# CPR Whats the point



## jameswf (Jul 14, 2012)

I don't want to be "that guy" but it's coming. 

I am sure the argument can be made anything that saves just one life is "worth it." 

I have been seeing that CPR when done properly has about a 3% success rate.  So for every hundered people you do CPR on 97 will probably die.  They put such an enphasis on everyone and their dog learning CPR with such a high mortality rate.   It just all seems like a lost cause.


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## Handsome Robb (Jul 14, 2012)

Is this a serious question?


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## JPINFV (Jul 14, 2012)

The purpose of CPR is not to directly save a life.

The purpose of CPR is to buy time for other interventions (fixing the 5 Ts and 5 Hs, defibrillation, etc) that have a higher chance of saving a life. This is especially true in the time between recognizing a cardiac arrest and obtaining a defibrillator or having EMS arrive.


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## Veneficus (Jul 14, 2012)

jameswf said:


> I don't want to be "that guy" but it's coming.
> 
> I am sure the argument can be made anything that saves just one life is "worth it."
> 
> I have been seeing that CPR when done properly has about a 3% success rate.  So for every hundered people you do CPR on 97 will probably die.  They put such an enphasis on everyone and their dog learning CPR with such a high mortality rate.   It just all seems like a lost cause.



What determines life and death is not CPR.

CPR determines whether or not the person has a chance.

There are many studies and statistics on it over the years. It has even been challenged by some very exceptional minds.

The last numbers I have heard is that sudden cardiac arrest is caused by MI about 70% of the time. The number one complication of MI is a lethal rhythm.

Which means that CPR+defib, the proven methods that work, are going to leave behind 30% of all victims prior to their effectiveness.

However, the caviat is "early CPR and defib" which means if it is to be effective, it will be bystanders, not EMS professionals who make the difference.

For non healthcare professionals, it is probably the cheapest and easiest way to learn and make a difference. (since they don't have to recert every 2 years)

But there are many variables that ultimately determine effectiveness.

The time before compressions.
Quality of compressions.
Regional health and wellness levels.
individual comorbidities.

Just to name a few.

If a victim of cardiac arrest has to wait the 6+ minutes for a professional healthcare provider to show up prior to compressions begining, then even 3% leaving the hospital would be a generous number.

Why should it be taught?

It is cheap, can easily be performed, and the more people who know it and are willing to perform it will reduce the time to first compressions thus buying time for ALS intervention, and ultimately definitive care of the underlying cause when possible.

That is what increases survival and justifies its value.


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## VFlutter (Jul 14, 2012)

Do you have a link for that data? CPR is rarely done properly but I think when it is properly done the survival rate would be slightly higher (depending on circumstances). I can say for personal experience the majority of codes that occur in the hospital (people already patients) do have positive outcomes.

And as just said it is all about buying time for definitive treatment and fixing reversible causes. 

Why not put everyone that codes on ECMO?


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## Veneficus (Jul 14, 2012)

NVRob said:


> Is this a serious question?



It is a serious question and one even asked by some very reputable doctors.

We must always question the convention in order to check ourselves and progress.


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## medicdan (Jul 14, 2012)

Agreed. CPR (or associated similar interventions) CAN have decent outcomes, if properly practiced. CCR (hands only), use of a Lucas, team approaches, etc have all been shown to bring survival to closer to 35%, and there is still much more to be done.

Many of our prehospital interventions have been proven to be detrimental or not effective, and especially with CPR, there is constant research and improvement of guidelines and protocol. Look up the current ILCOR/ECC research, and look at Seattle, WA (King County Medics) survival rates.
I'm not advertising these sucess rates broadly, but for those services that really invest the time, research, training, etc.


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## firetender (Jul 14, 2012)

JPINFV said:


> The purpose of CPR is not to directly save a life.


 
The purpose of CPR is to do something rather than just watch someone die.

Three out of a hundred ain't bad, especially if you're one of them!


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## jameswf (Jul 14, 2012)

*Thanks*

Thanks for all the feedback.

It was a serious question. I knew it may come across as trolling but had to ask.  I have read posts that give the high mortality rate nothing overly official. I watched my neighbor die and he was given CPR (low quality). I hadn't done CPR in almost 20 years and never on a real person. I had considered doing the EMT thing on the path to paramedic for a while and this event inspired me a bit. Nothing like watching someone die and being completely helpless/useless.
So I did my Healthcare provider CPR class (pre-req for the EMT class) and was all gung-ho I am the awesome but then start reading that even with CPR the end result is likely still death. Well that is a way to deflate the sail.   So really was looking for some real feedback to know it's worth it. You hear the anicdotes from the CPR teacher but those may just be something they read in a book somewhere and they don't tell you the bad stuff.


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## VFlutter (Jul 14, 2012)

jameswf said:


> Thanks for all the feedback.
> 
> It was a serious question. I knew it may come across as trolling but had to ask.  I have read posts that give the high mortality rate nothing overly official. I watched my neighbor die and he was given CPR (low quality). I hadn't done CPR in almost 20 years and never on a real person. I had considered doing the EMT thing on the path to paramedic for a while and this event inspired me a bit. Nothing like watching someone die and being completely helpless/useless.
> So I did my Healthcare provider CPR class (pre-req for the EMT class) and was all gung-ho I am the awesome but then start reading that even with CPR the end result is likely still death. Well that is a way to deflate the sail.   So really was looking for some real feedback to know it's worth it. You hear the anicdotes from the CPR teacher but those may just be something they read in a book somewhere and they don't tell you the bad stuff.



First of all what do you mean by "worth it"? Worth it to who? If I saw a random person collapsed on the street would I spend the time and energy to start CPR on them? Personally, Yes! They are dead, if you do nothing they are still going to be dead. If you do CPR they will most likely still be dead but at least you are giving them some chance. So if you spend 30 mins doing CPR, what is the end result? You are going to be very tired and probably sore for a day or two, that doesn't sound like much of a cost to me. Worst case scenario you wasted a half hour and got a good workout and did nothing for the patient. But best case scenario you save someone's life.


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## shiroun (Jul 14, 2012)

Veneficus said:


> If a victim of cardiac arrest has to wait the 6+ minutes for a professional healthcare provider to show up prior to compressions begining, then even 3% leaving the hospital would be a generous number.



Just a slight tangent, I believe that the human body is able to sustain life without any extra o2 for around 6-8 minutes* before major brain damage sets in. Heard it in class, may only apply to respiratory attacks though, which might make a bit of sense since in MI patients they mostly have asystole or VFib, and in asystole no blood would be flowing, and vfib would have very little.

If the patients were mostly VFib, they could potentially survive 6 or so minutes if proper CPR and the use of an AED were administered when the EMTs showed up

Thats just my two cents though, correct me if I'm wrong.


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## medicdan (Jul 14, 2012)

shiroun said:


> Just a slight tangent, I believe that the human body is able to sustain life without any extra o2 for around 6-8 minutes* before major brain damage sets in. Heard it in class, may only apply to respiratory attacks though, which might make a bit of sense since in MI patients they mostly have asystole or VFib, and in asystole no blood would be flowing, and vfib would have very little.
> 
> If the patients were mostly VFib, they could potentially survive 6 or so minutes if proper CPR and the use of an AED were administered when the EMTs showed up
> 
> Thats just my two cents though, correct me if I'm wrong.



Quick correction... While the research has shown that a paralyzed patient with a good pulse won't drop their O2 sat below 90% for 8 minutes or so, remember their heart is working, and circulating blood to the brain. Early research and anecdotal evidence shows that performing only compressions for those 8 min before attempting ventilator, intubation, etc, we can improve survival-- that's what is called CCR, cardio cerebral resuscitation.


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## CANDawg (Jul 14, 2012)

shiroun said:


> Just a slight tangent, I believe that the human body is able to sustain life without any extra o2 for around 6-8 minutes* before major brain damage sets in. Heard it in class, may only apply to respiratory attacks though, which might make a bit of sense since in MI patients they mostly have asystole or VFib, and in asystole no blood would be flowing, and vfib would have very little.
> 
> If the patients were mostly VFib, they could potentially survive 6 or so minutes if proper CPR and the use of an AED were administered when the EMTs showed up
> 
> Thats just my two cents though, correct me if I'm wrong.



I've actually been taught 4-6 minutes before significant brain damage starts to set in. That said, brain cells can start dying in 30 seconds to a minute if deprived of oxygen.


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## OIFXGunner (Jul 14, 2012)

I wish I had a link to post, but in Richmond they've been running trials with therapeutic hypothermia in the field and they've been having some amazing results with survival-to-discharge statistics.  Of course that's post-resuscitation care, but the biggest thing that they have going is their quick response times.  I'll see if I can find some literature on the study.


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## medicdan (Jul 14, 2012)

OIFXGunner said:


> I wish I had a link to post, but in Richmond they've been running trials with therapeutic hypothermia in the field and they've been having some amazing results with survival-to-discharge statistics.  Of course that's post-resuscitation care, but the biggest thing that they have going is their quick response times.  I'll see if I can find some literature on the study.



Post ROSC cooling has become standard protocol in MA because of the promising results... and is one part of the greater science improving survival rates. In EMS we've gotten good at getting more patients to the hospital with a pulse, the idea with this is to get more of them to survival until hospital discharge.


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## STXmedic (Jul 14, 2012)

Post-ROSC hypothermia is fairly standard and accepted now, depending on your area and hospitals. Some systems (mine included) are participating in trials for inta-arrest hypothermia. n=1 here, but I've used it twice so far, and both were legitimate saves with good neuro recovery per hospital. Now whether that's just luck, or can be contributed to the early hypothermia, I will not speculate.


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## phideux (Jul 14, 2012)

I've initiated CPR 3 times in the last few months, 1 made it back to normal with no deficits. So personally I can tell you there has been a 33.333% success rate when CPR is initiated. To me it's "worth it".


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## OIFXGunner (Jul 14, 2012)

PoeticInjustice said:


> Post-ROSC hypothermia is fairly standard and accepted now, depending on your area and hospitals. Some systems (mine included) are participating in trials for inta-arrest hypothermia. n=1 here, but I've used it twice so far, and both were legitimate saves with good neuro recovery per hospital. Now whether that's just luck, or can be contributed to the early hypothermia, I will not speculate.



Around here it's just beginning to make its way into the field, so it's relatively new and shiny for us.  Most of our local hospitals are using it (at the minimum initiating it on good candidates prior to transferring them to a cardiac center) but only two EMS agencies are using it to my knowledge.  I'd be interested to see some of the numbers on intra-arrest hypothermia.  The theory makes good sense, at least.


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## Skittles (Jul 14, 2012)

If I remember correctly from when I was in school to be an MA, your body only utilizes 17% of the oxygen that you take in. So when you exhale, you would also be exhaling 83% of the oxygen you took in in the first place. Therefore, when you give the two rescue breaths, there would be utilizable oxygen. And compressions when done properly, massage the heart and keep the blood moving, even if slower than normal. So the oxygen provided in the rescue breaths along with the compressions to help move the blood through the body would help to prolong cellular life long enough for EMS to get there. 

I could be completely wrong, but that is how it was explained to us in class. And, if this is true, I believe that it is worth it. You may loose two out of three patients, but you did help to give them another chance at life.


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## AnthonyM83 (Jul 14, 2012)

jameswf said:


> I don't want to be "that guy" but it's coming.
> 
> I am sure the argument can be made anything that saves just one life is "worth it."
> 
> I have been seeing that CPR when done properly has about a 3% success rate.  So for every hundered people you do CPR on 97 will probably die.  They put such an enphasis on everyone and their dog learning CPR with such a high mortality rate.   It just all seems like a lost cause.


I dunno man. I had a 5 out of 5 return of spontaneous circulation rate a bit ago. Wasn't able to track them out of hospital, but I gave them a chance. Separate from that 5/5 streak, I've had countless others (literally, I lost count...probably in the high teens or lower 20s). One, I even had a conversation with before leaving the ER. Alert, oriented, wanting to leave the hospital, not understanding he had just coded.


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## OIFXGunner (Jul 14, 2012)

Another thing- if we hadn't been providing CPR all of these years, improvements to resuscitative medicine would never have been made.  I like to think that if we keep practicing the medicine now, who's to say that 20, 30 years down the road we might be seeing resuscitation statistics of 50-70% of arrests getting a return.  Perhaps better?  We won't know unless we keep working at it :-D


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## JPINFV (Jul 14, 2012)

OIFXGunner said:


> who's to say that 20, 30 years down the road we might be seeing resuscitation statistics of 50-70% of arrests getting a return.  Perhaps better?  We won't know unless we keep working at it :-D



[raises hand]

I have the general feeling that the vast majority of arrests are unwitnessed, which by the time they are found they're well outside of any real window for successful resuscitation.


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## NYMedic828 (Jul 14, 2012)

Without reading the entire thread,

I've had patients where CPR was initiated immediately, and I had the pleasure of having a conversation with them in the ICU the next day.

One in particular was only in his 50s. He is relatively undamaged from the occurrence.

These patients are VERY few and far between, but why would we remove something that can legitimately save a life.

What DOES need to be changed, is this criteria to which we actually begin resuscitation.

There should be age criteria primarily...


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## EpiEMS (Jul 15, 2012)

NYMedic828 said:


> What DOES need to be changed, is this criteria to which we actually begin resuscitation.
> 
> There should be age criteria primarily...



I dunno about age criteria, but I certainly agree that conditions incompatible with life is not broad enough. What might you add? I was thinking that many traumatic arrests would be better off called than worked, considering the near-zero survival rates.


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## gw812 (Jul 15, 2012)

Hey, CPR is like getting a cardio and upper-body workout, and you get paid to do it! Stealth corporate fitness plan!


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## mycrofft (Jul 15, 2012)

*Reasons to do CPR, and why it often fails.*

1. It is their only chance to survive long enough for advanced measures, transport,etc.
2. In cases where the initiating cause is transient (electrocution, blunt trauma to the chest, suffocation) it can "bring them back to life. This is especially true with younger people, who have a higher percentage of non-cardiac codes.
3. It, like all EMS, is also social glue, reassuring us that someone will come and give us a chance when we screw up or misfortune overtakes us.
4. If it was my wife/kid/friend down there, I'd sure as hell want you to give it a try. 

As I've said before, however, I think many of the CPR survivors either had an undetectable pulse (we don't even teach taking pulses to laypersons), or  had a transient cause for apparent clinical death.

Why CPR fails: done wrong, but since each new iteration makes the last one "wrong", this is only part of it. If the heart or whatever organ failed so badly as to cause loss of resp and pulse, there is an excellent chance it is lethal and irreversible.

Use search and see the long debate we had about ECMO.


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## bahnrokt (Jul 16, 2012)

Low chance of recovery but zero risk associated with it so why not?

Personally, Id rather do cpr for 20 minutes than walk into a room full of the guys family and say "Yup, he's dead" and walk out.


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## Dwindlin (Jul 16, 2012)

bahnrokt said:


> Low chance of recovery but zero risk associated with it so why not?
> 
> Personally, Id rather do cpr for 20 minutes than walk into a room full of the guys family and say "Yup, he's dead" and walk out.



CPR is not zero risk.


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## EpiEMS (Jul 16, 2012)

Dwindlin said:


> CPR is not zero risk.



Assuming the scene is safe, the provider is suitably PPE'd, and there is a patient who is actually in need of CPR, then where's the risk (beyond any other EMS activity)?


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## Dwindlin (Jul 16, 2012)

EpiEMS said:


> Assuming the scene is safe, the provider is suitably PPE'd, and there is a patient who is actually in need of CPR, then where's the risk (beyond any other EMS activity)?



I'm not talking risk to me, I read his comment as risk to patient.  CPR is not zero risk, does risk outweigh benefits? Yeah, but to say zero risk is untrue.


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## bahnrokt (Jul 16, 2012)

Dwindlin said:


> I'm not talking risk to me, I read his comment as risk to patient.  CPR is not zero risok, does risk outweigh benefits? Yeah, but to say zero risk is untrue.



So what are these hidden risks that are worse than death?


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## AnthonyM83 (Jul 16, 2012)

mycrofft said:


> As I've said before, however, I think many of the CPR survivors either had an undetectable pulse (we don't even teach taking pulses to laypersons), or  had a transient cause for apparent clinical death.
> 
> Why CPR fails: done wrong, but since each new iteration makes the last one "wrong", this is only part of it. If the heart or whatever organ failed so badly as to cause loss of resp and pulse, there is an excellent chance it is lethal and irreversible.



Absolutely. I have no doubt that many of my cardiac arrests who regained pulses still had a non-detectible heartbeat...but CPR is for people with heartbeats too (since the criteria is no caratoid/femoral pulse). So, you could see yourself as having saved them from death by not intervening with compressions....


As far as the new science proving the old science wrong....I've always accepted that's how it works. I hate when people get pissed off about the new updates...aren't they used to it already? Don't know they you gotta be trying different things out in order to narrow in on the things that work better and better? It doesn't make CPR wrong....just helps refine it each time.

When you work up your next cardiac arrest patient, you might not be doing it for him...you might be doing it for the guy ten years from now...


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## Dwindlin (Jul 16, 2012)

bahnrokt said:


> So what are these hidden risks that are worse than death?



I already said the benefits outweigh the risks, again, only pointing out that CPR is not without risk to the patient (e.g. cardiac contusion, sternal fracture, punctured lung, spleen, liver, etc). 

Again, not suggesting CPR shouldn't be started, simply clearing up that CPR is in fact not without risk, and should the patient survive may have real consequence to deal with as a direct result of the CPR.


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## Farmer2DO (Jul 16, 2012)

ChaseZ33 said:


> Why not put everyone that codes on ECMO?



This is certainly becoming more in vogue.  

There are 2 forms:  veno-venous ECMO (V/V) and veno-arterial ECMO (V/A).  V/V requires cannulation of 2 large central veins, while V/A requires venous and arterial cannulation.  V/V performs only the work of the lungs, and requires a heart that is pumping and not in failure.  V/A is essentially cardio-pulmonary bypass, and also performs the pumping of the heart.

There are 3 big limitations, from my experience:

1.  The ability of someone to quickly and efficiently cannulate 2 large vessels:  a central vein and an artery.  This is usually a surgeon, an anesthesiologist, or an intensivist.  These providers aren't always just hanging around a hospital, and when you need them, you need them NOW.  So this will predispose the larger hospitals, tertiary care centers, trauma centers, and academic centers to be able to do this.

2.  The cost to keep the equipment around is likely prohibitive.  Usually your hospitals that perform open heart surgery are most likely to have it.

3.  The people to maintain the therapy once started.  Generally this is a cardiovascular ICU with a perfusionist on staff.  We have 2 large medical centers in town; one is university based and is a major transplant center.  They put in VADs all the time.  They are comfortable using ECMO.  The other one is a large hospital, licensed for around 550 beds, an ED that sees over 100K patients a year, and does about 3X the cardiac work (caths and CABGs) that the university medical center does.  They will occasionally put it in, but they transfer them across town, to the University hospital, because they just don't do it that often, and don't feel comfortable managing them.

They're a good idea, but they take a lot to initiate in reality.


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## mycrofft (Jul 17, 2012)

Anthony, the latest revisions seem tone the most science-orioented ones yet. Many prior iterations seemed to be General Custer polishing his saddles. (Rearranging deck chairs on the Titanic?), an excuse to make updates and refreshers and separating the ARC "brand" from the AHA one.


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## shiroun (Jul 17, 2012)

EpiEMS said:


> Assuming the scene is safe, the provider is suitably PPE'd, and there is a patient who is actually in need of CPR, then where's the risk (beyond any other EMS activity)?





Dwindlin said:


> I'm not talking risk to me, I read his comment as risk to patient.  CPR is not zero risk, does risk outweigh benefits? Yeah, but to say zero risk is untrue.



Dwindlin is right. It IS NOT zero risk. If you break a rib, and keep going, it can puncture the pleura space, causing a collapsed lung.


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## leoemt (Jul 17, 2012)

Hi, I've been lurking on this site for about 6 months, figured now that I am an official EMT it was time to join. What better topic for a first post than one that is dear to me as CPR.

Even though I am a new EMT I am in no way a stranger to trauma and medical emergencies. I have been a cop and have worked security for Boeing.

When I was a cop, I never once performed CPR. Had a couple of people die infront of me but never did CPR. When I was with Boeing though, I performed CPR 5 times. Of those 5 patients, 3 were brought back by the time they were loaded into the medic unit. Whether they made it out of the hospital or not I don't know as I wasn't privy to that info. 

CPR saves lives, and AED saves lives. Here in WA State we are very proactive with our EMS and health systems. At Boeing every patrol car, fire truck, aid unit, and support vehicle had an AED. Thats not including the AED's spread throughout the buildings.  At the Everett site where I worked, a person experiencing a cardiac event can have an AED on them within approximately 30 seconds in most instances. Security had a less than 2 minute response time and our fire department wasn't much longer.  About 80% of the 60,000 employees at the site were first aid / CPR trained. 

Having a trained populous willing to perform compression only CPR at a minimum will drastically increase survival rates in sudden cardiac arrest events. We are fortunate here to have such a large populous of trained people thanks in part to Boeing, Microsoft, and the Military which routinely put their employees through this training.

I can't comment on the EMS side yet as I haven't started my ambulance job yet. However, if I ever saw someone who was in need of CPR I would jump in and do it. Not because I'm an EMT, but because it is the right thing to do. As previous posters stated, you have nothing to lose.


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## Veneficus (Jul 17, 2012)

bahnrokt said:


> So what are these hidden risks that are worse than death?



Keep in mind death is not always the enemy to be conquered.

There are many patients where a peaceful end is better than a thrashing and being turned into Frankenstein's monster.


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## OIFXGunner (Jul 17, 2012)

Veneficus said:


> Keep in mind death is not always the enemy to be conquered.
> 
> There are many patients where a peaceful end is better than a thrashing and being turned into Frankenstein's monster.



Which is what a dnr is for. Without a dnr, we have to assume that they would like to become the Frankenstein monster, so death is still the enemy.


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## Veneficus (Jul 17, 2012)

OIFXGunner said:


> Which is what a dnr is for. Without a dnr, we have to assume that they would like to become the Frankenstein monster, so death is still the enemy.



That is what a phone call to medical control is for.


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## DrParasite (Jul 17, 2012)

CPR is maybe 30% as effective as the hearts own heartbeat.  It in and of itself doesn't save lives.  What it does it extend the time until the fatal cardiac rythym becomes unrecoverable, giving you a couple extra minutes until defib can be applied, which is what you need to get a good rythym.

In 14 years, I have less than a dozen saves, where we found the patient in cardiac arrest and had a pulse when we got to the ER.  Maybe 4 walked out of the ER.

typically a save comes with a defib is applied immediately, CPR is applied immediately (followed by a rapid defib), or EMS witnesses it (and defib is immediately applied).

The large majority of patients (both old and young) who go into cardiac arrest won't survive.  That's the simple fact.  The overwhelming number of people who are transported to the hospital in cardiac arrest won't walk out of the hospital.  Also a documented fact.

Life is a fatal condition.  100%.  If you have a patient in cardiac arrest who is between 2 years old and 60, the survival chances are pretty good, if CPR (and EARLY Defib) are done (assuming no other complications already exist).  under 2 (and not an airway condition, which you need to clear the airway or else all the CPR in the world won't help) and it's probably an undiagnosed congenital condition.  After 60 (and the old you get, the lower the chances), you might bring it back, but when you get a save on an 80 year old, did you really save a life?  sometimes if it's your time to go, nothing on earth can stop that.


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## Handsome Robb (Jul 17, 2012)

Veneficus said:


> That is what a phone call to medical control is for.



This is a very good point.


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## OIFXGunner (Jul 17, 2012)

Veneficus said:


> That is what a phone call to medical control is for.



If the patient presents in a manner consistent with cease resuscitation. However, beyond medical reasons, it is not our place to decide that someone should not be resuscitated.


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## Bullets (Jul 17, 2012)

If we really wanted to follow the bouncing ball, the better question is why do we do ACLS, compressions and electricity are being shown to be the most effective treatments, ACLS is being shown to be at best ineffective and at worst actually harms the patient


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## Handsome Robb (Jul 17, 2012)

OIFXGunner said:


> If the patient presents in a manner consistent with cease resuscitation. However, beyond medical reasons, it is not our place to decide that someone should not be resuscitated.



So you have a family telling you that the patient doesn't want to resuscitation efforts however the paperwork hasn't gone through yet, are you really going to pull out the cannon and disregard the family or are you going to do BLS and make a phone call?

Just one example that's a pretty common occurrence.


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## Veneficus (Jul 17, 2012)

OIFXGunner said:


> If the patient presents in a manner consistent with cease resuscitation. However, beyond medical reasons, it is not our place to decide that someone should not be resuscitated.



I am not sure what you mean by this. Is there a reason outside of a medical  you would not initiate efforts or cease resuscitation?


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## Christopher (Jul 17, 2012)

jameswf said:


> So really was looking for some real feedback to know it's worth it. You hear the anicdotes from the CPR teacher but those may just be something they read in a book somewhere and they don't tell you the bad stuff.



"Worth it." It is a little jarring to hear CPR phrased like that.

In areas which treat cardiac arrest appropriately, it isn't 6% which survive but 15-20% that survive intact. This is an all-comers approach too, so it isn't a number which is cherry picked.

Better yet, if you start CPR when you see a victim collapse, some areas will send you home 50% of the time (or better). I know my service area does.

If you're looking for what's "worth it", there are three interventions which have been proven to improve survival to discharge neurologically intact:

Continuous, uninterrupted chest compressions
Early and appropriately timed defibrillation
Therapeutic hypothermia

Do these three and you'll make a real difference.


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## OIFXGunner (Jul 17, 2012)

NVRob said:


> So you have a family telling you that the patient doesn't want to resuscitation efforts however the paperwork hasn't gone through yet, are you really going to pull out the cannon and disregard the family or are you going to do BLS and make a phone call?
> 
> Just one example that's a pretty common occurrence.



Absolutely I'm going to disregard the family.  It might be entirely true that the person did not want to be resuscitated, but from a legal standpoint, if they were truly serious about not being resuscitated, they would have a DNR in place.  Anything short of a valid DNR,a valid medical power of attorney, or obvious medical indications for ceasing arrest, and I'm resuscitating the patient.  It's always better to err on the side of saving someone's life as opposed to letting someone die who might possibly have wanted to live.



Veneficus said:


> I am not sure what you mean by this. Is there a reason outside of a medical  you would not initiate efforts or cease resuscitation?



I've run into several medics who have either called for cease resuscitation or have basically resuscitated half-:censored: because they felt that the person's quality of life was bad enough that the person should just be allowed to die without a DNR, medical power of attorney, or medical indications for ceasing resuscitation.  Your comment about allowing them to have "a peaceful end" reminded me of that.  I'm in no way saying that it's something that you specifically would do, but that's what it reminded me of.


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## Aidey (Jul 17, 2012)

OIFXGunner said:


> Absolutely I'm going to disregard the family.  It might be entirely true that the person did not want to be resuscitated, but from a legal standpoint, if they were truly serious about not being resuscitated, they would have a DNR in place.  Anything short of a valid DNR,a valid medical power of attorney, or obvious medical indications for ceasing arrest, and I'm resuscitating the patient.  It's always better to err on the side of saving someone's life as opposed to letting someone die who might possibly have wanted to live.



Correction, you're going to try to resuscitate the pt, chances are good you're not going to get anywhere. 

Now repeat after me, "That is what medical control is for". Seriously, I've run into this a few times, where the DNR is missing a signature, or it is in the wrong spot, or not dated. We call medical control, explain the pt is dead, they have a DNR with an error on it, and family is saying no CPR. I have yet to have a doc tell me to resuscitate.


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## OIFXGunner (Jul 17, 2012)

Aidey said:


> Correction, you're going to try to resuscitate the pt, chances are good you're not going to get anywhere.
> 
> Now repeat after me, "That is what medical control is for". Seriously, I've run into this a few times, where the DNR is missing a signature, or it is in the wrong spot, or not dated. We call medical control, explain the pt is dead, they have a DNR with an error on it, and family is saying no CPR. I have yet to have a doc tell me to resuscitate.



There's a big difference between a DNR with an error and a patient who doesn't have a DNR.  You're talking about two entirely different situations.

It's a lot easier to defend your position in court for attempting to resuscitate a patient than for withholding resuscitation efforts.


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## Shishkabob (Jul 17, 2012)

jameswf said:


> I have been seeing that CPR when done properly has about a 3% success rate.



Until you get to such places as mine where there's an ~7% survival-to-discharge with good neurological outcomes, and there are systems with better than that.




> So for every hundered people you do CPR on 97 will probably die.  They put such an enphasis on everyone and their dog learning CPR with such a high mortality rate.   It just all seems like a lost cause.



Why even do medicine at all?  Everyone dies at some point, right?


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## OzAmbo (Jul 18, 2012)

Linuss said:


> Until you get to such places as mine where there's an ~7% survival-to-discharge with good neurological outcomes, and there are systems with better than that.
> 
> 
> 
> ...



out of hospital cardiac arrest management here is achieving a 50% ROSC and 30% survival to discharge, most of which has been achieved through early access to CPR and defib by a first responder system, the remainder by aggressive management of B/P post arrest, RSI and then therapeutic cooling


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## STXmedic (Jul 18, 2012)

What parameters are you using to get those numbers? Many places here use the exact same strategy as yours, with similar results as Linuss.


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## Christopher (Jul 18, 2012)

PoeticInjustice said:


> What parameters are you using to get those numbers? Many places here use the exact same strategy as yours, with similar results as Linuss.



~15% all rhythms, ~60% Utstein (4 months under new system).

Continuous uninterrupted chest compressions
Delayed advanced airway (either BVM or NRB to start, King/ETT after) for 3 cycles
"Pit crew" rotation of compressors
Precharging defib
5 second interp/shock pauses
IO access first line, IV secondary
Standard ACLS meds (epi, amio/lido, mag/calcium/bicarb)
Therapeutic Hypothermia (one service is post arrest, one is intraarrest)


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## VirginiaEMT (Jul 18, 2012)

I actually asked a question similar to this in EMT-I class because it sure seemed like we spent a lot of time on something that usually does not have a good outcome, when we could have spent many more hours on topics that were actually of far greater benefit, at least that is what I thought at the time. The one scenario that is used to release an EMT-I/99 provider is the mega-code. Wouldn't it be of greater benefit for a provider to know more about acidodsis, hyperkalemia, crush injuries and compartment syndrome, MI's, EKGs, pediatrics, etc. instead of spending so much time on how to work a code?( I could use any example here) There is only 2 stations at the NREMT-I that involves pediatrics and those were airway and I.O.




jameswf said:


> I don't want to be "that guy" but it's coming.
> 
> I am sure the argument can be made anything that saves just one life is "worth it."
> 
> I have been seeing that CPR when done properly has about a 3% success rate.  So for every hundered people you do CPR on 97 will probably die.  They put such an enphasis on everyone and their dog learning CPR with such a high mortality rate.   It just all seems like a lost cause.


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## Veneficus (Jul 18, 2012)

VirginiaEMT said:


> I actually asked a question similar to this in EMT-I class because it sure seemed like we spent a lot of time on something that usually does not have a good outcome, when we could have spent many more hours on topics that were actually of far greater benefit, at least that is what I thought at the time. The one scenario that is used to release an EMT-I/99 provider is the mega-code. Wouldn't it be of greater benefit for a provider to know more about acidodsis, hyperkalemia, crush injuries and compartment syndrome, MI's, EKGs, pediatrics, etc. instead of spending so much time on how to work a code?( I could use any example here) There is only 2 stations at the NREMT-I that involves pediatrics and those were airway and I.O.



If you cannot keep a patient alive while you figure those things out, what good is knowing about them?


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## VirginiaEMT (Jul 18, 2012)

Veneficus said:


> If you cannot keep a patient alive while you figure those things out, what good is knowing about them?



good point


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## Sandog (Jul 18, 2012)

VirginiaEMT said:


> good point



You caved so easily


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## VirginiaEMT (Jul 19, 2012)

I was in a hurry and didn't have time for a rebuttal. LOL!!




Sandog said:


> You caved so easily


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## NYMedic828 (Jul 19, 2012)

Literally had a ROSC 5 minutes ago.

CPR 30 minutes, shocked v fib 7 times.

On her way to cath lab now.


CPR was started immediately upon arrest. 

CPR obviously works...


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## Veneficus (Jul 19, 2012)

NYMedic828 said:


> Literally had a ROSC 5 minutes ago.
> 
> CPR 30 minutes, shocked v fib 7 times.
> 
> ...



Strong work my friend.


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## mycrofft (Jul 19, 2012)

Here's a reason for CPR: if I don't tell you not to, I'm going to be on you like paint on wallboard if you DON'T.:angry:


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## VirginiaEMT (Jul 19, 2012)

nymedic828 said:


> literally had a rosc 5 minutes ago.
> 
> Cpr 30 minutes, shocked v fib 7 times.
> 
> ...



congratulations!!


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## NYMedic828 (Jul 19, 2012)

Fingers crossed she makes it out of hospital.

Tried to give her epi/vasopressin pretty sparingly with her age. 

Hopefully get a chance to find her tomorrow.


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## RustyShackleford (Jul 20, 2012)

How old was she?  Good job regardless of the outcome.


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## OIFXGunner (Jul 20, 2012)

One of our crews worked one not terribly long ago where the patient coded, his wife was there and called 911, and the medic unit made it there within five minutes of his collapse.  CPR was started w/ an initial rhythm of VF.  The first shock was successful and the rhythm converted to Sinus.  He was taken to the closest hospital, hypothermia was induced and he was flown to a facility capable of sustaining the hypothermia protocol.  He had coded somewhere around 9AM and by 3PM the he was following commands in the CICU.  He was extubated later that evening, and was discharged several days later.  A few days after the arrest, one of my mom's old coworkers asked me if I was on the ambulance that day- turns out the patient was her dad.  That kind of thing is what makes it all seem worth it to me.


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## NYMedic828 (Jul 20, 2012)

RustyShackleford said:


> How old was she?  Good job regardless of the outcome.



Late 70s.

1 liter of cold saline 
4mg epi
40 units of vasopressin
300mg amiodarone
7 shocks
35 minutes of CPR

She had a stent placed and today is alive and well in the CCU, extubated I believe.


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## mycrofft (Jul 20, 2012)

OOOraw. ARC or AHA style CPR?


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## NYMedic828 (Jul 20, 2012)

mycrofft said:


> OOOraw. ARC or AHA style CPR?



I couldn't tell you the difference but we follow AHA...

Push down on chest, add in some oxygen = CPR last i knew.


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## Handsome Robb (Jul 21, 2012)

NYMedic828 said:


> Late 70s.
> 
> 1 liter of cold saline
> 4mg epi
> ...



I bet she's sore. Good on ya though! :beerchug:

Just wondering why no 150 mg second dose of Amio? Going that deep into the algorithm seems like it would have been included as current guidelines stand. Not trying to second guess you whatsoever, just wondering.

Either way congrats and double congrats if she's extubated at talking!

I wish we had a post-ROSC or intra-arrest hypothermia protocol in place, one of my first projects to present to our MD if I clear my TAP if I can get other medics onboard with it. Although I think a big reason we don't have it is area hospitals, except for one, aren't onboard with it which makes it pretty much pointless in the prehospital field if it isn't continued. On second thought I should probably make sure my position is cemented in place before I start bringing up protocol changes. 

It's cases like NY's that make CPR worth it. We can't save 'em all but the ones we do save are reason enough.


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## NYMedic828 (Jul 21, 2012)

Second dose of amio is a medical control order and I doubt it would of done anything compared to the 7 shocks.

Hard to do CPR and stay on the phone to get orders in a moving vehicle :blush:


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## MedicalSlick (Aug 21, 2012)

This honestly can't be a question.. Your occupation says student.. student of what? construction? Cause it's obviously not medicine.


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## Veneficus (Aug 21, 2012)

MedicalSlick said:


> This honestly can't be a question.. Your occupation says student.. student of what? construction? Cause it's obviously not medicine.



It is a legit question.

As I said, one that has been asked by some very capable doctors and medical scientists.

In medicine, as in any true profession, we constantly challenge the "norm" in order to make sure we are doing the best we can.

A student who can ask such a question in the face of overwhelming tradition and dogma is a student who is going to do well not only for him/her self, but also for the profession or vocation of healthcare they end up in.

It is the ones who do what they are told without question who you need to watch out for.


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## Schroeder (Aug 21, 2012)

Out here in king county, we have had a 50%+ survival rate of witnessed cardiac arrest. Since we have a tiered system, CPR will be done for quite a bit of time before the medics show up. 

There has also been research done (I'll try to find it, but it came up a lot when I was in training) that shows improved defib. results with CPR done for 2 minutes before the first shock. Something along the lines of increasing the blood pressure primed the heart to accept a shock better. 

The numbers speak for themselves in my opinion.


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## Brandon O (Aug 21, 2012)

You do it because it works.


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## Sandog (Aug 21, 2012)

Schroeder said:


> Out here in king county, we have had a 50%+ survival rate of witnessed cardiac arrest. Since we have a tiered system, CPR will be done for quite a bit of time before the medics show up.
> 
> There has also been research done (I'll try to find it, but it came up a lot when I was in training) that shows improved defib. results with CPR done for 2 minutes before the first shock. Something along the lines of increasing the blood pressure primed the heart to accept a shock better.
> 
> The numbers speak for themselves in my opinion.



I would like to see how they came up with those numbers. Was it a 2 patient study?


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## Christopher (Aug 21, 2012)

Sandog said:


> I would like to see how they came up with those numbers. Was it a 2 patient study?



I wouldn't mock King County's numbers...they lay it all out there (for better or worse).

Adult non-traumatic cardiac arrest, all rhythms, King County is 16.8% survival to discharge intact. Utstein (VF/VT) is 48% in 2009. (n=5958, Jan'01-Dec'09, PubMed) 

Pediatric non-traumatic cardiac arrest, all rhythms, King County is 26.9% survival to discharge intact. (n=361, 1980-2009, PubMed)


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## Brandon O (Aug 21, 2012)

Unless there's other research that examines compressions between the first and second shock (I know of none, but that doesn't mean much), I suspect Schroeder is referring to the old literature that suggested patients with long downtimes would benefit from a couple minutes of compressions before attempting to defibrillate ("priming the pump"). Anyone who certified in CPR more recently than the past couple years learned this method. It was instrumental in the 2005 recommendations, but due to conflicting evidence has now been deemphasized post-2010.


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## Veneficus (Aug 22, 2012)

Brandon Oto said:


> Unless there's other research that examines compressions between the first and second shock (I know of none, but that doesn't mean much), I suspect Schroeder is referring to the old literature that suggested patients with long downtimes would benefit from a couple minutes of compressions before attempting to defibrillate ("priming the pump"). Anyone who certified in CPR more recently than the past couple years learned this method. It was instrumental in the 2005 recommendations, but due to conflicting evidence has now been deemphasized post-2010.



Just my opinion on the matter, but I think it is because whether it works or not is pathology specific. 

Without getting into the minute details, if vfib is secondary to an acute MI, "priming the pump" is largely going to be pointless. You won't likely clear coronary artery occlusions with CPR.

However, if the inciting pathology causes shock because of inadequete coronary artery perfusion and the vfib is secondary due to non occlusive inadequete flow, then "priming the pump" seems not only reasonable, but actually required.

If you shock a heart with no blood flowing to it, the only logical outcome is a refractory vfib. 

The exact same mechanism as arrest for hemorrhage but with a (mostly)closed circuit such as in septic shock or reduced stroke volume.


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## NYMedic828 (Aug 22, 2012)

But considering we have no way of knowing the cause, wouldn't it be the wiser to "prime the pump" anyway?


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## Brandon O (Aug 22, 2012)

Veneficus said:


> Just my opinion on the matter, but I think it is because whether it works or not is pathology specific.
> 
> Without getting into the minute details, if vfib is secondary to an acute MI, "priming the pump" is largely going to be pointless. You won't likely clear coronary artery occlusions with CPR.



I partially disagree.

Obviously, if a total occlusion has caused a large infarct, resulting in massive HF and dysfunction (i.e. cardiogenic shock), the pump is simply broken. The classic presentation here may actually be PEA or asystole, possibly with a last stuttering arrythmia, but as you say, it's not like either pushing on their chest or exiting VF is going to fix the pump. (In an ideal world, we would perhaps be giving these people continuous compressions while we cath them to reopen that artery.)

However, if we imagine a descending pathway from stable baseline to irrecoverable death, many patients who suffer MI follow a gradual downward slope until "falling" off a cliff when their struggling heart drops the ball and enters VF or VT. At that point, the entire heart becomes ischemic, not just the localized area distal to occlusion, but if we can return them to a perfusing rhythm, they might still have many minutes until the actual infarct creates a non-viable myocardium.

In the handful of minutes after this, it's a solely electrical problem, and immediate defibrillation would probably get them back to their prior -- obviously somewhat unstable, but still perfusing -- rhythm. But the longer we wait, the more ischemic the heart becomes globally, and the less likely that it'll have the coordinated automaticity we desire if we electrocute it. So a bit of assisted circulation to refresh ATP and so forth makes sense. (This "three phase" model of arrest -- electrical, hemodynamic, then a metabolic phase involving toxic products and other derangement -- has become popular to explain the need for different therapies at different times.)

So goes the theory, anyway. Again, there's some literature against it now, so it's been downplayed -- although I do think that (as Vene alluded to) with an appropriately discerning eye toward the individual etiologies we might understand why it seems to sometimes work. But part of the idea now is that if you walk in, one person's setting up the defib while the other's doing compressions... it's a parallel, team-based process rather than a serial one, so it's really a false dichotomy.


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## Veneficus (Aug 22, 2012)

Brandon Oto said:


> I partially disagree.
> 
> Obviously, if a total occlusion has caused a large infarct, resulting in massive HF and dysfunction (i.e. cardiogenic shock), the pump is simply broken. The classic presentation here may actually be PEA or asystole, possibly with a last stuttering arrythmia, but as you say, it's not like either pushing on their chest or exiting VF is going to fix the pump. (In an ideal world, we would perhaps be giving these people continuous compressions while we cath them to reopen that artery.)
> 
> ...



That sounds very linear.


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## Brandon O (Aug 22, 2012)

Veneficus said:


> That sounds very linear.



Not sure what that means, but I like it.


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## Veneficus (Aug 22, 2012)

Brandon Oto said:


> Not sure what that means, but I like it.



I do not think the process is a linear progression as you described.

Whether the prevalent thinking or not, the idea that there will be electrical conduction disturbance before metabolic disturbance just doesn't seem logical.


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## Christopher (Aug 22, 2012)

Veneficus said:


> I do not think the process is a linear progression as you described.
> 
> Whether the prevalent thinking or not, the idea that there will be electrical conduction disturbance before metabolic disturbance just doesn't seem logical.



Primary VF (i.e. from ischemia) is very amenable to defibrillation, which is why I believe they labeled it the "electrical phase". Cessation of the reentrant wavefronts doesn't equate to cardiac output, but it may improve the situation from VF to PEA; assuming some automatic tissue decides to take over and the zone of ischemia doesn't precipitate VT/VF again. CPR post-defib is the means to improve PEA to "perfusing-EA" if the volume status is too low to support perfusion after VF.

"Priming the pump," I've always understood to mean ensuring some coronary perfusion pressure which in turn means some restoration of the normal flow of O2/glucose/waste products.

I really think we're all talking about the same thing just overloading terms...


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## OzAmbo (Aug 22, 2012)

Devils advocate

If i changed the neame of the thread to "Whats the point of BLS" would you then have a diferent point of view?


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