# Sellick maneuver for BASIC resuscitation...what's up?



## mycrofft (Jul 9, 2010)

My boss/friend says a local EMS instructor is asking about it because his students are asking about it, allegedly it is "becoming the standard".
I get the basics (use the hard cartilige around the cricoid to compress the esophagus without shutting off the airway), but it ties up another rescuer, one more set of feet and shoulders etc to work around and coordinate, and has some important contraindications, plus it hurts _mui grandioso_ and has people squishing the neck by the thyroids.

What say? Is it YOUR standard? How does it work?


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## Veneficus (Jul 9, 2010)

mycrofft said:


> My boss/friend says a local EMS instructor is asking about it because his students are asking about it, allegedly it is "becoming the standard".
> I get the basics (use the hard cartilige around the cricoid to compress the esophagus without shutting off the airway), but it ties up another rescuer, one more set of feet and shoulders etc to work around and coordinate, and has some important contraindications, plus it hurts _mui grandioso_ and has people squishing the neck by the thyroids.
> 
> What say? Is it YOUR standard? How does it work?



Only if there is an extra pair of hands.

A lot of people teach it improperly though. It should not hurt. The pressure should also not be straight back, it should be like pushing skin away from the center. The more diffuse the pressure the more of the esophagus is occluded. If you are performing the procedure correctly, you can do it even to yourself without discomfort, you will sound like a duck when you talk and your secretions will build really fast because you cannot swallow but aside from that there is no pain.

It is also important that it is the cricoid ring that is depressed not the thyroid. For the same reason the emergent cric exists, it should keep away from the coomon location of the thyroid, and the pressure is not really enough to cause a rupture unless you have a hot nodule,neoplasm, or destruction from hasmimotos or the like.

If we have an extra set of hands we employ it. We do not call for additional aid to do it. Rather then crowd them in we have them reach through people already there.


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## mycrofft (Jul 9, 2010)

*Sort of like I used to do with a too-tight helmet chin strap.*

..only lower.

Hurts if I do it, and things crackle. 

And the extra hands...all I keep seeing is "One...two...THREE!" (shuffle ouch shuffle yikes shuffle ow shuffle).
Seriously, when I googled it,the first article said it's practicality was being calle dinto question, but the NIH cited article from Aussieland said it was taught as the standard by AHA since 2007 for resuscitation (news to me).

Thanks!


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## Veneficus (Jul 9, 2010)

it's even in the video from AHA and the instructor is supposed to pause and discuss it.


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## mycrofft (Jul 9, 2010)

*Geez, am I behind. And I'm certified to teach CPR.*

I guess it will be in the profesional CPR stuff I'm about to learn.
Pssst, cheese it, I gave my boss the URL and maybe he'll join in.


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## Meursault (Jul 10, 2010)

http://www.scielo.br/scielo.php?scr...0034-70942008000600010&lng=en&nrm=iso&tlng=en

http://www3.interscience.wiley.com/cgi-bin/fulltext/118802143/HTMLSTART

Interesting stuff in these reviews. Apparently, 20 N of force on the cricoid hurts in a conscious patient, 30 is recommended, and 40 starts interfering with intubation. And on top of that, positioning matters. The second review talks about a study that tested periop RNs, and about others that tested residents and anesthesiologists. All three concluded that it needs specific training, particularly in the amount of force applied, and both reviews have suggestions for training devices.

In short, it's not something that most basics can be trusted with, and even if it were, it's not clear how useful it is.


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## MusicMedic (Jul 10, 2010)

Everytime somone mentions the Sellick Manever i cant help but think of this guy:


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## MrBrown (Jul 10, 2010)

Unless I am trying to intubate somebody after giving them really awesome drugs that the helicopter registrar and/or paramedic carries in the Thomas pack I don't see the point of using Sellick as part of standard CPR.

If you are worried about distending the stomatch while bagging somebody for example, then your technique sucks.


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## Sassafras (Jul 10, 2010)

I've only been on one cardiac arrest and we used it. Witnessed arrest aed in place in 30 seconds and still it was difficult to keep his head in a neutral position because he started stiffening up within ten minutes. There were 4 of us. One did compressions, one held the mask in place as we were having a heck of a time sealing it because he was so stiff already and his head would not go neutral completely.  one bagged him and the medic. Medic had me apply pressure with my free hand since I was bagging him. He did get meds and tubed and ventelations went easier then but he never puked. We were not clamoring over each other either. With good communication we switched rolls as one became fatigued and the medic just stepped back for a second and returned. No tripping or elbows in the face or other unpleasant things.  Sadly for how well we all worked together he didn't survive but all that to say yes we were trained to do it and yes we use it when indicated.


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## Veneficus (Jul 10, 2010)

MrConspiracy said:


> http://www.scielo.br/scielo.php?scr...0034-70942008000600010&lng=en&nrm=iso&tlng=en
> 
> http://www3.interscience.wiley.com/cgi-bin/fulltext/118802143/HTMLSTART
> 
> ...



"Vanner e Pryle 19 observed that 30 N (equivalent to 3 kg) was the necessary force that should be applied on the cricoid cartilage to prevent regurgitation of NS in 10 cadavers with esophageal pressure of up to 55 cmH2O."

If these cadavers were preserved, there would be a reduction in the elasticity of the esophagus, requiring more force to close it completely. You see the same thing with the pyloric sphincter in the stomach on preserved bodies. A few other sphyncters and vaults have similar characteristics in the preserved. It makes these numbers a bit suspect in my mind.

There is also the relative viscocity of stomoach contents compared to NS. again, I would take these numbers with a grain of salt.


"In awake individuals, applying more than 20 N on the cricoid cartilage can cause pain, cough and nausea. Thus, during anesthetic induction, while the patient is awake, 10 to 20 N should be applied, and 30 to 40 N when the patient is unconscious20."

I only got to read the study out of Brazil, the other wants me to buy it. (which isn't in the plan) "can cause pain" I find a bit suspect as well. Pain being not only subjective, but I encourage anyone to experiment with the difference in reported pain in hispanic cultures compared to any other culture. 

From my observations they have a broad definition of "pain" which seems to refer to anything that is abnormal.  They are also extremely vocal about pain, which itself can be a way to cope with it.

I don't agree with the AHA on everything, actually, rather a few things, but they decided to put the instruction in the BLS video for healthcare providers, so at least their consensus seems to think even non emergency HCPs (like LPNs, and nursing aides) can perform it effectively and safely enough.

Anyone performing any procedure improperly creates risk. All procedures have some level of risk, as always it is a decision that has to be weighed.

Going soley on education I could make a very strong argument that only a physician should be able to care for patients, but as always. Medics talk about how little basics know, nurses, the same with medics...

Taking a leaf from Mycroftt, 

"Five is four"


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## zmedic (Jul 11, 2010)

I don't understand why everyone is stressing about whether this procedure hurts on awake volunteers. To be doing this procedure means that someone isn't breathing (at least not enough to support them) and are likely unconscious. You don't do cricoid on awake patients. 

CPR, defibrillation, intubation etc hurt a lot too, there is a reason that we do them on people who are not awake.


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## 8jimi8 (Jul 11, 2010)

backwards upward reverse pressure.  I learned about it in basic school only because i read ahead and asked about it.  They didn't teach it other than that.

I've assisted with many intubations in the ICU and often been the one holding sellicks.  Not too difficult and the intubator can always tell you more or less pressure.

Education is definitely in order


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## alphatrauma (Jul 11, 2010)

*Sellick maneuver - sayonara*

Something (someone) tells me that the 2010 AHA guidelines will be moving away from the application of cricoid pressure during intubation... for whatever that's worth.

Not that what the AHA says actually means anything <_<


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## Veneficus (Jul 11, 2010)

alphatrauma said:


> Not that what the AHA says actually means anything <_<



Unfortunately the more I learn the more AHA loses credibility.


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## zmedic (Jul 11, 2010)

The big thing is that they are going to be moving away from intubation during arrests all together.


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## jjesusfreak01 (Jul 11, 2010)

zmedic said:


> The big thing is that they are going to be moving away from intubation during arrests all together.



Ahh, so we are now coming to the conclusion that the body magically refreshes the air in the lungs to maintain perfusion, or are they proposing that intubation be replaced with BIADs, a res-q-pod, and good compressions?

I would agree it seems difficult to argue that this is evidence-based medicine when somehow the evidence changes every few years. At least at the moment it does seem to make sense.


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## Shishkabob (Jul 11, 2010)

jjesusfreak01 said:


> Ahh, so we are now coming to the conclusion that the body magically refreshes the air in the lungs to maintain perfusion, or are they proposing that intubation be replaced with BIADs, a res-q-pod, and good compressions?




Well... when compressions are done a vacuum IS created in the chest, which is why some places are doing an NRB and nothing more.  


However, I believe they will just (again) downplay the importance of intubation, but not completely un-recommend it.  They just don't want compressions to stop for an intubation to take place.


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## Sassafras (Jul 11, 2010)

Linuss said:


> Well... when compressions are done a vacuum IS created in the chest, which is why some places are doing an NRB and nothing more.
> 
> 
> However, I believe they will just (again) downplay the importance of intubation, but not completely un-recommend it.  They just don't want compressions to stop for an intubation to take place.



Is a paramedic really going to be alone during an arrest to have to make that decision?  Wouldn't they at least have a partner that could continue compressions while they intubated? And that my friends, is my newb question of the day. :blush:


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## CAOX3 (Jul 12, 2010)

You have to stop compressions in order to intubate.


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## alphatrauma (Jul 12, 2010)

jjesusfreak01 said:


> Ahh, so we are now coming to the conclusion that the body magically refreshes the air in the lungs to maintain perfusion, or are they proposing that intubation be replaced with BIADs, a res-q-pod, and good compressions?



_There is no_ substitution for good quality compressions (when/if they can make a difference).

Plain and simple, the cardiac arrest survival rate is abysmal at best... let's define "survival" as _Mr. Jones_ achieving ROSC, enjoying a moderate hospital stay, and returning to life/work/whatever after being discharged. Pacing a patient, dropping them off at the ER, and Hi Fiving back at the station that "you brought him back" doesn't count for squat. These patients, for the most part, are dead when we arrive and all we are doing is going through the motions. 

The witnessed arrest is where the real difference can be made. Read up on the *3 Phases of Cardiac Arrest - Time Sensitive Model ( Lance Becker, MD)*. I found it quite fascinating, and relatively enlightening.


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## zmedic (Jul 12, 2010)

It's not really that the evidence changes every few years, it's that the research evolves. It takes awhile for something to go from an idea to being piloted to having enough studies done that big groups like the AHA or NREMT feel comfortable changing national policy. Also every time you make a change need to study the new situation. So if AHA rolls out single shock, no pause after shock for CPR, you then start looking at outcomes with the new guidelines. People found those with decreased pauses in compressions do better, and intubations often cause long delays in compressions. Now those studies are coming out, which is why they update protocols every few years. 

I think the reasons that there are so many unsettling changes in medicine is because so much of what we do is not based on any evidence or studies. The protocols started because something made sense, and it took 20 years for someone to get around to studying it. The issue wasn't that the research said something was good and now the research says it's bad. The issue is that you go from no research to suddenly some data. (Look at MAST pants, IVs for trauma, bicarb for arrests etc)


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## mycrofft (Jul 12, 2010)

*Yup five is four.*

To paraphrase myself, since we have been perfecting CPR for about fifty years now, why isn't it perfect?

1. As Z said, sort of, these are dead people we are doing it to. I do not hear the old distinction about clinical versus biological death spoken of anymore. As Magic Max said, there's dead  and there's *almost dead*

2. Personal hypotheses: 
a. Many or most so-called successful codes away from a hospital (and some there) didn't need CPR, or only needed it long enough for their homeostatic mechanisims to survive anoxia and kick in again (e.g., electrocution, blunt chest concussion with subsequent arrythmia, asphyxia by exclusion of air, and a few others). I've seen this.
b. As long as there is so much money and clout to be made from CPR, constant but irrelevant-to-clinical outcome revisions will continue, justifying updates and pormpting frequent refreshers and purchase of new training materials. (If CPR is such a universal lifesaver, how come we can't just have the updates, but have to pay significantly for them?).
c. As long as people do not recover from whatever led someone to perform CPR on them, whomever is teaching it is *obligated* to continue to "improve" it as a matter of due dilgence or be "guilty" of teaching a "faulty" procedure, whether it is or not.


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## Veneficus (Jul 12, 2010)

mycrofft said:


> To paraphrase myself, since we have been perfecting CPR for about fifty years now, why isn't it perfect?
> 
> 1. As Z said, sort of, these are dead people we are doing it to. I do not hear the old distinction about clinical versus biological death spoken of anymore. As Magic Max said, there's dead  and there's *almost dead*
> 
> ...



I think I might have some insight on the question.

The first part of the problem is we don't actually know what perfect CPR is. This can be evidenced by the outcome of compression only cpr.

AHA then delved into the resuscitative medicine concept in both ACLS and PALS. Only the American academy of Pediatrics in their NRP course took issue with the AHA and have so far held their ground.

As we learned more about medicine AHA did start research as to how well our intervention of CPR worked. It would seem from the research, (available in a nice book from the AHA for about $80 because book sales is how research is funded)  The problem wasn't CPR the problem was the "advanced stuff." Most of it doesn't work and people were neglecting CPR to do it. In response to this an an increase of 20% mortality in cardiac arrest between 2000 and 2005, an effort was made to refocus on CPR and less on the "advanced" stuff. But the world is not filled with people like you and I. It requires breaking the  habits of tens of thousands of providers. 

CPR throughout history has gone through numerous changes in the effort to make it better. compression ratios, ventilation ratios, the importance of ventilation, compression depth, etc. The AHA has the largest body of compiled research and on going study anywhere. But as with all research some of it is inconclusive, some is poorly reported, and some is set up with bias. 

Believe it or not, we know what perfect cpr is, there are some problems. 250 compressions a minute is impossible to maintain any quality not to mention without a professional compressor, most people don't have the physical ability to perform that without going into arrest themselves.

In the short term the body has an oxygen reserve, but what about 6+ minutes later? How do we maintain perfusion pressures and ventilate? What is the perfect medium? Add in the compressions and perfusion pressure, when and how is the most beneficial ratio?

Then the AHA has to get a large body (hundreds) of "experts" to come to a consensus. In the EU they don't like the AHA consensus and use the same body of research to create their own guidlines which look quite different from the AHA.

Look at what the AHA really "credentials" you in. It simply means you have attended the course and demonstrated competency in their procedures. That's what CPR, ACLS, and PALS is. A procedure. No different from starting an IV, intubating, changing dressings, or whatever.

It is the basic guidlines of "resuscitation" that epidemiologically make sense until "reversible causes" can be found. It is not a class designed to make people experts in the subject. After all of my education I would feel like a retard if I could have learned how to bring people back to life following a procedure that can be taught in 16 hours and I can sum all of it up in 342 words. (I know because I made a bet I could summarize ACLS to get people to pass in less than 500 words)   

The guidlines are simply what the non expert does, until the expert can be brought to bear. If that were not so, "reversible causes" would be the number one thing on the algorythm, not an afterthought at the bottom of the page. People survive because the cause of the arrest is dealt with, not because anyone flawlessly followed an algorythm. It would be like saying a septic patient should be cured because you flawlessly started an IV and started antibiotics without regard to what antibiotics you were using.

Change must also come slowly. Not because I said so, but because it seems most people don't like radical change. So I expect to see a series of changes over time instead of radical shifts. Look at other medical breakthroughs. We know high concentration O2 is harmful in most cases, we know backboards don't really help, we know capnography is a better indicatior than Spo2, we know about hypothermia therapy, but we still keep doing some and are not so fast to adopt others. Hell we can't even get paramedics in the US to universally interpret a 12 lead EKG, how else do we go about changes the ingrained experiences and habits of the entire US healthcare population?


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## zmedic (Jul 12, 2010)

Everywhere I've worked you didn't have to pay for special update classes, you just got the new info when you took your CPR/ACLS refresher. You aren't paying for the update, you are paying for the books, instructor time etc. Most of the data is collected by people not paid by the AHA, rather it's from NIH or other funding sources, so it's not like by taking the class you are paying for research to fund the AHA. 

I don't think it's a matter of perfecting it over the last 50 years, a lot has changed not only with the research but with the systems. A system that has community CPR, community defibrillation, first responders with defib and CPR training, early hypothermia, early ALS is very very different then what was being done 50 years ago. We've only been measuring delays in compressions for the last few years because before that we didn't have the technology to look at compressions in real codes. 

It bothers me this idea that "what we do doesn't really matter because they are basically dead anyway." I know the save percentage is low but that is more an issue with the fact that a large percentage of arrests are unwitnessed. Witnessed arrests with good CPR and early defib have a pretty good chance of survival neurologically intact. 

A lot of the changes aren't from some lab or a group sitting around arguing about what the proper ratio of compressions should be in an ideal world. More and more of this research is from work done on real patients where they can say "if you don't interupt compressions, more people live and live better." That's not a meaningless change. 

http://www.med.upenn.edu/resuscitation/ 

These guys at Upenn are doing some cool stuff with looking at CPR on real patients and outcomes, also doing a lot of the hypothermia work.


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## Shishkabob (Jul 12, 2010)

CAOX3 said:


> You have to stop compressions in order to intubate.



Says who?


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## Veneficus (Jul 12, 2010)

zmedic said:


> Everywhere I've worked you didn't have to pay for special update classes, you just got the new info when you took your CPR/ACLS refresher. You aren't paying for the update, you are paying for the books, instructor time etc. Most of the data is collected by people not paid by the AHA, rather it's from NIH or other funding sources, so it's not like by taking the class you are paying for research to fund the AHA.



I don't think I made my point very well. 

The course fee and the book fee are seperate. The procedes from the book fee (after printing, etc) do go to the AHA, which is why they are so fanatical about 1 book per student and even require each student to have a book in class. (It is on the regional faculty evaluation form of programs) That does generate money to help pay the AHA and their ability to operate.

The class fee goes to pay me. (and other instructors) The videos are quite boring, and poorly made so if I have to babysit through it, I want some money for it. The equipment also needs repaired/replaced, and consumables refilled.


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## mycrofft (Jul 12, 2010)

*Good points Vene et al*

I still _*personally*_ hold my hypotheses because I see the administrative overheads and have witnessed CPR started when the pt was not even pulseless. I have witnessed the micturation contests between ARC (who has not been in the conversations here) and AHA for decades.

Good instructors need good pay, and equip does need renovation etc. However, such practices as signing a noncompetition clause (and also stating I would only buy ARC materials whenever I teach) when I went to the ARC a couple years ago to get my cert are signs of the underlying malaise. 

(250 a minute. Get someone out to start MY CPR).

Someone/something needs to be created or called in from outside the usual list of suspects, take the whole thing by the nape of the neck and shake it until the jujubees fall out, as NHSTA did long ago when the health dept's and AMA couldn't get it together. Organizations cannot help becoming more inbred and conservative with time, and the result is gilded lillies, people defending their turf instead of meeting the mission, and longer/more intricate SOP's, protocols, manuals etc. We need a "Unified Theory of EMS".


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