Rescue breathing when there is no pulse

[ssra30]

ScottNY, I think you are right on! Checking for pulse is not always easy, giving a diving situation, being in less than ideal environment, wetsuit, victim clamped down due to hypothermia etc, it is very difficult to assess pulses, circulation etc accurately so I agree that when in doubt, rescue breathe should be applied and assume that there might be circulation.
The only situation that it should not be applied is where the rescuer could be put at risk or less likely when it might slow down the transport time significantly, stressing significantly!

 

[cmay]

This is just my $.02, but the idea is to keep things simple. Personally, I will not waste the time to try and check for a pulse in the water. It is irrelevant whether there is a pulse or not. There is nothing you can do about it if one is not present, until you get the victim out of the water. I am a K.I.S.S. kind of person. The idea is to start rescue breathing and "haul a**" for the boat/shore. If you are having trouble performing rescue breathing and moving at the same time, practice. It will get better.

 

[g8trdiver]

divemed06, this is the information I recently received at my CPR/First Aid refresher course - that they no longer teach to check the pulse, but rather check for breathing, open the airway and administer 2 rescue breaths, then check for "signs of circulation" - the (according to the class) most obvious of which would be a change in coloration.... Though - I guess that's questionable too according to some here....???

In fact, they were still using a video made prior to the adoption of the new phiilosophy, and the instructor stopped it where they showed the pulse-checking part to make that point.

 

[ssra30]

g8trdiver once bubbled...
divemed06, this is the information I recently received at my CPR/First Aid refresher course - that they no longer teach to check the pulse, but rather check for breathing, open the airway and administer 2 rescue breaths, then check for "signs of circulation" - the (according to the class) most obvious of which would be a change in coloration.... Though - I guess that's questionable too according to some here....???

I am curious about sign of circulation bit. What did they actually say to check for in class. My usual assessment for circulation would be something like check for pulses, coloration, mottling of the skin (rather vague and again, hypothermia or hypoxia alone would make a person blue even with circulation intact), feeling for warmth in extremity (again rather vague), capillary refill (again, rather controversal in its usefulness, beside I doubt you would waste your time trying to take a glove off and check the finger in a rescue situation). My feeling is that they are replacing checking for pulses with something rather more vague and more subjective. Also how could you tell in a person who is not breathing whether the change in coloration is due to lack of oxygen or lack or circulation. Giving two rescue breath would certainly not neccessarily restore in coloration in someone who has intact circulation and not breathing. Just a thought...

 

[g8trdiver]

I totally agree that this is a more vague means of determining whether there is a pulse - maybe they do not want to leave it to a non-professional to determine whether there is a pulse.

If you're going to err on one side or the other - best to err on the side of "no pulse" , and start compressions - rather than "think" you feel a pulse and not. People with more experience checking pulses would be more accurate - where checking for "signs" (the ones you mention) is less conclusive, and would lead one to err on the "no circulation" side, if it is so difficult to tell. (I guess one could have visual hallucinations as well as tactile ones, though)....

The protocol goes on to recommend that assuming no circulation was detected after the 2 initial breaths, begin compressions, and after 100 compressions (comprised of 15 compressions then 2 breaths...(for adults)...), pause and check once more for "signs of circulation".

After that, there is no more pausing and checking for signs - it's just continue the compressions/breaths until you are relieved or keel over from exhaustion (or until the victim revives - which - of course, they stress is highly unlikely without advanced care).

I'm not reading this off anything - I'm going from my memory from the class - so if I have something wrong, please someone correct me. However - this is the protocol as I remember it from the class.

I will contact the instructor for the class with these questions, though. If this protocol was adopted, as divemed06 indicated too, then I guess the questions should be answered by those institutions. I'll look also on the American Safety and Health Institute site to see if they have anything about it.

 

[divemed06]

Here is a link to the Canadian guidelines and the rationale behind some of the changes. Go to page 2 for the pulse issue.
http://www.hsfpe.org/ClientImages/1/BCLS Guidelines Summary HSFC.pdf

The Heart and Stroke of Canada is the equivalent to the American Heart Association in the US.

 

[ScottNY]

The Canadian change sheet is interesting. I like the format and it's a sensible way to present such things. Answers questions any trainers would clearly have during a change.

But for the pulse check, the rationale is not rally that clear. For example, they seem to be concenred about someone unnecessarily hooking up an AED. But so what? An AED won't shock unless there's a shockable rhythm.

I don't know... in general... that particular block just seems strage to interpret. The only part that's clear - to me anyway - is their concern about lay rescuers missing the pulse. (I guess all in all that's ok since that's maybe the most important point.)

Scott

 

[divemed06]

ScottNY once bubbled...
The Canadian change sheet is interesting. I like the format and it's a sensible way to present such things. Answers questions any trainers would clearly have during a change.

But for the pulse check, the rationale is not rally that clear. For example, they seem to be concenred about someone unnecessarily hooking up an AED. But so what? An AED won't shock unless there's a shockable rhythm.

I don't know... in general... that particular block just seems strage to interpret. The only part that's clear - to me anyway - is their concern about lay rescuers missing the pulse. (I guess all in all that's ok since that's maybe the most important point.)

Scott

Scott,
I agree with you that the explanations arn't detailed but they are targeted to the lay person. In regards to putting the AED on a patient with a pulse, I believe what they meen is that the time wasted doing this could be used giving rescue breaths. If you want a more complete explanation, look the scientific journal : Circulation. Do a search for 2000 consensus on CPR and it should bring up the the article which highlights the 2000 ECC conference in San DIegi where all these changes took place. You may have to go to a University library (ie. medline database)to look this journal up because otherwise you have to pay a fee to acces articles. Good luck!

 

[g8trdiver]

I got a response to my questions from the instructor of my CPR refresher course.

Here is an excerpt from one of her emails:

"....My best educated "guess" in handling a water situation would
be to think about how long the person has been unconscious.
If it has been less than 3-4 minutes, let's assume they DO
have a pulse and rescue breathing should be
given...otherwise you are likely to lose a pulse in
transport. Longer than 5 minutes of unconsciousness,
definitely get them to the boat ASAP.

You can always try to feel for a carotid pulse if you can
get to it and wasn't to confirm your suspicions. Most divers
are in better shape than the usual population so a pulse
will be easier to determine. As far as other "obvious signs
of circulation" are concerned, the coolness of the water
will make those signs not so obvious and it probably would
appear like they do NOT have a pulse....."

She said that the explaination of the changes in CPR recommendations is explained in a 200 page publication which you can order from the American Heart Association or download in .pdf form. www.americanheart.org

I haven't had time to go looking for it yet..... so if anyone finds it, please let me know. When I have the time, I'll check it out too.

Meanwhile, her husband is also a certified Rescue diver and Paramedic. Not to re-hash the debate over rescue breathing with no pulse, but here is an excerpt from the email she sent me:

"....He said to definitely continue doing
rescue breathing all the way to the boat. The oxygen will
enter the blood stream regardless of heart beat and this
prevents hypoxia (which can change the acid/base balance of
the body and present a whole host of other problems). The
brain will also benefit from the mouth to mouth breathing...."

 

[jbd]

keep in mind. If the standard of care is to provide rescue breaths from the point of surfacing to the point of exit then that is what will be required to hold up in a court of law.