aversion to m-to-m contact notwithstanding, I found in my CPR training that stopping the compressions to do the breaths and then repositioning to start the compressions again to be extremely exhausting while just doing compressions was not that taxing if positioned right. So, if CCC was almost as good I could do it for a much longer time.
Heart Center Recommends New CPR Guidelines
Experts Move to Resuscitate CPR
Yeah, let's not start with the assumption that Dr. Ewy is some crank from the hinterlands in Arizona - he is one of the founders of the heart program at the UofArizona medical center, a professor of cardiology, and has been recognized by the American Heart Association as one of the "giants" of CPR (an award of which I was not formerly aware). The Arizona heart center is one of the better heart programs in the country, and Ewy is one of the big names in his field.MookieMoose:
They also have some actual research data to back up their recommendations:
"Students who were taught the simplified chest-compression delivered 113 compressions per minute. Animal studies show this dramatically improves survival. One showed 100 percent of animals getting more than 80 chest compressions per minute were resuscitated, but only 10 percent of those getting less than 80 survived, Ewy and Sanders wrote. 'It is time to focus on simplifying the technique,' the editorial stated. Under current guidelines, 'long and possibly lethal interruptions in chest compressions are the norm. The unintended consequences are . . . not enough survivors.'"
I'm no expert myself, but the theory behind CCC-CPR makes perfect sense to me, and ultimately results matter. It's also important to note that they are not just "simplifying" the process by recommending chest compression only, but are also emphasizing the importance of sufficiently forceful chest compression to actually move blood through the system.
MookieMoose
Guest
H2Andy:
From what I've seen, Dr Ewy's changes to local EMS procedures in Tuscon are the first step to changing standards on a wider scale. Keep in mind that the changes he is proposing are for bystander initiated, pre-hospital CPR. Major agencies like AHA and the Heart and Stroke Foundation are always slow to change their recomendations - they want to be sure that they will 'improve' things by changing their recomendations, and they won't be convinced until they have data from clinical trials, and it's very difficult to do clinical trials in CPR here in the US because it's very difficult to get around the informed consent issue (it's hard to get consent form a guy who needs CPR to do something non-standard!)
Laurence Stein DDS
Medical Moderator
Stirling, your point is well taken. By nature we all are averse to change and fight it even when a new (and perhaps) a better idea comes around.
I'm not saying that we have to immediately embrace the new idea but when somebody with this doctor's credentials makes this suggestion, we should at least entertain the idea that if proven, this technique may in fact, be better than the one we have been using for 40+ years. Keep using your training but be open to changes.
It's funny how sometimes conventional wisdom is wrong...ulcers for instance. The story goes sort of like this...a number of years ago a doctor in Australia (a medical resident I believe) had the audacity to suggest that a bacterial infection is the actual cause. He was laughed at by his more "learned" attending physicians.
This doctor noticed that on pathology slides of stomachs of ulcer patients there were bacteria within the tissues. To him this was significant...I mean, bacteria are not supposed to be found in tissue unless...there is infection. Conventional wisdom was that this bacteria were normal residents of the stomach.
To make a long story short, it is now accepted that the majority of gastric ulcers are a result of infection by H. pylori. Treatment for ulcers now includes taking several antibiotics and proton pump suppressors. It turned out that this "odd" suggestion was right on the money.
I don't know about the rest of you, but between my general anesthesia training and CPR updates, I find that CPR "rules" have become more confusing and it is exhausing to do what we are trained to do for very long. If there is a better idea (and it properly evaluated) then let's not shoot it down from the get-go.
The TV report also included paramedics that currently use the new technique and they admitted that they were skeptics AND that this works!
A few more points to ponder. Does everyone remember the "old" method of drowning revival? You put the victim face down, pulled on the arms like chicken wings and then pushed on the back. Now certainly some of these victims were in respiratory arrest but some had to be dead. It turns out that the movements would both ventilate and compress...perhaps not very effectively but it could work, people were saved. Then they came up with a "new way"...rescue breathng and chest compressions. Do you think the rescuers of the time thought the new was was stupid? What do YOU think of the old technique now?
Does anyone remember about 10-15 years ago when it was suggested that chest compressions could be done with a toilet plunger or a device that stuck to the chest by a vacuum? Not only would it compress the chest when plunged, it would also create additional inspiration when pulled. There was still rescue breathing to be performed but perhaps that idea is not so bizzare when you think about it. It sounds cumbersome and perhaps that is one of the reasons it wasn't accepted. Conceptually though, it made some sense.
Anyway, you don't have to jump onto a new change...but don't dogmatically suggest that it won't work. Let's keep an open mind and perhaps hope that this simplifies a technique that does not really have a high survival rate. Keep in mind that it's not so great if you do manage to restart the heart and the victim is severely brain-damaged for lack of circulation.
My CPR recertification is this year...it's gonna be interesting...for a change!
Larry Stein
I'm not saying that we have to immediately embrace the new idea but when somebody with this doctor's credentials makes this suggestion, we should at least entertain the idea that if proven, this technique may in fact, be better than the one we have been using for 40+ years. Keep using your training but be open to changes.
It's funny how sometimes conventional wisdom is wrong...ulcers for instance. The story goes sort of like this...a number of years ago a doctor in Australia (a medical resident I believe) had the audacity to suggest that a bacterial infection is the actual cause. He was laughed at by his more "learned" attending physicians.
This doctor noticed that on pathology slides of stomachs of ulcer patients there were bacteria within the tissues. To him this was significant...I mean, bacteria are not supposed to be found in tissue unless...there is infection. Conventional wisdom was that this bacteria were normal residents of the stomach.
To make a long story short, it is now accepted that the majority of gastric ulcers are a result of infection by H. pylori. Treatment for ulcers now includes taking several antibiotics and proton pump suppressors. It turned out that this "odd" suggestion was right on the money.
I don't know about the rest of you, but between my general anesthesia training and CPR updates, I find that CPR "rules" have become more confusing and it is exhausing to do what we are trained to do for very long. If there is a better idea (and it properly evaluated) then let's not shoot it down from the get-go.
The TV report also included paramedics that currently use the new technique and they admitted that they were skeptics AND that this works!
A few more points to ponder. Does everyone remember the "old" method of drowning revival? You put the victim face down, pulled on the arms like chicken wings and then pushed on the back. Now certainly some of these victims were in respiratory arrest but some had to be dead. It turns out that the movements would both ventilate and compress...perhaps not very effectively but it could work, people were saved. Then they came up with a "new way"...rescue breathng and chest compressions. Do you think the rescuers of the time thought the new was was stupid? What do YOU think of the old technique now?
Does anyone remember about 10-15 years ago when it was suggested that chest compressions could be done with a toilet plunger or a device that stuck to the chest by a vacuum? Not only would it compress the chest when plunged, it would also create additional inspiration when pulled. There was still rescue breathing to be performed but perhaps that idea is not so bizzare when you think about it. It sounds cumbersome and perhaps that is one of the reasons it wasn't accepted. Conceptually though, it made some sense.
Anyway, you don't have to jump onto a new change...but don't dogmatically suggest that it won't work. Let's keep an open mind and perhaps hope that this simplifies a technique that does not really have a high survival rate. Keep in mind that it's not so great if you do manage to restart the heart and the victim is severely brain-damaged for lack of circulation.
My CPR recertification is this year...it's gonna be interesting...for a change!
Larry Stein
derwoodwithasherwood
Contributor
Actually, we are doing it now at work.
For the last 6 or 8 years, we were part of a North American study werein our objective was to shock as quickly as possible. CPR was delayed until we had completed a stack of 3 or 1 NSA. Other cities were using a CPR-weighted protocol as part of the same study. Everybody was compared against the "standard" protocols (ie 1 minute CPR followed by de-fib). I don't have the exact numbers, but IIRC, we saved around 15%, the standard method slightly more and the "rapid compressions-only" group was over 20%. We are now switching over to the "rapid compressions-only" algorithm. I don't know if it's just us or if everybody else will be switching over too.
As explained during our re-certs this year, the blood carries enough oxygen to do some good for several minutes, even without breaths. And apparently the heart is more likely to successfully 'reset' if it's own tissues have been oxygenated. So one rescuer now does 2 minutes of compressions only at 100 per minute while the other sets up the equipment, inserts the OPA, etc. followed by 1 minute of two person, 15:1 CPR before the SAED is fired up. (as always, there are certain exeptions to the protocol)
Of course, I am speaking as a professional firefighter working at the direction of a base hospital physician. This is not to say that the protocol for the general public has or will change. You should do CPR however you were taught.
For the last 6 or 8 years, we were part of a North American study werein our objective was to shock as quickly as possible. CPR was delayed until we had completed a stack of 3 or 1 NSA. Other cities were using a CPR-weighted protocol as part of the same study. Everybody was compared against the "standard" protocols (ie 1 minute CPR followed by de-fib). I don't have the exact numbers, but IIRC, we saved around 15%, the standard method slightly more and the "rapid compressions-only" group was over 20%. We are now switching over to the "rapid compressions-only" algorithm. I don't know if it's just us or if everybody else will be switching over too.
As explained during our re-certs this year, the blood carries enough oxygen to do some good for several minutes, even without breaths. And apparently the heart is more likely to successfully 'reset' if it's own tissues have been oxygenated. So one rescuer now does 2 minutes of compressions only at 100 per minute while the other sets up the equipment, inserts the OPA, etc. followed by 1 minute of two person, 15:1 CPR before the SAED is fired up. (as always, there are certain exeptions to the protocol)
Of course, I am speaking as a professional firefighter working at the direction of a base hospital physician. This is not to say that the protocol for the general public has or will change. You should do CPR however you were taught.
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Laurence Stein DDS:
I did my EFRI (Translation CPR Instructor) this year. The biggest change I noticed is the lack of a pulse check. The current training is that the pulse check is at best optional. If the patient is not breathing and shows no other signs of cirulation, i.e. movement, etc. Then do the compressions.
What I find odd about this is the reasoning. It was stated to me that the reason is many people cannot find a pulse even if it is there, due to lack of practice or a weak pulse. I find the idea of not checking because you might get a false negative odd. Not checking because you might get a false posetive makes more sense, but that is not the case.
On the no breathing thing, here is somthing else to consider: Almost nobody teaches 2 person CPR anymore. As I understand it there are 2 reasons:
1. Unlikely to have to rescuers trained in 2 person CPR
2. It is almost always done improperly.
On number 2, the problem is that it should not be done as 5 compressions/pause/breath/etc. It should be done as continuous compressions with a breath on every 5th compression.
Now, consider that 2 person CPR is not taught, at least partially because the pauses are no good. No consider that 1 person CPR has a built in pause....
Somthing to think about...
James
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