# Could use a little CPR help



## Gothemi (Dec 2, 2009)

Sorry if this is a dumb question, but in studying for this NREMT my mind is numb...

I have been reading my textbook front to back and found a few errors here and there.  I am looking at the CPR/AED use portion and the text say in regards to SINGLE rescuer CPR/AED after verifying pulseness and apnea "turn on AED power, attach the device to the patient, initiate analysis of the rhythim, and deliever a shock if necessary."  

I read the AHA guidelines and it seems to reference providing CPR first for 2 minutes and then applying and using the AED.  I know if the event was witnessed (except for children and infants) to go straight to AED, but if unwitnessed, shouldn't I be applying an AED after attempting CPR?  

Sorry if it is dumb, I would ask if I haven't read it several times and wasn't still having trouble.  

Thanks,


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## nomofica (Dec 2, 2009)

I was taught 2 mins. of CPR and then apply/use AED for a single-rescuer unwitnessed arrest.


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## medicdan (Dec 2, 2009)

CPR protocols have changed greatly in the past years, and will again soon. Individual state protocols have started to differ from AHA, ARC and textbook recommendation. 
Ultimately, the answer depends on who is asking the question, and the specific situation. Recent protocols call for 2 minutes of good CPR before analyzing and shocking, except in the case of a witness arrest, where you would analyze and shock immediately. 

If alone, and without an AED or pocket mask, I would confirm unresponsiveness and pulselessness, and begin compressions immediately, after making sure ALS is on the way, in addition to an AED.


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## nomofica (Dec 2, 2009)

Ditto on no BSI; I'm even really iffy on mouth-to-mouth with close friends/family.


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## squrt29batt12 (Dec 2, 2009)

For NREMT testing purposes, use what the NREMT says, regardless of current AHA guidelines. For field purposes, obviously use the current guideline.


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## Micro_87 (Dec 2, 2009)

whatever the AHA say's go with that, and that's the way that i was taught as well.


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## medichopeful (Dec 3, 2009)

I don't really know what the NREMT protocol is, but here's the deal.

In any arrest, the priority is to use the AED ASAP.  That being said, there are some things that must be taken into consideration.

If the arrest was UNWITNESSED, there needs to be 2 minutes of CPR administered BEFORE the AED is used.  The reason behind this is relatively simple.  If the patient has been in cardiac arrest for any length of time, the blood will not have been moving, which would prevent many bodily processes from happening, such as exchange of oxygen and nutrients.  If the blood has just been sitting there, it will be "stale" and old.  In order for an AED to be most effective, this blood must be circulated, so that oxygen gets into the bloodstream (remember, you are providing 2 rescue breaths before compression, and then you are circulating that air throughout the body).  The 2 minutes of CPR basically "primes the pump," and prepares the body for defibrillation.  If you get called to a scene where good, effective CPR is being performed, and it was started after collapse and has been going on for at least 2 minutes, go straight to the AED, because of the fact that the body will have already been "prepared."

For a WITNESSED arrest, go straight to the AED, if it's immediately available.  If not (or even just while it's being set up), do CPR until it tells you to clear the patient.

Again, I don't know what the NREMT standards are, so be careful.  But in real life, this is the correct way to do it as far as I know.

I hope this helps!


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## dmc2007 (Dec 3, 2009)

medichopeful said:


> If the arrest was UNWITNESSED, there needs to be 2 minutes of CPR administered BEFORE the AED is used.  The reason behind this is relatively simple.  If the patient has been in cardiac arrest for any length of time, the blood will not have been moving, which would prevent many bodily processes from happening, such as exchange of oxygen and nutrients.  If the blood has just been sitting there, it will be "stale" and old.  In order for an AED to be most effective, this blood must be circulated, so that oxygen gets into the bloodstream (remember, you are providing 2 rescue breaths before compression, and then you are circulating that air throughout the body).  The 2 minutes of CPR basically "primes the pump," and prepares the body for defibrillation.  If you get called to a scene where good, effective CPR is being performed, and it was started after collapse and has been going on for at least 2 minutes, go straight to the AED, because of the fact that the body will have already been "prepared."



The 2 minutes/5 cycles of CPR before AED application only applies when the call-to-arrival time is greater than 4-5 minutes.  In most EMS situations this will be the case, but it is worth noting.


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## reaper (Dec 3, 2009)

2 minutes of CPR in any unwitnessed arrest! 

You have no idea how long they have been down!


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## TheMowingMonk (Dec 3, 2009)

DMC2007 has it right. for NREMT, they use what ever AHA says is the current guidelines. basically NREMT follows the 2005 AHA guidelines. By AHA guidelines for BLS for the Healthcare provider for an adult victim you attach the AED after Doing 2 minute/5 cycles if the call to arrival time is greater then 4-5 minutes. Because current science is showing that if the AED is not applied immediately you increase the survival rate of the pt but doing CPR and priming the heart making sure it has blood in it before shocking. If you have a witnessed arrest though and the AED is applied immediately this isnt an issue cause the heart is already primed with blood since it was beating right before. And this is a point the AHA is going to empasize more when they change their guidelines in 2010.


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## CountryEMT-bGurl (Dec 3, 2009)

*NREMT Skills sheet*

OKay, so for your NREMT. They will state CPR by a bystander is already in progress when you arrive. You when then do per NREMT testing.. 



ASSESSMENT
Takes, or verbalizes, body substance isolation precautions 1
Briefly questions the rescuer about arrest events 1
Turns on AED power 1
Attached AED to the Patient 1
Directs rescuer to stop CPR and ensures all individuals are clear of the patient 1
Initiates analysis of the rhythm 1
Delivers shock 1
Directs resumption of CPR 1
TRANSITION 1
Gathers additional information about arrest event 1
Confirms effectiveness of CPR (ventilation and compressions) 1
INTEGRATION
Verbalizes or directs insertion of a simple airway adjunct (oral/nasal airway) 1
Ventilates, or directs ventilation of, the patient 1
Assures high concentration of oxygen is delivered to the patient 1
Assures adequate CPR continues without unnecessary/prolonged interruption 1
Continues CPR for 2 minutes 1
Directs rescuer to stop CPR and ensures all individuals are clear of the patient 1
Initiates analysis of the rhythm 1
Delivers shock 1
Directs resumption of CPR 1
TRANSPORTATION
Verbalizes transportation of patient 1


Critical FAIL
Did not take, or verbalize, body substance isolation precautions
Did not evaluate the need for immediate use of the AED
Did not immediately direct initiation/resumption of ventilation/compressions at appropriate times
Did not assure all individuals were clear of patient before delivering each shock
Did not operate the AED properly (inability to deliver shock)
Prevented the defibrillator from delivering indicated stacked shocks


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## wyoskibum (Dec 3, 2009)

Here is a link to the National Registry Skill Sheets:

http://www.nremt.org/nremt/about/exam_coord_man.asp#BSkillSheets


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## CountryEMT-bGurl (Dec 3, 2009)

wyoskibum said:


> Here is a link to the National Registry Skill Sheets:
> 
> http://www.nremt.org/nremt/about/exam_coord_man.asp#BSkillSheets



Also you can go to EMTB.com
Good site that has the skills on there as well.


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## Gothemi (Dec 3, 2009)

Thank you, I think that has cleared up a lot.  

CPR in progress upon arrival=AED

No CPR in progress and you did not witness the event=CPR for 2 min (5 cycles) and then AED.  

Witnessed by you=AED then CPR.


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## medichopeful (Dec 3, 2009)

Gothemi said:


> Thank you, I think that has cleared up a lot.
> 
> CPR in progress upon arrival=AED



only if it's effective CPR and has been been going on for at least two minutes or since collapse


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## Gothemi (Dec 3, 2009)

Right, if there are not doing it correctly you must intervene then correct?  

Now let me ask you this.  My book indicates you should check pulse after delievery of shock, however, it looks as though (according to AHA) you should actually go straight into CPR for 2 minutes w/o checking the pulse after shock.  

That seems strange, but I guess it is too assist with getting good oxygen to a freshly shock heart???


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## reaper (Dec 3, 2009)

Here's a small hint, They teach all this in a CPR class!


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## Gothemi (Dec 3, 2009)

I understand, but like I said I wouldn't ask if I wasn't looking for some help in understanding.  My instructor wasn't/isn't much help.  

My class was pretty much read out of your text book, then answer some basic questions.  I am now attempting to gain a better understanding of the hows and whys as opposed to the "do it because the text says to."


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## zmedic (Dec 3, 2009)

Yes, right to CPR after shock because:

1. They found even after sucessful defib it takes several seconds (like 30-60) for the heart to start pumping enough to perfuse and detect a pulse. Therefore you need to support the body for those next two minutes until the heart builds up pressure. 

2. If the shock didn't work delays in compressions are bad.

3. Compressions to a heart that has been sucessfully shocked are unlikely to cause harm or cause a revert to v fib/v tach.


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## medichopeful (Dec 3, 2009)

Gothemi said:


> Right, if there are not doing it correctly you must intervene then correct?



Correct.  If they are doing it incorrectly (say, on the abdomen), you need to intervene ASAP and also do your best to correct their error (for example, in the example I provided, there's a good chance they will need some serious suctioning).  Keep in mind that an intervention could just be a correction (such as, "move your hands here for me, sir").  The determination is going to be yours to make.  If it's adequate, and it's getting the job done, go to the AED.  If it's not being done correctly, and it's not getting the job done, take over, whether it's just by giving directions or by taking over completely.

As somebody else said, the 2 minutes of CPR is the case if the response time is greater than 4-5 minutes.  If it's less than that (from time of collapse to patient contact), I believe you should just use the AED ASAP.  SOMEBODY CORRECT ME IF I'M WRONG.



> Now let me ask you this.  My book indicates you should check pulse after delievery of shock, however, it looks as though (according to AHA) you should actually go straight into CPR for 2 minutes w/o checking the pulse after shock.
> 
> That seems strange, but I guess it is too assist with getting good oxygen to a freshly shock heart???



Are you using the Brady book ("Emergency Care")?  Go with what AHA says.  Go straight into CPR, like the AED tells you.  Don't check for a pulse, unless they either start moving by themselves, or you are going to transport them.  And even then, make the pulse check quick.  Don't let it delay compressions (if still needed).

I hope this helps.


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## medichopeful (Dec 3, 2009)

Gothemi said:


> I understand, but like I said I wouldn't ask if I wasn't looking for some help in understanding.  My instructor wasn't/isn't much help.
> 
> My class was pretty much read out of your text book, then answer some basic questions.



Don't ever be ashamed or feel it's unnecessary to ask questions.  How else will you learn?



> I am now attempting to gain a better understanding of the hows and whys as opposed to the "do it because the text says to."



Good for you!  That's a very good attitude to have.  Don't lose it.


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## Gothemi (Dec 3, 2009)

Thank you that does help.  Our assigned book for my class was the Mosbys EMT-Basic 2nd edition.  Not a great book IMO.  

I am not trying to blame the book or class, but I have found several contraditions between the book and the AHA.  

Ie; provide art. vent. and chest compressions on infant with pulse less than 80, where AHA states less than 60.  

Check pulse after delievery of shock

and so on.  

I was supposed to take my NREMT today, but have since rescheduled as I don't feel 100% ready in light of these and other issues.


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## VentMedic (Dec 3, 2009)

CPR is some of the meat and potatoes of being an EMT.  Sitting through another 4 hour CPR class at the AHA won't hurt you and you will get more hands on experience to perfect the information and skills. You may also get a decent instructor who knows a little about CPR.   The more times you do it in a practice session the more it will start to make sense.  Just memorizing a few words for a test will not be of much help when it counts once you are faced with a situation requiring CPR.


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## medichopeful (Dec 3, 2009)

Gothemi said:


> Thank you that does help.  Our assigned book for my class was the Mosbys EMT-Basic 2nd edition.  Not a great book IMO.
> 
> I am not trying to blame the book or class, but I have found several contraditions between the book and the AHA.
> 
> ...



I would say almost always go with what the AHA says when it comes to CPR.  It's their specialty.


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## imurphy (Dec 3, 2009)

To the OP.

This is a question that people get wrong in all levels be it CPR, EMT, Paramedic or ACLS. The simple reason is you are reading too much into the question. 

The question is asking you of the correct use of an AED. The question assumes that you have already *assertained the need for AED use.* The question is about AED specifically, not about CPR. 

The correct answer is:

Power on the AED, Apply Pads, Analyze Rythm, and Shock if indicated.

Hope this helps


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## zmedic (Dec 3, 2009)

medichopeful said:


> As somebody else said, the 2 minutes of CPR is the case if the response time is greater than 4-5 minutes.  If it's less than that (from time of collapse to patient contact), I believe you should just use the AED ASAP.  SOMEBODY CORRECT ME IF I'M WRONG.



That's right, but to emphasize if you are responding to a 911 call you should be expecting to do CPR first. When you figure the time it takes for someone to realize there is a problem, call 911, dispatch to sort out what's up, you to get toned and moving etc there is almost no way you are there in 4 minutes from collapse. I'm just pointing this out because I feel like there are some people who say "it only took us 5 minutes to get there, so we went to shock," not thinking about how long it took to get things moving. 

If they go down in front of you that's pretty much the only time you should start with a shock. Easier to think that way than try to time your response time.


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## gamma6 (Dec 16, 2009)

field vs. book, 2 totally different monsters..for testing use the book. 

witnessed: shock em 
unwitnessed: 2 min cpr then defib em

only if in v-fib or pulseless v-tach!

asystole (fine v-fib) :well you'll only shock em once. (joke)


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## claytondirk (Dec 16, 2009)

gamma6 said:


> field vs. book, 2 totally different monsters..for testing use the book.
> 
> witnessed: shock em
> unwitnessed: 2 min cpr then defib em
> ...



could not have said it any better my self you will get in the field you will learn how much different things really are.


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## gamma6 (Dec 16, 2009)

thank you...finally some one that agrees....

being in the field you will learn tricks of the trade that you will never learn in the book or cpr class......that you are never in perfect world in the field

if you don't think it will go wrong, it will go wrong...ajust to the situation....


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## EMTecBOB (Dec 20, 2009)

On my AED skill sheet, there was nothing about preventing stacked shocks. I did not think we did stacked shocks anymore.


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## TheMowingMonk (Dec 20, 2009)

EMTecBOB said:


> On my AED skill sheet, there was nothing about preventing stacked shocks. I did not think we did stacked shocks anymore.



no more stacked shocks, if your AED sheet says that its outdated


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## reaper (Dec 20, 2009)

Some of the older AED's still do stacked shocks. They would have to have the software updated to change that.


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