In my CPR refresher course, the instructor insisted that rescue breathing can be effective in delivering oxygen to the brain even if there is no pulse. The NAUI and PADI Rescue Diver courses teach one to do in-water rescue breathing on a non-breathing diver whether or not there is a pulse. Considering the necessity of speed in getting oxygen to the brain in a person with no pulse and who is not breathing, it seems counterproductive to delay getting a victim out of the water by performing rescue breathing while towing a non-breathing diver with no pulse. Does rescue breathing provide any benefit to a person with no pulse?
Rescue breathing when there is no pulse
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Here's my take as an old ACLS Instructor:
With no pulse, rescue breathing will have little or no effect on oxygen delivery to the brain.
With a pulse but no breathing, the lack of rescue breathing will soon result in a no pulse situation.
It is difficult to accurately assess the presence or absence of a pulse while in-water. You cannot adequately peform chest compressions in-water.
So...the theory is that you don't know if there is a pulse, so get the patient to shore as quickly and efficiently as possible while doing rescue breathing. The proper administration of rescue breathing should not excessively delay removal from the water. This approach takes care of both "pulse" situations.
With no pulse, rescue breathing will have little or no effect on oxygen delivery to the brain.
With a pulse but no breathing, the lack of rescue breathing will soon result in a no pulse situation.
It is difficult to accurately assess the presence or absence of a pulse while in-water. You cannot adequately peform chest compressions in-water.
So...the theory is that you don't know if there is a pulse, so get the patient to shore as quickly and efficiently as possible while doing rescue breathing. The proper administration of rescue breathing should not excessively delay removal from the water. This approach takes care of both "pulse" situations.
chrpai
Contributor
I had the same question in my rescue class and never had a good answer either.
I understand what the last poster said, but I think when one gets in the water and practices rescue breathing while doing a tow the "should not delay" part seems kinda impossible. We aren't all muscle bound perfectly conditioned machines that can tow, strip and breath at the same time.
I think the reality for many of us the rescue breathing will delay the exit so the question remains, which is more important? Get out fast or keep breathing when there may or may not be a pulse.
I understand what the last poster said, but I think when one gets in the water and practices rescue breathing while doing a tow the "should not delay" part seems kinda impossible. We aren't all muscle bound perfectly conditioned machines that can tow, strip and breath at the same time.
I think the reality for many of us the rescue breathing will delay the exit so the question remains, which is more important? Get out fast or keep breathing when there may or may not be a pulse.
The "should not excessively delay removal from the water" was the point behind my question. Rescue breathing will substantially delay removal of the victim from the water. But, as I have thought about it, maybe this doesn't make any difference.
Assuming that 4 minutes without oxygen pretty much guarantees brain death, my question comes from a possible situation of being able to tow a diver to CPR in under 4 minutes, or needing to take more than 4 minutes to get the victim to CPR while giving rescue breathing. The options are:
1. You don't find a pulse. Assume that there may be a pulse and provide rescue breathing. If there isn't one, then the victim will be dead when CPR might have worked (about 10% chance of survival). If there is in fact a heartbeat, then this is the best chance at a rescue.
2. You don't find a pulse. Conclude that you are right and get the person to CPR as soon as possible (about 10% chance of survival). But, if you are wrong, you may have substantially reduced the chance of survival.
Because an existing pulse may be difficult to find and the success rate of CPR is low, it looks like the best decision considering the odds is option 1 -- assuming that you choose to rescue or have a duty to do so. Did I miss anything here?
Also, I am still curious to know whether there is any evidence that rescue breathing could help a victim without a heartbeat survive.
Assuming that 4 minutes without oxygen pretty much guarantees brain death, my question comes from a possible situation of being able to tow a diver to CPR in under 4 minutes, or needing to take more than 4 minutes to get the victim to CPR while giving rescue breathing. The options are:
1. You don't find a pulse. Assume that there may be a pulse and provide rescue breathing. If there isn't one, then the victim will be dead when CPR might have worked (about 10% chance of survival). If there is in fact a heartbeat, then this is the best chance at a rescue.
2. You don't find a pulse. Conclude that you are right and get the person to CPR as soon as possible (about 10% chance of survival). But, if you are wrong, you may have substantially reduced the chance of survival.
Because an existing pulse may be difficult to find and the success rate of CPR is low, it looks like the best decision considering the odds is option 1 -- assuming that you choose to rescue or have a duty to do so. Did I miss anything here?
Also, I am still curious to know whether there is any evidence that rescue breathing could help a victim without a heartbeat survive.
I definitely agree wtih randyjoy here. Having done quite a bit of BLS/ACLS stuff, I think whether you are on land or water, establish airway and breathing is always a priority, pulse or no pulse. I agree that with no pulse, rescue breathing alone is not effective. However with a person in wetsuit, it is difficult to accurately detect a pulse. Let say that you have to tow a person to a boat 50 yards away, how much longer would it take you to tow the person there if you admisnister rescue breath vs just towing?
Personally, I probably would throw in couple of ventricular thump if I can't feel the pulse either. I think this is one of the situation where at worse, it does not make a difference but it can also potentially save life.
Personally, I probably would throw in couple of ventricular thump if I can't feel the pulse either. I think this is one of the situation where at worse, it does not make a difference but it can also potentially save life.
I started teaching CPR in 1976, and have seen CPR evolve over the years from several different types of procedures (witnessed arrest, unwitnesed, etc.) to just one basic procedure for all types of cardiac arrest situations; both to simplify the steps so that any and everyone could administer CPR, and to take the choices out of the equation. The odds are looked at, and a procedure is developed that should help the greatest number. You don't have to worry about "Should I have done this instead?"
The pulse present/no breathing situation has the greatest odds at survival, since the heart is still beating. Once the heart has stopped, it is generally accepted that it takes 4-6 minutes for cerebral biological death to begin (and that is temperature dependent). If you can start ventilations before the heart stops, then ventilations can keep the brain and heart oxygenated and hopefully, keep everything working.
Bottom line, in theory, it shouldn't take 4 EXTRA minutes to get a person out of the water. Towing a victim to shore/boat vs. towing a victim while administering artificial ventilations shouldn't excessively (a that is a key word) delay removal. Can anyone come help or are you alone?
In my line of work, we will begin artificial ventilations on any person we bring up if from time of notification to recovery is 60 minutes or less. In cold water, many public safety dive (PSD) teams extend that time (though some teams do not advocate any in-water ventilations, but removal before any care is administered. Remember, though, a fully deployed PSD team has the equipment and ability to almost immediately remove the victim from water).
I've seen little evidence that breathing for a patient with no pulse will have any benefit. However, if the patient has a pulse with a low enough pressure, you may not be able to feel a pulse, even though one is present; likewise, you may not be able to feel a pulse because of your own adrenaline, cold water, clothing, gloves, etc. Ventilations alone will be a benefit to these patients.
The pulse present/no breathing situation has the greatest odds at survival, since the heart is still beating. Once the heart has stopped, it is generally accepted that it takes 4-6 minutes for cerebral biological death to begin (and that is temperature dependent). If you can start ventilations before the heart stops, then ventilations can keep the brain and heart oxygenated and hopefully, keep everything working.
Bottom line, in theory, it shouldn't take 4 EXTRA minutes to get a person out of the water. Towing a victim to shore/boat vs. towing a victim while administering artificial ventilations shouldn't excessively (a that is a key word) delay removal. Can anyone come help or are you alone?
In my line of work, we will begin artificial ventilations on any person we bring up if from time of notification to recovery is 60 minutes or less. In cold water, many public safety dive (PSD) teams extend that time (though some teams do not advocate any in-water ventilations, but removal before any care is administered. Remember, though, a fully deployed PSD team has the equipment and ability to almost immediately remove the victim from water).
I've seen little evidence that breathing for a patient with no pulse will have any benefit. However, if the patient has a pulse with a low enough pressure, you may not be able to feel a pulse, even though one is present; likewise, you may not be able to feel a pulse because of your own adrenaline, cold water, clothing, gloves, etc. Ventilations alone will be a benefit to these patients.
Some good answers here. What concerns me is that some of you couldn't get an answer to the question in your rescue class.
Just because you practice towing, removing gear and rescue breathing all at the same time in class doesn't mean that's always the best way to do it. The instructor should have stressed "thinking on your feet" and doing what makes the most sense for the situation.
Breath for them. If it takes much longer to tow them because of it, practice more. Since it's hard to tell if they have a pulse in the water we assume that they do. Remove the gear you need to remove to facilitate egress.
Just because you practice towing, removing gear and rescue breathing all at the same time in class doesn't mean that's always the best way to do it. The instructor should have stressed "thinking on your feet" and doing what makes the most sense for the situation.
Breath for them. If it takes much longer to tow them because of it, practice more. Since it's hard to tell if they have a pulse in the water we assume that they do. Remove the gear you need to remove to facilitate egress.
chrpai
Contributor
Well they did stress thinking on your feet. But on the other hand when your going through the drills being evaluated on the skills you dont exactly feel like your allowed to break out of the mold.
I can just hope that if the time comes I'll have other people with me so that we can do the rescue breathing while still hauling ass for the exit.
I can just hope that if the time comes I'll have other people with me so that we can do the rescue breathing while still hauling ass for the exit.
I talked to a surgeon who dives and an anesthesiologist today. Both confirmed that rescue breathing is of no benefit to a person with no heartbeat. They also noted that there is a substantial possibility of missing an existing pulse on a diver/victim in the water. According to both of them, the best choice based on the odds from all possible situations, actions, and outcomes is to do rescue breathing for a not-breathing victim/diver in the water.
ScottNY
Contributor
Some thoughts on the topic...
(FYI... I'm not a doc... but volunteer EMT for 18 years.)
* Artificial respirations in a pulseless individual are pointless. Without circulation, no tissue, (including brain), oxygenation will occur.
* If the issue is not being sure of pulse, I'd suggest trying to be more sure of this by...
+ practicing finding and testing for pulse in BOTH carotid, (neck), arteries. (Yes, some people may have weaker pulses and bobbing in waves can make this difficult.) And give yourself a bit mroe time to relax and try to find it. You're going to throw a couple of rescue breaths in first anyway. It's more important to know what you're dealing with and do the right thing rather than do the wrong thing quickly.
* The "pericardial thump" or "precordial thump" is kind of an unknown. While there's no way I can see you can really do effective CPR without a firm surface behind the victim, MAYBE you could try that sharp blow to sternum, BUT, there is nothing I've ever read anywhere that indicates this as an accepted protocol for diving emergencies. (And I'm not quite sure how you'd effectively do it in the water with BC's and wetsuits anyway.) The thump is administered with one sharp closed fisted hit to the mid/lower part of sternum. The theory is that it can convert some heart rhythms back to sinus rhythm. In the end, it's your call and if the person's dead, it can't hurt. If they do have a pulse, and you do this it could; however hurt. If someone SEES you do this, you could also have a legal issue unless you have some really good reason why you did it. (You'll need to check the Good Samaritan laws in your state for details... but usually, these are based on what a "prudent reasonable person would do." Morever, if you do have a CPR card or training, and you go beyond that "standard of care" you may not be just a "reasonable prudent person" but a trained person who did something not indicated by their training.
For details on the thump, see... Colqhhoun, M et al. 1995. ABC of Resuscitation. 3rd edn. BMJ Publishing Group. London (or just search for "precodial thump" in Google or something.)
Remember, the way CPR actually works is part using pressure to push blood, but also may stimulate the electrical parts of the heart to beat and push blood. There was a REASON for the arrest. If it was trauma or something reversible, great. If not, it's a done deal.
The bottom line though, is CPR alone, even if almost immediate, still has a tiny percentage of bringing someone out of it. (Like under 5%.) What you really need is an Automated External Defribrilator, which supposedly increases chances to a whoppingly different 43/% IF CPR was started immediately and defib happens within 8 minutes... chances decreases 10% every minute thereafter that there's no defib. Without defib, sorry... but chances are real slim.
Details: http://www.delmarhealthcare.com/pdf/ch25.pdf
Lastly, and most importantly, protect yourself. If you are bobbing around in the seas, you have to be concerned with your own survival as well as the patients. If you are not fully buoyant and become exausted assisted a victim, you could have problems of your own. You've now doubled the workload of anyone else coming to assist as well as put yourself at risk. If you ever have the unfortunate luck to have to do this; do what you can, but don't kick yourself if things don't work out like on television. It's rarely like that.
Scott
(FYI... I'm not a doc... but volunteer EMT for 18 years.)
* Artificial respirations in a pulseless individual are pointless. Without circulation, no tissue, (including brain), oxygenation will occur.
* If the issue is not being sure of pulse, I'd suggest trying to be more sure of this by...
+ practicing finding and testing for pulse in BOTH carotid, (neck), arteries. (Yes, some people may have weaker pulses and bobbing in waves can make this difficult.) And give yourself a bit mroe time to relax and try to find it. You're going to throw a couple of rescue breaths in first anyway. It's more important to know what you're dealing with and do the right thing rather than do the wrong thing quickly.
* The "pericardial thump" or "precordial thump" is kind of an unknown. While there's no way I can see you can really do effective CPR without a firm surface behind the victim, MAYBE you could try that sharp blow to sternum, BUT, there is nothing I've ever read anywhere that indicates this as an accepted protocol for diving emergencies. (And I'm not quite sure how you'd effectively do it in the water with BC's and wetsuits anyway.) The thump is administered with one sharp closed fisted hit to the mid/lower part of sternum. The theory is that it can convert some heart rhythms back to sinus rhythm. In the end, it's your call and if the person's dead, it can't hurt. If they do have a pulse, and you do this it could; however hurt. If someone SEES you do this, you could also have a legal issue unless you have some really good reason why you did it. (You'll need to check the Good Samaritan laws in your state for details... but usually, these are based on what a "prudent reasonable person would do." Morever, if you do have a CPR card or training, and you go beyond that "standard of care" you may not be just a "reasonable prudent person" but a trained person who did something not indicated by their training.
For details on the thump, see... Colqhhoun, M et al. 1995. ABC of Resuscitation. 3rd edn. BMJ Publishing Group. London (or just search for "precodial thump" in Google or something.)
Remember, the way CPR actually works is part using pressure to push blood, but also may stimulate the electrical parts of the heart to beat and push blood. There was a REASON for the arrest. If it was trauma or something reversible, great. If not, it's a done deal.
The bottom line though, is CPR alone, even if almost immediate, still has a tiny percentage of bringing someone out of it. (Like under 5%.) What you really need is an Automated External Defribrilator, which supposedly increases chances to a whoppingly different 43/% IF CPR was started immediately and defib happens within 8 minutes... chances decreases 10% every minute thereafter that there's no defib. Without defib, sorry... but chances are real slim.
Details: http://www.delmarhealthcare.com/pdf/ch25.pdf
Lastly, and most importantly, protect yourself. If you are bobbing around in the seas, you have to be concerned with your own survival as well as the patients. If you are not fully buoyant and become exausted assisted a victim, you could have problems of your own. You've now doubled the workload of anyone else coming to assist as well as put yourself at risk. If you ever have the unfortunate luck to have to do this; do what you can, but don't kick yourself if things don't work out like on television. It's rarely like that.
Scott
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