# CPR for ten minutes?



## Skittles (Jan 21, 2013)

I'm still in EMT class... However, right before Christmas break, my instructor went to a class, research discussion thingy, where he came back to us with some interesting info.

This was done at a local, well respected teaching hospital. Apparently, they have discovered that CPR only for ten minutes, no AED, no clot-busting drugs, NOTHING, except for hands only CPR increased survival. No rescue breaths, just straight compressions. After 100 compressions, the person doing compressions switched with the person counting. For ten minutes. They even advised against transport for those ten minutes, because even in the hospital with the doctors who can do all the goodies would be doing the same thing. 

Thoughts?


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## STXmedic (Jan 21, 2013)

That knowledge has been around for awhile. Good, early, uninterrupted CPR + early defibrillation = best outcomes for survival. All of our wonderful "life-saving" drugs and procedures really haven't proven to be that beneficial.


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## Skittles (Jan 21, 2013)

It was just weird. The class before we were getting it drilled into our heads that while one person was doing compressions, the other was hooking up the AED and attaching pads to analyze, getting the O2 and BVM ready and prepping the suction unit. He came back next class and said nope. Forget everything we just taught you. Also in our books (most recent orange book) it says that AED use in the first ten minutes gives best chances of survival.

ETA: They said no AED for the first ten minutes. No rescue breaths for the same. So would defib at minute 11 still be considered early, considering response times, time the pt was potential down before being found, etc.?


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## VFlutter (Jan 21, 2013)

Our policy is definitive airway by 10mins of CPR. Usually we don't do much with the airway until that 10 min point. However we do a lot more than just CPR during that time. Usually drawing labs, ABGs, and throwing in a femoral and Arterial line. Also there is a lot of detective work going on in that first 10 minutes.


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## STXmedic (Jan 21, 2013)

You will still get the AED on as soon as possible, thus the early defibrillation. Typically a round of CPR before the initial shock, dont wait for 10min to press the shock button. As far as BVM and other airway maneuvers and pharmacologic interventions, almost all systems will still be having you perform those as usual. BVM as soon as possible. IV/IO, epi or vaso, and anti arrhythmics as well. While there may be some advances in medicine, unfortunately EMS is typically well behind current science. And while I hate citing protocols, you will still need to work within them.* 

I believe Williamson Co EMS is participating in a study using only a NRB for the first 10 minutes of an arrest before moving to more advanced measures. I'm not sure if any other systems are doing anything similar.

*Many people here will talk about using common-sense, standard medical practice, and slight deviations from protocols to provide the best benefit and care to the patient instead of blindly following protocols to a tee. However, many here are experienced, well-educated, and typically have good working relationships with their medical directors. Don't get yourself fired.


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## STXmedic (Jan 21, 2013)

Chase said:


> Our policy is definitive airway by 10mins of CPR. Usually we don't do much with the airway until that 10 min point. However we do a lot more than just CPR during that time. Usually drawing labs, ABGs, and throwing in a femoral and Arterial line. Also there is a lot of detective work going on in that first 10 minutes.



Sure... Rub it in... "Oh look at me, I'm in a hospital and have access to labs, fem lines, and manpower!" :glare:


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## Skittles (Jan 21, 2013)

Absolutely, I will do everything I was trained to, including shocking as soon as possible, suctioning if there is vomit, O2 on the BVM, etc. I actually brought that point up in class, that a doctor at the ED could do more than I can, with their anti-clotting drugs and the like. I was terribly confused. However, I will follow protocol, and I will do what I was trained to, per my CPR card and emt-class, at least until standards change. It just really seems like it would be a waste of time, when I have more advanced treatments at my disposal.


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## medicdan (Jan 21, 2013)

Skittles, if you're interested in more information about this procedure (and how/why it works), consider researching CCR-- Cardiocerebral resuscitation. The CARES registry has some high performance departments doing this, and showing promising statistics. It takes some system coordination, but is really quite simple. Contrary to what your instructor said, CPR, and the current ECC/AHA guidelines are the standard in the vast majority of cities, and you should only perform CCR if in a system with specific protocols covering it, and physician oversight.


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## medicdan (Jan 21, 2013)

Also note, some systems allow for additional interventions in the first few minutes, most notably, opening the airway, inserting an OPA, and placing an NRB at 15lpm, with the thinking that the chest compressions allow positive and negative pressure gradients within the chest, and passive gas exchange within the lungs.


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## joegrizzly (Jan 21, 2013)

emt.dan said:


> If you're interested in more information about this procedure (and how/why it works), consider researching CCR-- Cardiocerebral resuscitation.



That is amazing, obviously protocols and SOPs come first but I'm stoked to have read about this. Thank you.

Ninja edit: I'll post my link to where I read up on CCR and if anyone finds anything better please give it a post. http://www.medscape.com/viewarticle/707616


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## VFlutter (Jan 21, 2013)

PoeticInjustice said:


> Sure... Rub it in... "Oh look at me, I'm in a hospital and have access to labs, fem lines, and manpower!" :glare:



Be jealous 

I love having arterial lines during codes. Gives you great feedback on the quality of compressions.


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## mycrofft (Jan 21, 2013)

skittles said:


> i'm still in emt class... However, right before christmas break, my instructor went to a class, research discussion thingy, where he came back to us with some interesting info.
> 
> This was done at a local, well respected teaching hospital. Apparently, they have discovered that cpr only for ten minutes, no aed, no clot-busting drugs, nothing, except for hands only cpr increased survival. No rescue breaths, just straight compressions. After 100 compressions, the person doing compressions switched with the person counting. For ten minutes. they even advised against transport for those ten minutes, because even in the hospital with the doctors who can do all the goodies would be doing the same thing.
> 
> Thoughts?



bs..............

EDIT: One person doing "compressions only" may be able to get better efficiency by skipping inflations (depends on how quickly he can do them) but if 911 shows up and you wave them off someone needs to net you. WHat sort of nonsense is "the hospital can't do anything more than one person doing hands-only CPR....
Oh, I've been punked again haven't I.  Dammit!


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## slewy (Jan 22, 2013)

Skittles said:


> ETA: They said no AED for the first ten minutes. No rescue breaths for the same. So would defib at minute 11 still be considered early, considering response times, time the pt was potential down before being found, etc.?



The main reason for taking an EMT-B class is to prepare the students to pass the NREMT, so that your teacher is trying to confuse you is wrong. You need to have a solid base foundation before taking the test, so follow the book, and not your teacher on this one. I know the teachers says a lot of time about how you need to do something different from the book, but you will learn that in the field. Make sure to follow the book exactly because the NREMT questions are exact replicas. The whole reason you are taking the EMT class is to prepare yourself for the NREMT. 

Follow the steps that will be on NREMT for full arrest:
1.Scene safe & BSI
2.Is this only patient? will you need resources?
3. consider c spine
4. Shake and shout
5. Check pulse
5. No pulse, 30 compressions
6. 2 rescue breaths
7.After 2 minutes of CPR, reassess 
8. When AED comes on scene attach and use
9. Resume CPR


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## Christopher (Jan 22, 2013)

slewy said:


> The main reason for taking an EMT-B class is to prepare the students to pass the NREMT, so that your teacher is trying to confuse you is wrong. You need to have a solid base foundation before taking the test, so follow the book, and not your teacher on this one. I know the teachers says a lot of time about how you need to do something different from the book, but you will learn that in the field. Make sure to follow the book exactly because the NREMT questions are exact replicas. The whole reason you are taking the EMT class is to prepare yourself for the NREMT.
> 
> Follow the steps that will be on NREMT for full arrest:
> 1.Scene safe & BSI
> ...



An EMT class is not meant to prepare you for the NREMT exam, unless it is a crappy class.

It is meant to prepare you to be an EMT.


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## Christopher (Jan 22, 2013)

Skittles said:


> I'm still in EMT class... However, right before Christmas break, my instructor went to a class, research discussion thingy, where he came back to us with some interesting info.
> 
> This was done at a local, well respected teaching hospital. Apparently, they have discovered that CPR only for ten minutes, no AED, no clot-busting drugs, NOTHING, except for hands only CPR increased survival. No rescue breaths, just straight compressions. After 100 compressions, the person doing compressions switched with the person counting. For ten minutes. They even advised against transport for those ten minutes, because even in the hospital with the doctors who can do all the goodies would be doing the same thing.
> 
> Thoughts?



10 minutes? Bizarre. They probably were talking about airway management.

Continuous chest compressions plus early appropriate defibrillation, probably within the first 2-4 minutes, is what the literature shows. The literature also shows a clear negative trend with increasing delays in defibrillation.

I would be very surprised if it ended up they did not defib for 10 minutes. Very surprised. If anything researchers are moving to 1 minute cycles.


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## VFlutter (Jan 22, 2013)

What teaching hospital is it? Do you have a link for information? I can't imagine not defibrillating at all until 10 mins. I missed that at first. 

I did my clinicals at a progressive teaching hospital and their codes still revolve around early and frequent defibrillation for shockable rhythms. Maybe 10mins of straight compressions for asystole?


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## RichLew (Jan 22, 2013)

Slightly off topic, but still related to working a code... "apneic oxygenation" is anyone else familiar with this or know of any departments that use it?


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## Christopher (Jan 22, 2013)

RichLew said:


> Slightly off topic, but still related to working a code... "apneic oxygenation" is anyone else familiar with this or know of any departments that use it?



We use it during pre-intubation and peri-intubation via nasal cannula. Dr. Levitan came up with NO-DESAT (Nasal Oxygenation During Efforts Securing A Tube) and Drs. Levitan and Weingart began pushing it hard in their PreOx/ApOx/DeOx/ReOx paper. (Keep in mind ApOx is meant for oxygenation rather than ventilation.)

North Carolina has added NO-DESAT to the 2012 intubation procedure as well.

It probably has limited use in a code due to a lack of physiologic perfusion to produce adequate gradients, but you'll find a similar approach with an OPA+NRB for passive oxygenation during CPR.


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## Brandon O (Jan 22, 2013)

Christopher said:


> 10 minutes? Bizarre. They probably were talking about airway management.
> 
> Continuous chest compressions plus early appropriate defibrillation, probably within the first 2-4 minutes, is what the literature shows. The literature also shows a clear negative trend with increasing delays in defibrillation.
> 
> I would be very surprised if it ended up they did not defib for 10 minutes. Very surprised. If anything researchers are moving to 1 minute cycles.



I agree. I suspect the research mentioned by the OP was misunderstood by either the instructor or by himself. Otherwise this would be quite a game-changing study.


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## Summit (Jan 22, 2013)

Regional protocols have use doing 200 compressions first.

"In unwitnessed cardiac arrest, give first 2 minutes of CPR without interruptions for ventilation. During this time period passive oxygenation is preferred with OPA and NRB facemask. If arrest is witnessed by EMS, immediate defibrillation is first priority" and thus get a monitor on and ALS can shock VF/VT ASAP, but PEA/Asystole, 2 minutes of straight compressions before you go to epi, then they want another two minutes of straight CPR without ventilation before more drugs, airway interventions, or BVM.


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## Brandon O (Jan 22, 2013)

Summit said:


> Regional protocols have use doing 200 compressions before AED.
> 
> "In unwitnessed cardiac arrest, give first 2 minutes of CPR without interruptions for ventilation. During this time period passive oxygenation is preferred with OPA and NRB facemask. If arrest is witnessed by EMS, immediate defibrillation is first priority" and thus get a monitor on and ALS can shock VF/VT ASAP, but PEA/Asystole, 2 minutes of straight compressions before you go to epi, then they want another two minutes of straight CPR without ventilation before more drugs, airway interventions, or BVM.



Yes, this concept was taught in the 2005 protocols -- if you didn't see it and no bystander CPR was provided, start with a couple minutes of compressions to "prime the pump." Further research suggested it may or may not be beneficial, so the 2010 recommendations deemphasized it. However, I've never seen anything that supported 10 minutes.


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## Handsome Robb (Jan 22, 2013)

joegrizzly said:


> That is amazing, obviously protocols and SOPs come first but I'm stoked to have read about this. Thank you.
> 
> Ninja edit: I'll post my link to where I read up on CCR and if anyone finds anything better please give it a post. http://www.medscape.com/viewarticle/707616



I may or may not work for one of the agencies that participates in CARES and uses CCR.

It's a pretty cool system. You should see the look on fire's faces when I throw then a NRB and OPA then tell them to move on.

Like everything CCR has indications and contraindications.


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## Veneficus (Jan 22, 2013)

Christopher said:


> I would be very surprised if it ended up they did not defib for 10 minutes. Very surprised. If anything researchers are moving to 1 minute cycles.



I would be very surprised if an ethical committee would even consider letting somebody do that.

From experience, "new and novel" ideas are not well received in medical research. It takes baby steps.

This is talking about something that goes against all the current knowledge.

I think something was misunderstood or not reported here properly.


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## TheLocalMedic (Jan 22, 2013)

One thing that I have seen getting attention lately is the idea of continuous CPR at all times.  This includes during defibrillation...  just keep right on going through the shocks.  I don't know all the details, or the actual safety of the practice, but that seems to be an interesting idea and "keeps the pump primed".


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## Summit (Jan 22, 2013)

Brandon Oto said:


> Yes, this concept was taught in the 2005 protocols -- if you didn't see it and no bystander CPR was provided, start with a couple minutes of compressions to "prime the pump." Further research suggested it may or may not be beneficial, so the 2010 recommendations deemphasized it. However, I've never seen anything that supported 10 minutes.



It is interesting to me that in their latest protocol update, they added the second set of 200 straight compression.


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## Brandon O (Jan 22, 2013)

Summit said:


> It is interesting to me that in their latest protocol update, they added the second set of 200 straight compression.



I'm not sure what you're referring to here.


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## Summit (Jan 22, 2013)

Brandon Oto said:


> I'm not sure what you're referring to here.



To clarify, the recent update calls for not one, but two cycles of no-ventilation/passive oxygenation CPR (compressions only with a NRB and OPA) unless there is an indication of non-cardiac etiology (eg asphyxiation of any cause) before switching to 30:2 ratio or attempting a King/ETT.


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## Shishkabob (Jan 22, 2013)

I don't do CPR.  That's what firefighters are for.   h34r:


I haven't done a single compression in the last 5+ arrests.


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## Brandon O (Jan 22, 2013)

Summit said:


> To clarify, the recent update calls for not one, but two cycles of no-ventilation/passive oxygenation CPR (compressions only with a NRB and OPA) unless there is an indication of non-cardiac etiology (eg asphyxiation of any cause) before switching to 30:2 ratio or attempting a King/ETT.



If you're referring to the 2010 AHA guidelines, I don't think this is correct. The guidelines decline to offer any specific recommendations on this subject, due to ambiguous evidence; instead they simply emphasize that in most cases, it's usually a moot point because compressions can be offered simultaneously while the defibrillator is readied.

"There is insufficient evidence to recommend for or against delaying defibrillation to provide a period of CPR for patients in VF/pulseless VT out-of-hospital cardiac arrest. In settings with lay rescuer AED programs (AED onsite and available) and for in-hospital environments, or if the EMS rescuer witnesses the collapse, the rescuer should use the defibrillator as soon as it is available (Class IIa, LOE C). When more than one rescuer is available, one rescuer should provide chest compressions while another activates the emergency response system and retrieves the defibrillator."

http://circ.ahajournals.org/content/122/18_suppl_3/S685.full

"When an out-of-hospital cardiac arrest is not witnessed by EMS personnel, EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation. There is insufficient evidence to determine if 1 ½ to 3 minutes of CPR should be provided prior to defibrillation. CPR should be performed while a defibrillator is being readied (Class I, LOE B). One cycle of CPR consists of 30 compressions and 2 breaths. When compressions are delivered at a rate of about 100 per minute, 5 cycles of CPR should take roughly 2 minutes (range: about 1 ½ to 3 minutes).

"EMS system medical directors may consider implementing a protocol that allows EMS responders to provide CPR while preparing for defibrillation of patients found by EMS personnel to be in VF. In practice, however, CPR can be initiated while the AED is being readied."

http://circ.ahajournals.org/content/122/18_suppl_3/S706.full


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## shfd739 (Jan 22, 2013)

PoeticInjustice said:


> I believe Williamson Co EMS is participating in a study using only a NRB for the first 10 minutes of an arrest before moving to more advanced measures. I'm not sure if any other systems are doing anything similar.



We do something similar. NRB until minute8-10 or so then intubation. 

Codes are broken down into 2 minute blocks with assigned tasks to each partner, or delegated to other responders. 

We're seeing some improved success with neuro intact post arrest discharges.


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## Summit (Jan 23, 2013)

Brandon Oto said:


> If you're referring to the 2010 AHA guidelines, I don't think this is correct.



I continue to be unclear :unsure:

I was referring to the recent update to the regional EMS protocol (which is well post-2010).

And these protocols do allow for shocking VF/PVT ASAP.


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## Skittles (Jan 24, 2013)

Brandon Oto said:


> I agree. I suspect the research mentioned by the OP was misunderstood by either the instructor or by himself. Otherwise this would be quite a game-changing study.



Stupid point, but I'm a girl. 

Hershey medical center is where it was being done. When I go back to class Tuesday, I will ask of he knows of any resources provided by Hershey to the public about this. And he wasn't trying to confuse us, or tell us to not follow protocol or current CPR standards. More of a point of interest discussion


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## Skittles (Jan 25, 2013)

TheLocalMedic said:


> One thing that I have seen getting attention lately is the idea of continuous CPR at all times.  This includes during defibrillation...  just keep right on going through the shocks.  I don't know all the details, or the actual safety of the practice, but that seems to be an interesting idea and "keeps the pump primed".



This was also mentioned. It's possible I misunderstood, but the nothing but compressions for ten minutes, not even AED was quite clear and adamant.


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## Brandon O (Jan 25, 2013)

Skittles said:


> Stupid point, but I'm a girl.
> 
> Hershey medical center is where it was being done. When I go back to class Tuesday, I will ask of he knows of any resources provided by Hershey to the public about this. And he wasn't trying to confuse us, or tell us to not follow protocol or current CPR standards. More of a point of interest discussion



Sorry girl! Let us know what you hear, sounds like interesting stuff.


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## Handsome Robb (Jan 25, 2013)

Skittles said:


> This was also mentioned. It's possible I misunderstood, but the nothing but compressions for ten minutes, not even AED was quite clear and adamant.



That doesn't make any sense to me. Not saying you're wrong, just that from what I've been taught and read, it doesn't add up. 

CPR and *early* defibrillation are the two interventions proven effective to increase survival to discharge rather than everything else included in ACLS.


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## downunderwunda (Jan 30, 2013)

slewy said:


> The main reason for taking an EMT-B class is to prepare the students to pass the NREMT, so that your teacher is trying to confuse you is wrong. You need to have a solid base foundation before taking the test, so follow the book, and not your teacher on this one. I know the teachers says a lot of time about how you need to do something different from the book, but you will learn that in the field. Make sure to follow the book exactly because the NREMT questions are exact replicas. The whole reason you are taking the EMT class is to prepare yourself for the NREMT.
> 
> Follow the steps that will be on NREMT for full arrest:
> 1.Scene safe & BSI
> ...



Shake & shout has been amended after a nurse in the UK used it to get off a shaken baby murder charge…


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## RustyShackleford (Jan 30, 2013)

CPR and no defib.....remind me never to arrest in central pa


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## Handsome Robb (Dec 15, 2013)

I don't believe it until I see studies. Compressions *and* early defibrillation save lives, not compressions by themselves.

As far as transporting, I don't transport with CPR in progress. If we get ROSC then they lose it again we continue to work until it comes back or it doesn't.


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## Christopher (Dec 15, 2013)

Robb said:


> I don't believe it until I see studies. Compressions *and* early defibrillation save lives, not compressions by themselves.
> 
> As far as transporting, I don't transport with CPR in progress. If we get ROSC then they lose it again we continue to work until it comes back or it doesn't.



I'm sure they meant compressions without ventilations for 10 minutes.


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## NomadicMedic (Dec 15, 2013)

And we brought this year old thread back from the dead, why?


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## Handsome Robb (Dec 15, 2013)

DEmedic said:


> And we brought this year old thread back from the dead, why?



dude...it popped up in the new tappatalk. 

that's my fault.

can i still blame it on the pain killers? lol

I said basically the same thing too, at least I'm consistent.


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## ffemt8978 (Dec 15, 2013)

Here I was going to say at least somebody used the search feature, but you blew it.


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