# Putting AED, CPR, Intubation Together



## WuLabsWuTecH (Jul 13, 2008)

When we learned all of this stuff, we learned CPR and AED together and Apenic Pt BVM and Intubation together, but we never learned how one integrates the two.

For CPR- Start CPR for 2 minutes unless it was witnessed and non-cardiac in nature.  Then hook up AED.  Shock once, resume CPR, shock again resume CPR and start transport.  If it indicates no shock advised check for pulse.

With Apneic Pt (with a pulse) BVM 1 breath every 5-6 sec.  If pulseox drops too low or you have issues with a seal, intubate taking no more than 30 seconds, auscultate lung sounds and epigastrum, and keep going at 5-6 second intervals.

What if you're in a cardiac arrest when the pulseox is poor and you have issues with a seal around the face?  When do you intubate within the CPR/AED cycles?  What happens if while you're intubating the AED starts analyzing and asks you to stand clear?  Now your pt is not intubated and has not had oxygen for the last 30ish seconds!


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## MSDeltaFlt (Jul 13, 2008)

WuLabsWuTecH said:


> When we learned all of this stuff, we learned CPR and AED together and Apenic Pt BVM and Intubation together, but we never learned how one integrates the two.
> 
> For CPR- Start CPR for 2 minutes unless it was witnessed and non-cardiac in nature.  Then hook up AED.  Shock once, resume CPR, shock again resume CPR and start transport.  If it indicates no shock advised check for pulse.
> 
> ...



Here's the deal from my point of view as a non-CPR instructor.  Instructors please correct me if I'm wrong.

If your pt is in cardiac arrest, you're not going to have a pulseox reading worth a d*mn because it takes a *perfusing BP to circulate oxygenated blood to the distal end of their finger so it can be read by the pulse ox probe*.

You essentially do not stop CPR to intubate.  The AHA focuses on "Airway".  Define airway.  An airway, by my Tabers medical encyclopedia, is a natural pathway from the air to your lungs.  It does not say ETT, Combitube, PTL, King LT, LMA, OPA, NPA, or what-have-you.  It says *natural path*, or unobstructed path.  If your AED says shock, and you're in the middle of intubating, *STOP INTUBATING* and shock them.  Reoxygenate and ventilate with BVM as soon as possible, then try again.  

If you're having issues with the mask seal, it depends.  If you're not having good rise and fall of the chest, you don't have an airway.  Reposition and *get a good seal for "airway"*.  If you *are* getting good rise and fall of the chest, don't worry about it.  You have an airway.

That's the way I see it at least.  Instructors, what do ya'll think?


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## BLSBoy (Jul 13, 2008)

Depending on your skill, you can intubate during CPR. 
If you are getting good complience with a BVM, you don't necessarily need to go to ETT, but it is preferred. 

And like it was said, don't delay electrical therapy!


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## mikeylikesit (Jul 13, 2008)

the profusion of blood during CPR is more important than the oxygenation. so i wouldn't delay CPR unless the patients airways was completely blocked off.


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## zacdav89 (Jul 13, 2008)

The saying used to be airway airway airway, but now it is more important like said above to keep things circulating. Now you do have to have a “patent” airway, but that could be anything. If bagging is giving you trouble, try to intubate if that is giving you trouble drop a king airway or combitube and forget it. If you’re getting good response with the BVM, leave it at that unless protocols say different why mess with something that isn’t broke? Just remember not to delay CPR/Defib. To intubate, practice and try to get the tube in a 10 sec window (rhythm/pulse check) and try with someone pounding down on the manikin so you get somewhat of a feel of how it might be like in the field.


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## mikie (Jul 13, 2008)

I was able to place a combi-tube while compressions were being preformed, with a patent airway already established... but i'm sure its different for everyone and every situation


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## Ridryder911 (Jul 13, 2008)

Okay.. if you don't know the orchestration of working an arrest, then one should not be performing the ALS procedures yet. Sorry, there is much more than just the skills. 

As MSDeltaFlt described there are other factors. Personally, take that Pulse-Ox piece of crap and place in a sealed baggie. 

* Remember this: DEAD PEOPLE HAVE NO PERFUSSION!* The only perfusion you have is the amount being given per compressions. 

Please never.. never... * Check blood pressures in a cardiac arrest*.. unless you want to impress how much you do NOT know.. 

One has to have Cardiac Output = Heart Rate X Stroke Volume (amount ejected from one heart beat). Again no heart beat NO stroke volume, No stroke volume no Cardiac Output. 

Really pretty simplistic.. Dead people are really in serious shape.. nope, can't get much worse.. (there is no degrees of death) 

R/r 911


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## mikeylikesit (Jul 13, 2008)

i recommend taking an ACLS course if you're curious about the procedure. i took it as a basic. as it didn't teach me things that i could use...it taught me a lot about whats going on in a code and what to look for and when.


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## firecoins (Jul 13, 2008)

mikeylikesit said:


> i recommend taking an ACLS course if you're curious about the procedure. i took it as a basic. as it didn't teach me things that i could use...it taught me a lot about whats going on in a code and what to look for and when.



I don't think they understand the BLS yet.


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## MMiz (Jul 14, 2008)

Hey now, lets keep this thread civil and on topic


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## MRE (Jul 14, 2008)

WuLabsWuTecH said:


> For CPR- Start CPR for 2 minutes unless it was witnessed and non-cardiac in nature.  Then hook up AED.  Shock once, resume CPR, shock again resume CPR and start transport.  If it indicates no shock advised check for pulse.




From a CPR Instructor and Basic;

Current procedures say that the AED should be hooked up and used as soon as possible, not after 2 min of CPR.  Between shocks you do perform 2 min of CPR though.  If no shock is indicated, do 2 min of CPR and re-analyze.

I can't comment on ACLS procedures but I'm sure others have it covered.


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## BLSBoy (Jul 14, 2008)

KB1OEV said:


> Current procedures say that the AED should be hooked up and used as soon as possible, not after 2 min of CPR.  Between shocks you do perform 2 min of CPR though.  If no shock is indicated, do 2 min of CPR and re-analyze.



Gotta prime the pump, unless it happened right in front of you.


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## Ridryder911 (Jul 14, 2008)

MMiz said:


> Hey now, lets keep this thread civil and on topic



It is and has been...


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## MRE (Jul 14, 2008)

BLSBoy said:


> Gotta prime the pump, unless it happened right in front of you.



I believe that is something that has been pushed in EMS, but it is not a part of the normal CPR courses (ARC Pro Rescuer/AHA Healthcare Provider).

However, think about it for a second.  You attach the AED to a person with an unwitnessed arrest, without doing CPR first, and regardless of if it shocks or not, if the PT does not regain a pulse, CPR is done for 2 min and the PT is re-analyzed.  It really doesn't change much if the AED goes on without any CPR first.  The only difference is the fairly short analyzing time at the beginning.

I did check my Basic book and it shows that the AED is attached as soon as it arrives.  I don't have time to go through the whole chapter to find if it mentions priming the pump.


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## BLSBoy (Jul 14, 2008)

When we were taught ACLS, it was instructed to do CPR first for an unwitnessed arrest, to give it a prime, then analyze rhythm.


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## reaper (Jul 14, 2008)

All new AHA standards are 2 minutes of CPR first, in unwitnessed arrest.


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## WuLabsWuTecH (Jul 14, 2008)

reaper said:


> All new AHA standards are 2 minutes of CPR first, in unwitnessed arrest.


Thats what I was taught--defib is more effective in an oxegenated pt was the stated reason if I am correct.

And I agree, the course we took did a poor job of covering Integration of techniques.  It wasn't until the last week of class that we obtained a *NEW* AED-trainer that didn't stack shocks (The real AED didn't stack shocks, but we can't use a real AED in our practicals!)  We were taught 6 shocks before going or 3 no shock advised before going which caused our time on scene with a *NEW* AED to be over 20 minutes.  This was corrected out last week of class by the instructor, but the NR sheets still haven't been updated to the new AHA Standards.


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## MRE (Jul 14, 2008)

reaper said:


> All new AHA standards are 2 minutes of CPR first, in unwitnessed arrest.




The only times I have seen the 2 min of CPR mentioned in an unwitnessed arrest (or a child/infant) is when a single person finds the victim and needs to leave to call 911.  They do 2 min of CPR, leave to call 911 and return.  In a witnessed arrest of an adult, they call and then provide care.

I can't recall ever seeing it mentioned with an AED.  I believe it always says that the AED should be attached as soon as possible, which usually means that one person begins CPR and the other prepares the AED.  

I'm at work right now, but I will pull out the ARC and AHA CPR literature when I get home tonight and double check.

Also, please remember I am talking about what is taught in CPR classes only, and not modifications or additions to those skills done in EMT/Medic/ACLS classes.


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## MSDeltaFlt (Jul 14, 2008)

Ridryder911 said:


> As MSDeltaFlt described there are other factors. Personally, take that Pulse-Ox piece of crap and place in a sealed baggie.
> 
> 
> 
> R/r 911



Personally, during cardiac arrest, I like to check the aerodynamics of those monstrocities.


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## skyemt (Jul 14, 2008)

also, without getting too far ahead, it is important to understand the hemodynamics of CPR first...

for example, during compressions, not that much blood is pumped out... the hemodynamic principal of negative intrathoracic pressure has been proven to be the most important, and least understood.  basically, the upstroke cycle of CPR is what helps perfusion the most, increasing preload and filling chambers...

also, understanding things like why you don't do compressions if an arrest is witnessed, but why you do at least 2 minutes if it isn't... why compressions are more important then ventilations, what happens when you interrupt the compression cycle, etc...

Some EMT's take CPR for granted because the chances for saving someone are slim to begin with... others take it for granted because they don't know any better...

if you really want to know how to do it correctly, have a real working knowledge not of the steps, but "why" the steps.


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## WuLabsWuTecH (Jul 14, 2008)

skyemt said:


> also, without getting too far ahead, it is important to understand the hemodynamics of CPR first...
> 
> for example, during compressions, not that much blood is pumped out... the hemodynamic principal of negative intrathoracic pressure has been proven to be the most important, and least understood.  basically, the upstroke cycle of CPR is what helps perfusion the most, increasing preload and filling chambers...
> 
> ...



They why you do 2 minutes of CPR first is to ensure adequate oxegenation.  When you defib, you try to get the heart to stop firing randomly, and hope that it resets itself into firing in a synch'd pattern.  What happens is that the myocardium is a special muscle that can cause electrical impulses w/o the brain through various uses of nodes. Anyway, it has a better chance of resetting itself when its oxegenated.  If you see the guy fall, he was breathing just a second ago so it shuold be oxygenated.  If you arrive on scene, he may have gone w/o oxygen for 5 minutes.  If old-school (January 2008 style) bystander CPR in progress and you think he is adequately oxygenated, then go ahead and defib.  If new-school "compressions only" CPR in progress, Take over and do Real CPR for 2 minutes to oxygenate the myocardium.

Am i correct?


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## MRE (Jul 14, 2008)

WuLabsWuTecH said:


> They why you do 2 minutes of CPR first is to ensure adequate oxegenation.  When you defib, you try to get the heart to stop firing randomly, and hope that it resets itself into firing in a synch'd pattern.  What happens is that the myocardium is a special muscle that can cause electrical impulses w/o the brain through various uses of nodes. Anyway, it has a better chance of resetting itself when its oxegenated.  If you see the guy fall, he was breathing just a second ago so it shuold be oxygenated.  If you arrive on scene, he may have gone w/o oxygen for 5 minutes.  If old-school (January 2008 style) bystander CPR in progress and you think he is adequately oxygenated, then go ahead and defib.  If new-school "compressions only" CPR in progress, Take over and do Real CPR for 2 minutes to oxygenate the myocardium.
> 
> Am i correct?



Sounds good.  Automacity is a neat thing.

I hope the compression only CPR hasn't taken over that much.

After a long day at work and a long squad meeting, I checked my books.  The Basic book does mention 2 min of CPR before sparking the PT in one place in the text and in one of the little side boxes.  Not visible enough in my opinion.

The ARC Pro Rescuer CPR does not mention it anywhere in the standalone book.  Instructions are to apply pads and spark as soon as AED becomes available.  

Turns out I don't have a standalone AHA BLS book, so I can't check that.

Going back to the original question/disagreement, I was incorrect and you should do 2 min of CPR prior to using the AED.  We should probably try to get this thread back on track now.  Phew.


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## Jon (Jul 14, 2008)

KB1OEV said:


> Sounds good.  Automacity is a neat thing.
> 
> I hope the compression only CPR hasn't taken over that much.
> 
> ...


I got my peepee smacked last time I co-taught an AHA HCP class... because I talked about CPR before AED in unwitnessed arrests.

AHA doesn't teach this (Yep... I checked, and I've got the BLS Instructor card, too). Some EMS services have it in protocols.


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## WuLabsWuTecH (Jul 15, 2008)

Well when you have that many organizations trying to teach CPR, you're bound to have conflicting opinions or at least disagreeing opinions.  Probably due ot everyone's different research?


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## ffemt8978 (Jul 15, 2008)

Jon said:


> I got my peepee smacked last time I co-taught an AHA HCP class... because I talked about CPR before AED in unwitnessed arrests.
> 
> AHA doesn't teach this (Yep... I checked, and I've got the BLS Instructor card, too). Some EMS services have it in protocols.



Pg 35 of the most recent BLS for HCP Student Manual under EMS Rescuers and AEDs



> EMS rescuers may provide 5 cycles of CPR before using the AED if they did not witness the cardiac arrest and their call to arrival time is more than 4 to 5 minutes.


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## firecoins (Jul 15, 2008)

KB1OEV said:


> The only times I have seen the 2 min of CPR mentioned in an unwitnessed arrest (or a child/infant) is when a single person finds the victim and needs to leave to call 911.  They do 2 min of CPR, leave to call 911 and return.  In a witnessed arrest of an adult, they call and then provide care.
> 
> I can't recall ever seeing it mentioned with an AED.  I believe it always says that the AED should be attached as soon as possible, which usually means that one person begins CPR and the other prepares the AED.
> 
> ...




i have seen 2 minutes of CPR on unwitnessed arrests in everything I have read.


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## skyemt (Jul 15, 2008)

firecoins said:


> i have seen 2 minutes of CPR on unwitnessed arrests in everything I have read.



2 minutes of CPR is on everything i have read as well, including my AHA materials...

basically, if someone is down for 5 minutes or more, and you go right to shocking, it will be a speedy way to make sure they will not make it.

there seems to be a lot of focus on "oxygenation", which is partially true, but what you are really after is "perfusion pressure" and adequate preload, which go together...


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