Efficacy of providing rescue breaths?

[Seefourdc]

I regularly provide ACLS at my job to patients (Multiple times a week) and I've been thinking about the AHA changing their guidelines for non-healthcare providers to no longer providing rescue breaths in an out of hospital code situation. It got me to thinking... doesn't it seem like bad practice to attempt to provide rescue breaths to a diver found unresponsive while towing them? If you look at the reasons they stopped teaching rescue breaths it makes even less sense to me to attempt to provide rescue breaths during an in water rescue situation. (You can't see chest rise effectively, it's harder to get head tilt, and the biggest one is if they are already in cardiac arrest you are wasting valuable time that decreases chances they will survive.)

I bring this up because even as someone who practices these skills numerous times a week I don't feel like the time used attempting to provide a rescue breath until the patient is on a stable surface would be time used valuably.

Thoughts?

 

[eponym]

In-water rescue breaths pose several problems. I teach no rescue breaths until the subject is on the hard. More reasons will follow.

-Bryan

PS. There are quite a few threads on this topic on SB. Here are some previous ones:

http://www.scubaboard.com/forums/basic-scuba-discussions/204454-rescue-breath.html

http://www.scubaboard.com/forums/accidents-incidents/194149-rescue-breathing-surface.html

http://www.scubaboard.com/forums/diving-medicine/123256-water-rescue-breaths.html

http://www.scubaboard.com/forums/diving-medicine/63148-rescue-breathing-ear-cpr-etc.html

http://www.scubaboard.com/forums/diving-medicine/29118-rescue-breathing-when-there-no-pulse.html

And it's always good to see more recent information, like the Rubicon and DAN pieces referred to below. Thanks!

 

[jewelofnile69]

I wondered this myself when taking my rescue course. After lifeguarding for years in high school and college, teaching combat water survival and being a combat life "taker" in the Army, and then having to numerous CPR courses for personal training, I've since wondered what this means for the rescue breathing for an unresponsive, non breathing diver.

I believe this is what Gene is talking about in this thread: http://www.scubaboard.com/forums/ba...merged-unresponsive-compressed-gas-diver.html. But I couldn't find the article/whitepaper that he is actually referring to. I have a feeling there is a link in his OP that I'm just missing. The post specifically asks the question "can effective rescue breaths be delivered in the water?" My thought is "no." I had a hard enough time doing that in lifeguarding when a "body" was on a floatable backboard. I argued this point in my rescue course. Our instructor (who is a very trusted friend and extremely capable diver) also said he questioned it but (don't quote me on this) said that since you cannot actually give compressions while in the water that the rescue breathing may be the difference between life and death for the victim.

---------- Post added February 27th, 2013 at 09:04 PM ----------

In-water rescue breaths pose several problems. I teach no rescue breaths until the subject is on the hard. More reasons will follow.

-Bryan

PS. There are quite a few threads on this topic on SB and a search will yield quite a trove.

I look forward to hearing them!

 

[PfcAJ]

Recommendations for rescue of a submerged unresponsive compressed-gas diver.

pdf link is at the bottom.

 

[jewelofnile69]

Recommendations for rescue of a submerged unresponsive compressed-gas diver.

pdf link is at the bottom.

Thanks!!

 

[261311]

to provide rescue breaths to a diver found unresponsive while towing them

Might be the way this is worded and my understanding them, but this would be incredibly hard. I believe that's why it was removed from PADI instruction, bring them to solid ground and treat the patient there. Shore, boat, whichever- you can't do compressions or check for pulse accurately while in the water. It's best to have their mask on so their nose is blocked and a reg in their mouth. If they're not breathing this keeps water out, if they are- they are ensured clear air until you're back to where you need to be to call for medical assistance.

 

[g1138]

Head tilts should be easier in the water, it's all about technique. If you can't get high enough to seal over the victims mouth, roll them towards you. The benefits of rescue breaths in water however are still a gray area in my mind. If there is no heart beat, rescue breaths don't help at all. If there is a heart beat, rescue breaths will get much needed oxygen circulating.

On land if you see a person pass out due to heart attack or what ever, they will still have a plentiful supply of O2 in their lungs and blood. So immediately circulating that via chest compression will do some good. Do chest compressions for 10minutes with no rescue breaths however, and you're not getting any helpful amount of fresh O2 content into the victim's blood system.
Rescuing a diver from the water however is different, because you have no idea how long they've been down, or what their blood O2 content is. So rescue breaths play an important part, assuming there is a way for the blood to flow and transport the O2 in that rescue breath.

The basic CPR clause of ignoring rescue breaths was to make it easier and participants more willing to render aid. Because chest compressions are easy and non-invasive. No mouth-to-mouth, no ratios to remember. For professional rescuers however, they still start with 2 rescue breaths then move to compressions.

Keep in mind too that a rescue breath into the lungs may help force some water out, if any is present.

 

[robertarak]

Hands-Only CPR Statement from DAN Training

"..While this change is important with regard to lay rescuers providing emergency care in the event of a collapse on the street, it will not affect the care of an unconscious diver. Many dive injuries involving an unconscious, non-breathing diver begin with respiratory arrest and drowning. DAN Training does not plan to change any DAN courses to feature hands-only CPR, which is relevant to the world at large but does not affect diving circumstances..."

Full document here.

 

[Seefourdc]

Head tilts should be easier in the water, it's all about technique. If you can't get high enough to seal over the victims mouth, roll them towards you. The benefits of rescue breaths in water however are still a gray area in my mind. If there is no heart beat, rescue breaths don't help at all. If there is a heart beat, rescue breaths will get much needed oxygen circulating.

On land if you see a person pass out due to heart attack or what ever, they will still have a plentiful supply of O2 in their lungs and blood. So immediately circulating that via chest compression will do some good. Do chest compressions for 10minutes with no rescue breaths however, and you're not getting any helpful amount of fresh O2 content into the victim's blood system.
Rescuing a diver from the water however is different, because you have no idea how long they've been down, or what their blood O2 content is. So rescue breaths play an important part, assuming there is a way for the blood to flow and transport the O2 in that rescue breath.

The basic CPR clause of ignoring rescue breaths was to make it easier and participants more willing to render aid. Because chest compressions are easy and non-invasive. No mouth-to-mouth, no ratios to remember. For professional rescuers however, they still start with 2 rescue breaths then move to compressions.

Keep in mind too that a rescue breath into the lungs may help force some water out, if any is present.

A lot of your reasoning is not the reason the AHA went to hands only for the public. That's actually beside the issue though, because with more and more research they have found healthcare providers shouldn't even start with rescue breaths. Compressions are the most important part of CPR by far and if a persons heart has stopped there is NO REASON to provide rescue breaths. No circulation means it doesn't matter whats in the lungs. The reason this stands out to me is if you don't know if the person has circulation every second you waste on rescue breaths before you begin CPR is more dead tissue (Time is tissue we say). The reason they want you to go straight to circulation is that even if you witness someone go down the time it takes to check AB before looking into circulation will cause anoxic brain injury (on average 45 seconds) if the heart has already stopped. The AHA does not recommend providing rescue breaths first for anyone.

The second thing I disagree with is the assertion that it's easier to open the airway. Since it takes extension to open the airway without a hard surface and especially with waves, I would expect that to be nearly impossible. Not only that but since the water conditions and equipment may preclude ease of seeing good chest rise it's harder to QC whether you are doing it right.

The third thing that comes to mind from my training is when you find an unresponsive person and the event was unwitnessed (which means you don't have a timeframe of how long down) you are expected to assume their heart has stopped. That's one of the primary reasons the AHA has decided that CPR should begin with compressions and eliminate breath checks/listening for breathing and to do a circulation check straight into compressions.

I don't disagree that rescue breaths should be administered, but I find it questionable in the water wasting time getting that person someplace you can provide compressions.

 

[lamont]

I could see a few rescue breaths in very narrow circumstances where the diver went unconscious only a few minutes previously and where not a lot of time was wasted doing them. The problem is that in an emergency situation a diver dealing with an unconscious buddy who has no other help in the water is still likely to be better off focusing on getting them to shore and additional help. I've dealt with getting an unconscious diver on the surface out of the water, and we had 4 or 5 divers in the water and help on the shore and we were only a few yards away from the dock, and it was still fairly overwhelming. For training OW divers, in the general case where circulation status is unknown and where there's less help available, then my bets are that rescue breathing will be a waste of time and the lightly trained solo rescuer will probably not be successful in even accomplishing it -- everyone wants to be perfect in a rescue situation, but everyone's effectiveness is slashed down 1/4 or less -- training needs to be simplistic and to handle the overwhelmingly likely cases. So outside of debating on the internet over edge cases, just get their gear off and get them out of the water, that will always be the right answer...