# Cpr -_-



## Alas (Oct 4, 2011)

Few questions on CPR that I can't seem to find anywhere on the net and forgot to ask my instructor:

The AHA 2010 CPR video in which i was trained, shows rescuer 1 who is performing compressions stop while rescuer 2 gives 2 ventilations, and rescuer 1 resumes 30 compressions. I've read/heard/seen(hospital setting) that cpr shouldn't stop and ventilations given during compressions except the first cycle to look for chest rise. Comments?

Am I correct when I state that during CPR, the only time to recheck pulse is when the patient starts to move.

AED should be put on ASAP- with a minimum of 1 cycle of CPR.

Thank you!
Alas


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## bradford (Oct 4, 2011)

"The AHA 2010 CPR video in which i was trained, shows rescuer 1 who is performing compressions stop while rescuer 2 gives 2 ventilations, and rescuer 1 resumes 30 compressions. I've read/heard/seen(hospital setting) that cpr shouldn't stop and ventilations given during compressions except the first cycle to look for chest rise. Comments?"
According to 2010 AHA BLS guidelines, the compression to ventilation ratio is 30:2, unless an advanced airway is in place. In the presence of an advanced airway, CPR changes to continuous compressions at a rate of at least 100/minute and 1 rescue breath every 6-8 seconds.
"Am I correct when I state that during CPR, the only time to recheck pulse is when the patient starts to move."
Depending on your environment. If you are working in a strictly BLS setting with just an AED, than yes (sort of). Any perceived voluntary movement or respiratory effort; than yes, a pulse check is in order. If in an ALS setting, during re-analyization period a pulse check may be in order as well, depending on ECG interpretation.
"AED should be put on ASAP- with a minimum of 1 cycle of CPR."
In a BLS (or bystander) setting, the AED takes precedent over manual CPR. 5 cycles, or 2 minutes, of CPR is preferred prior to initial AED analyzation. You want to "prime the pump." In the case of witnessed arrest, defibrillation should not be delayed.


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## HMartinho (Oct 4, 2011)

When you give the ventilations (30:2), CPR should be stopped, unless the patient is intubated (ETT or other).

Yes, you should check the pulse if the patient moves, or AED "says" no shock advised.


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## Anjel (Oct 4, 2011)

Yea what the last guy said. 

Unless there is a tube place then you stop compressions while giving 2 breaths. Then resume.


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## traumaluv2011 (Oct 4, 2011)

You should stop compressions when (and only when):

-Ventilating (BVM or mask-to-mouth)
-When AED is evaulating pulse (in apneic/pulse-less patients) 
-When AED is schocking patient (obviously)

The new guides do away with checking the pulse and breathing after ever cycle. I would do both before you start just to make sure you aren't doing CPR on someone who just has syncope.


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## Shishkabob (Oct 4, 2011)

traumaluv2011 said:


> make sure you aren't doing CPR on someone who just has syncope.



Syncope is generally a self-correcting condition and as such they would hopefully be awake before you get there, let alone before you start doing all the fun stuff.




In theory, yes, you do stop compressions every 30 to deliver the ventilations.   However, I'm lucky, as every single arrest I've worked I've just stuck an advanced airway in off the bat as to avoid the whole 'stopping' thing.  It takes 15ish compressions just to build up the momentum you lost when you stopped to do ventilations.  Granted BLS providers / Joe Public don't have the luxury of advanced airways...


As far as checking a pulse only when you see movement:  No.  Someone can get a pulse back and still be apneic.  Just because someone gets a pulse back doesn't mean they can move, and just because someone moves doesn't mean they have a pulse back.

Do the pulse checks periodically after a shock, or when no shock is advised.  It's not easy to determine with an AED, it's far more easy with a real monitor as when you stop to check a rhythm you can actually see if there's an organized rhythm capable of producing a pulse and if so, THAT'S when you check a pulse.

Just don't let a pulse check delay compressions.


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## Anjel (Oct 4, 2011)

Granted BLS providers have combitube


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## Alas (Oct 4, 2011)

Thanks bradford and everyone else for the input. That answered it 100 percent.


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## HMartinho (Oct 4, 2011)

Anjel1030 said:


> Granted BLS providers have combitube



In U.S. EMT-B and BLS providers can put combitube?


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## Shishkabob (Oct 4, 2011)

HMartinho said:


> In U.S. EMT-B and BLS providers can put combitube?



In some places, yes.


In my system, EMTs are allowed King airways.


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## HMartinho (Oct 4, 2011)

Linuss said:


> In some places, yes.
> 
> 
> In my system, EMTs are allowed King airways.



Lucky guys... In this respect, Portugal is very conservative. Just OPA's and NPA's.h34r:


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## WTEngel (Oct 4, 2011)

According to the most recent revision of BLS for Healthcare Providers, there is only one pulse check in the BLS pulseless arrest algorithm, and this is the initial one. The only time you check for a pulse after the initial analysis is if there is an obvious sign of life. There is no other recommended time to check a pulse, and the pulse check is not dependent on AED recommendation of shock vs. no shock.

After the initial pulse check, CPR is only paused to allow for AED analysis and AED shock. There is no pulse check after the shock is delivered, and there is not a pulse check recommended if the AED recommends "No Shock Advised." 

The current class I LOE B recommendation from AHA is to immediately resume CPR without delay and without a pulse check after a shock is delivered, or if no shock is advised.

Sorry to be repetitive, but this is something AHA is not ambiguous on, and the key point here is that obvious signs of life such as movement and adequate respiration have been proven to be equally as effective at assessing circulation as an actual pulse check. In fact, healthcare providers were unable to accurately detect a pulse up to 80% of the time in certain studies.Checking a pulse in the absence of signs of life is time consuming delays CPR delivery, which is the most critical intervention in pulseless arrest, second only to defibrillation in the VF/VT patient.


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## WTEngel (Oct 4, 2011)

The above info was pulled from the following link, published in Circulation, in the 2010 guidelines update edition. Check pg S707 for specific details.


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


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## jjesusfreak01 (Oct 8, 2011)

Linuss said:


> In my system, EMTs are allowed King airways.



Yay for Kings! Boo combitubes!

I don't see why anyone still uses those things. The chance of unintentionally putting the tube in the trachea with an unvisualized insertion is so low that you might as well just aim for the esophagus and be happy you have a good airway.


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## BrushBunny91 (Oct 22, 2011)

What are the ALS hospital guidelines for infant and child CPR? I understand adult is compressions at 100 per min and breathing is 12 at minimum per minute.


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## Handsome Robb (Oct 22, 2011)

We do 8-10 breaths per minute for adults...not 12.

Peds HR <60 with signs of severe cardiopulmonary compromise or pulseless get compressions 100/min, ventilations at the same rate as adults and epi 1:10,000 0.01 mg/kg q 3-5 minutes. Defibrillation as indicated 2 joules/kg max of 150 joules for the first shock, 4 joules/kg max of 150 J for the rest of the defibs. Also amiodorone 5 mg/kg, we cant repeat it once.


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## BrushBunny91 (Oct 22, 2011)

I've got San bernardino medical direction telling me 12 assisted ventaliations a minute.
Thank you for the ALS aed info but I can't do some of that with my two button device  start and shock.


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## WTEngel (Oct 22, 2011)

10-12 breaths per minute (every 5-6 seconds) without and advanced airway, or 30:2 during CPR.

8-10 breaths per minute (every 6-8 seconds) with an advanced airway, or continuous at the same rate (every 6-8 seconds) during CPR, without a pause.

That is per AHA, not sure what your department protocol is.

Your comments about peds were correct.


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## Brandon O (Oct 26, 2011)

Engel is describing this very well. Some general thoughts:

-- Many EMTs are confused when they work their first cardiac arrest with medics and discover that "30:2" has become continuous ventilation instead, at a rate of 8-10 times a minute (every 6-8 seconds). This is only applicable when an endotracheal tube or other advanced airway is in place; normal "pump and blow" with a BVM is still 30:2. It's just that many places nowadays it's hard to swing a dead cat without hitting a medic, and they all seem to show up at codes, so BLS CPR is less common.

-- Normal adult ventilations, a la for rescue breathing, are at a rate of every 5-6 seconds. Pediatrics get every 4-5 seconds. Neonates are their own deal.

-- With all of that said, the first, last, and middle priority at 99.9% of cardiac arrests is compressions and defibrillation. We _know_ that early compressions, deep, fast, with full recoil, minimal interruptions, and little delay prior to shock saves lives. We _know_ that defibrillating v-fib/v-tach arrests as early as possible saves lives. Absolutely everything else... we have no evidence that it does anything at all. At best (i.e. ventilations, cardiac drugs) it probably has some role, but it's not yet clear how it should best be used, and it has downsides that need to be understood. At worst (inappropriate endotracheal intubation) it may be killing a lot of patients. But no matter what, they should never take priority over the stuff that saves lives: compressions and defibrillation. So, for instance, why aren't we still checking for pulses every five seconds? Because like so many other things, this interrupts a lifesaving measure (compressions) for something largely pointless, and this is exactly what we don't want. Push until they start to pink up or squirm on you. Even the medics shouldn't be stopping for rhythm checks, although end-tidal CO2 is a legitimate indicator of ROSC, and some new technology lets them "read through" compression artifact to recognize the underlying rhythm.

Remember folks, PUSH AND SHOCK! You'll never do anything simpler yet more lifesaving with your two hands.


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## Brandon O (Oct 26, 2011)

Brandon Oto said:


> -- Normal adult ventilations, a la for rescue breathing, are at a rate of every 5-6 seconds. Pediatrics get every 4-5 seconds. Neonates are their own deal.



Just a small typo here -- peds are every 3-5 seconds.


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## mycrofft (Oct 26, 2011)

*Basic layperson CPR, or professional responder, or ...*

Different flavors nowadays. Plus "inflation-free".

Pulse checks eliminated from beginner CPR. Allgonebyebye


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## attnondeck (Oct 26, 2011)

mycrofft said:


> Different flavors nowadays. Plus "inflation-free".
> 
> Pulse checks eliminated from beginner CPR. Allgonebyebye





yeah  they teach to go right from shock to compressions again. they said something about there being studies that pulse is seldom found after shocking and keeping the heart primed is more important at that point...


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## WTEngel (Oct 26, 2011)

In the study they cited, there was zero incidence of a pulse associated with conversion to an organized rhythm post defibrillation.

The new standard is to base your interventions following defibrillation around the previous rhythm analyzed, not the rhythm that occurs after defibrillation...unless obvious signs of life are noted.


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