# Witnessed Arrest



## EMSTeen (Dec 26, 2013)

You see someone go down suddenly. Apneic and pulseless. You have an AED with you. Do you apply an AED immediately without CPR or do you perform CPR until you anylyze. Seems like a stupid question buts it's got me confused.


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## rwik123 (Dec 26, 2013)

If it was only you, apply the AED immediately since it's a witnesses arrest. If there is someone with you, have them perform compressions until the pads are on, then analyze.


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## mycrofft (Dec 27, 2013)

Call for help.

Remember: check call care.


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## UnkiEMT (Jan 25, 2014)

Unsurprisingly, mycrofft has the right answer, first is always call for help, if you've got bystanders, send them, otherwise what I like to do is pull out my phone, call 911, put it on speaker and drop it next to their head, that way I can roll into treatment while I'm still making the call.

That being said, on a witnessed arrest, my first step in treatment would be to do a precordial thump (Your scope may vary).

If that fails, on a multiple rescuer scenario, the answer is both, as rwik123 said.

If you're a solo rescuer, then get those pads on. Early defib is the number one predictor in good outcomes. Largely what CPR does is buy you time to get electricity and (depending on who you talk to) ACLS meds into them. That being said, I totally have brought witnessed arrests back with CPR only...in all but one case, I lost them again and didn't get them back for good until I got a shock and some epi in.

Once the AED is on, run the analyze, and if it advises the shock, while it's charging, get in there and run hands only.

Why do the CPR? Basically, if the AED calls it a shockable rhythm, then their cardiac tissue is burning fuels at a tremendous rate, and not replenishing itself, which will make it harder for the heart to maintain a functional rhythm, provided the Edison's Medicine does make a good restart. You can think of the compressions as repriming the pump, get some glucose and o2 into those coronary arteries. It's only good for a few percent on the save rate...but why wouldn't you do a few presses for a few percent.

Why hands only? With a witnessed arrest AED to hand, at this point your patient should only have been down absolutely no more than 1 minute, and likely 45 seconds or less, they still have plenty of o2 in their lungs, so no need for breaths. Unwitnessed, I might burn the 2-3 seconds to push in a single breath in before I hit analyze.


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## Handsome Robb (Jan 25, 2014)

Something else I'll add to the post above me is beyond supplying fuel to cardiac tissue a pump can't pump what's not there. Same concept as any other pump, you have to have fluid in it otherwise when it contracts, doesn't eject anything and doesn't fill again what's the point? 

I'll echo it to drive home a point, call for help, either yourself on speakerphone or designate a certain person, "You! (Point to make clear) call 911". 

If you've got an AED pop the pads on and analyze. If it says shock advised do compressions while it charges, clear, defib then right back in the chest with continuous compressions and confirm someone has called for help.


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## mycrofft (Jan 25, 2014)

Scene safety.(Check)

Assess (Check) for condition including massive wounds, protruding objects etc. LOOK AT THEIR BACK. This takes about fifteen seconds or less.

Call for help while baring the chest and, if you have it, slap on AED _FAST_. (Call and Care).

CPR until it analyzes. If a shock is administered, hit that CPR again before the smoke clears. If shock is not advised, CPR until relieved and following AED prompts.


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## mycrofft (Jan 25, 2014)

Robb said:


> Something else I'll add to the post above me is beyond supplying fuel to cardiac tissue a pump can't pump what's not there. Same concept as any other pump, you have to have fluid in it otherwise when it contracts, doesn't eject anything and doesn't fill again what's the point?
> 
> I'll echo it to drive home a point, call for help, either yourself on speakerphone or designate a certain person, "You! (Point to make clear) call 911".
> 
> If you've got an AED pop the pads on and analyze. If it says shock advised do compressions while it charges, clear, defib then right back in the chest with continuous compressions and confirm someone has called for help.



Yes. Like he says. Don't get tied down compressing when the cavalry isn't coming. However, two minutes of CPR/resuscitation of an immediate or witnessed drowning or electrocution (respiratory arrest with loss of consciousness) may measurably improve survival chances if no poison is involved.  So MULTITASK with that cell phone or an assistant.


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## 18G (Feb 2, 2014)

In a witnessed arrest with an AED immediately available, shock first. Defibrillation is the key to obtaining ROSC. Yes other modalities are integral but ultimately its the defibrillation thats key. You can do CPR all day long and its very unlikely your patient will obtain ROSC. 

Also, the AHA states that defibrillation performed within the first minute of arrest yields a 90% chance of ROSC. The other statistic is that for every minute that passes without defibrillation results in a 7-10% decrease in chance of survival. I think this pretty much sums up the importance of immediate defibrillation. 

As the others have said, CPR is key to buy time so defibrillation can work. But if you have an AED right there... shock ASAP. If you start CPR first, you lose that 90% chance of ROSC in the first minute and for every minute you delay shocking you're shaving 7-10% off the chance of ROSC.


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## mycrofft (Feb 2, 2014)

18G said:


> In a witnessed arrest with an AED immediately available, shock first. Defibrillation is the key to obtaining ROSC. Yes other modalities are integral but ultimately its the defibrillation thats key. You can do CPR all day long and its very unlikely your patient will obtain ROSC.
> 
> Also, the AHA states that defibrillation performed within the first minute of arrest yields a 90% chance of ROSC. The other statistic is that for every minute that passes without defibrillation results in a 7-10% decrease in chance of survival. I think this pretty much sums up the importance of immediate defibrillation.
> 
> As the others have said, CPR is key to buy time so defibrillation can work. But if you have an AED right there... shock ASAP. If you start CPR first, you lose that 90% chance of ROSC in the first minute and for every minute you delay shocking you're shaving 7-10% off the chance of ROSC.



If it is a lethal MI (not just one that irritated the heart into V-fib) that 90%is still a 0%. AHA (AND the ARC) both will tell you anything to get you to start CPR STAT, and it IS, after calling for help, the best thing. But as health care providers we have to acknowledge at least privately that CPR and AED, and even drugs and a fast drive, are all dependent upon the etiology for ultimate success. 

A heart consisting of MI scars and old bypasses is not going to stand the chance like an unscathed heart shut down by an electric shock or smothering does. Ditto a GSW versus a witnessed drug overdose collapse.


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## 18G (Feb 3, 2014)

I don't believe the statistics are propaganda. Absolute? Of course not. They serve to show what immediate defibrillation can do and illustrate why delay must be minimized.


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## mycrofft (Feb 3, 2014)

*I actually agree on your statement but we disagree on language.*



18G said:


> I don't believe the statistics are propaganda. Absolute? Of course not. They serve to show what immediate defibrillation can do and illustrate why delay must be minimized.



I think they're propaganda and I support their use to do what you say they are intended to do…get on it right now, and get on it properly.

OK, call it "conditioning" or "orientation" or "inculcation", but it is true the vast majority of dead people stay that way despite even perfect efforts. 

Yet I feel it is absolutely necessary, to give the patients a chance by making rescuers feel empowered enough to go to it STAT.

 I ask my students if they've done or seen CPR really done in person, ask them how it went. Most say "not so good". I praise them for responding, tell them that CPR is the last best chance, then tell them that if they see my wife or kids fall out in line at the Costco, I wish the students to go to it because _*"I want them back!"*_. (Line stolen from my mentor).


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## 18G (Feb 3, 2014)

I agree many arrest patients stay dead because the body is aged and it's time to die but many arrest patients don't fit that category and treatment is very time sensitive and as we've found out it needs to be well coordinated and calculated. 

Many ppl still don't understand the "why" behind the components of CPR which impedes optimal delivery on my opinion.


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## Handsome Robb (Feb 4, 2014)

18G said:


> I agree many arrest patients stay dead because the body is aged and it's time to die but many arrest patients don't fit that category and treatment is very time sensitive and as we've found out it needs to be well coordinated and calculated.
> 
> Many ppl still don't understand the "why" behind the components of CPR which impedes optimal delivery on my opinion.




You wanna know what's sad? That not know why isn't only limited to CPR and it's one of the simpler things to understand.


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## mycrofft (Feb 4, 2014)

18G said:


> I agree many arrest patients stay dead because the body is aged and it's time to die but many arrest patients don't fit that category and treatment is very time sensitive and as we've found out it needs to be well coordinated and calculated.
> 
> Many ppl still don't understand the "why" behind the components of CPR which impedes optimal delivery on my opinion.



Para 1: Agreed, especially witnessed arrests in kids and otherwise healthy people. We old crocks are a little closer to the finish line to begin with.

Para 2: Not sure if layperson CPR its aided by knowing the science, but I believe they need to know we are basically squishing the heart between the sternum and spine (so press straight down and HARD as you need) and that stopping sort of unravels what you've been trying to do already (so start NOW, go FAST and don't stop). 

As for the "CPRO", our professionals CPR class, time constraints make it hard to get it in, but I like to go more into the anatomy and what can get in your way.

Hope the OP got what he or she wanted.


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## bmedic1681 (Mar 14, 2014)

Have someone call 911, place pads on pt if AED is with you start compressions while it is charging if shock advised make sure everyone is clear of pt deliver shock…. if no shock advised continue CPR until it is time to analyze the rhythm again or until ambulance arrives


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## mycrofft (Mar 14, 2014)

What, you don't turn the machine off and on again to force a premature analysis?:huh: (NO, I'm kidding; although it works it makes for a bad report).


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