# CPR and advanced airway



## ironguy321 (Sep 29, 2007)

In my class we learned last night that if the patient has an advanced airway in place that one person provides breaths every 8-10 seconds while the other person provides 100 compressions.  Both of these are done as separate fuctions. Once we've done 100 compressions, do we switch, start back at ABC'S, keep going, etc.? (EMT-B Student here)


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## Buzz (Sep 29, 2007)

You were taught to do 100 compressions? You sure it wasn't 30 compressions at a rate of 100 per minute?

My book says to do 5 cycles of 30 compressions each at a rate of 100 per minute, and then switching with the person doing ventillations to avoid fatigue. Each person should be doing compressions for about two minutes. 

I hope that answered the question, but I wasn't really clear on what exactly you were asking...


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## ironguy321 (Sep 29, 2007)

Yeah thats what has me going, huh? Heres what it says word for word:

"If an advanced airway is being used on the victim compressions and ventilations are performed as separate functions. The ventilator provides 8 to 10 breaths per minute and the compressor performs 100 compressions per mintue uninterrupted"


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## Derf (Sep 29, 2007)

What I was taught is once an advanced airway is in place a breath is given about once every 5 secs with continuous compressions, switching out with your partner every 2 mins to avoid fatigue and to maintain good compressions.


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## BossyCow (Sep 29, 2007)

I've attended some classes lately that are recommneding reducing the amount and frequency of ventilations.  Research is showing that too much ventilation can impede the ability of the heart to re-fill with blood by decreasing the area of the thorascic cavity.  The lungs need to deflate to allow for the heart to fully expand bringing in as much of the oxygenated blood as possible.


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## volparamedic (Oct 5, 2007)

*Keep on truckin'*

You do not have to stop when an advanced airway is in place...only when the airway isn't secured. The compression ratio is 100 faster there's no time for ventricle to refill...slower not good priming. Resp rate 10-12....much faster will cause resp acidosis which in return can prevent resusitation of your patient.


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## Ridryder911 (Oct 5, 2007)

volparamedic said:


> You do not have to stop when an advanced airway is in place...only when the airway isn't secured. *The compression ratio is 100 faster there's no time for ventricle to refill...slower not good priming. Resp rate 10-12....much faster will cause resp acidosis which in return can prevent resusitation of your patient*.



First welcome to the site!

Second *WHOA!* Actually the faster rate * does and will still allow ventricular filling time *, (100/min is just tachycardia). The rate was to increase ATP level and inthoracic pressure thus increasing perfusion level, and as well outcome studies has shown that stopping CPR drastically reduces ATP thus reducing the possibility of survability

As well, faster ventilation will *NOT* produce respiratory acidosis actually the opposite, too much ventilation will produce alkalosis. (remember hyperventilation produces aklalosis, and < resp = acidosis) 

Current research as well, is now demonstrating that ventilations of 5-10 a minute is adequate, and it is now being explored of NOT doing any ventilations. Compressions only has equal to higher outcome levels for laymen CPR*. So, don't be surprised the next CPR will no longer have rescue breathing for common laymen... the research still continues.  

(Currents: In Emergency Cardiovascular Care; American Heart Association; Volume 3, No.18. 2007) 

Expect CPR changes again, in the next few years. 

R/r 911


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## triemal04 (Oct 5, 2007)

Actually, there is allready a push, small but still there, to remove ventilations from rescuer CPR until an ET tube is in place.  I want to say it's called CCR, cardio-cerbral resucitation, and from the results I heard (nothing official, just word of mouth) it works VERY well.


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## Asclepius (Oct 5, 2007)

ridryder 911 said:


> First welcome to the site!
> 
> Second *WHOA!* Actually the faster rate * does and will still allow ventricular filling time *, (100/min is just tachycardia). The rate was to increase ATP level and inthoracic pressure thus increasing perfusion level, and as well outcome studies has shown that stopping CPR drastically reduces ATP thus reducing the possibility of survability
> 
> ...



He's right! AHA guidelines have recently changed and they have found and are teaching now that it is not good to hyperventilate. The only exception to this is a suspected increase in intracranial pressure (then you should breathe a little faster for the patient).

The key in CPR is don't ever stop compressions. They want you now to breathe for the patient while you're doing compressions. The only time to stop is to check for a pulse and then that should last less than 10 seconds. 

And R/r is right...these guidelines will stand until it is time to sell more books.


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## skyemt (Oct 5, 2007)

let's not get carried away here... circulating oxygenated blood during CPR is always preferrable to deoxygenated blood... the push for "compression only" CPR is for laymen only, because they found that the breaks in compressions were too long, and all perfusion pressure was lost... also, laymen tend to "overventilate", increasing intrathoracie pressure and hindering preload to the heart, basically renedering the CPR given as almost useless.  that is where the impetus for the "compressions only" CPR came from.

in fact, for EMS the next change in protocols in many areas will not be the elimination of ventilation, but the introduction of a device, called a "rescue pod"... this device attaches to the BVM, and upon exhalation creates a vacuum in the chest, lowering intrathoracic pressure and vastly improving venous return to the heart... this increased preload due to the device has shown in studies to dramatically increase the effectiveness of CPR.


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## princess (Oct 6, 2007)

Anyone using the ResQPOD?  What are your thoughts?


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## skyemt (Oct 6, 2007)

Princess, the resQPOD is being rolled out in my county as part of our cardiac protocol sometime in '08.  apparently they have field tested it with good results... not too many times is there a device that is inexpensive, easy to use, and potentially makes i big improvement in what we do...

but, i am not using it yet, so time will tell..


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## MMiz (Oct 6, 2007)

princess said:


> Anyone using the ResQPOD?  What are your thoughts?


My service started using it in 2005, but I'm not so sure of the results.  It appears as though the trial is now being expanded.


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## Ridryder911 (Oct 6, 2007)

EMSA in OKC, has been using ResQPod with surprising increased survivaliblity. I had heard that it has had >20% which VERY impressive. Unfortunately, they are about $100 a pop, which a service cannot bill for, which means for many of us... no use.. 

It will be nice to see the results. 

R/r 911


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## triemal04 (Oct 8, 2007)

skyemt said:


> let's not get carried away here... circulating oxygenated blood during CPR is always preferrable to deoxygenated blood... the push for "compression only" CPR is for laymen only, because they found that the breaks in compressions were too long, and all perfusion pressure was lost... also, laymen tend to "overventilate", increasing intrathoracie pressure and hindering preload to the heart, basically renedering the CPR given as almost useless.  that is where the impetus for the "compressions only" CPR came from.
> 
> in fact, for EMS the next change in protocols in many areas will not be the elimination of ventilation, but the introduction of a device, called a "rescue pod"... this device attaches to the BVM, and upon exhalation creates a vacuum in the chest, lowering intrathoracic pressure and vastly improving venous return to the heart... this increased preload due to the device has shown in studies to dramatically increase the effectiveness of CPR.


Actually CCR is still being looked at as a possible tool for ALS personell as well and it's still being studied overall.  A dept in Wisconsin ran a trial with it that had some interesting results.  There isn't as much info there as I'd like, but enough that it brings up a few good points.  Unfortunately this was for witnessed arrests only...I'd like to see some hard data on a trial done on ALL cardiac arrests.
http://www.ncbi.nlm.nih.gov/sites/e...dopt=AbstractPlus&holding=f1000,f1000m,isrctn
http://web.kshb.com/kshb/pdf/ACurrentOpinionsCCREwy06MCC58.pdf

The second link is just basic info on what CCR is.  Boiled down it pretty much says that in the initial 8-15 minutes after arrest (which is usually caused by VF/VT...but not always) compressions have a better chance at restoring a rhythm than a combo of compressions/ventilations which reduce the amount of time that blood is flowing.  There's defintely some interesting info out there...like supplemental (non-positive pressure) oxygen having the same effect or better effects than positive pressure in the initial responce.  Helps to make a strong case for the resqpod if nothing else.


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## 1799687 (Oct 17, 2007)

precisely. 


volparamedic said:


> You do not have to stop when an advanced airway is in place...only when the airway isn't secured. The compression ratio is 100 faster there's no time for ventricle to refill...slower not good priming. Resp rate 10-12....much faster will cause resp acidosis which in return can prevent resusitation of your patient.


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## medic755 (Oct 18, 2007)

I have heard that this is the preferred method in some other countries (Sweden sounds familiar for some reason), anybody heard more about it?



triemal04 said:


> Actually CCR is still being looked at as a possible tool for ALS personell as well and it's still being studied overall.  A dept in Wisconsin ran a trial with it that had some interesting results.  There isn't as much info there as I'd like, but enough that it brings up a few good points.  Unfortunately this was for witnessed arrests only...I'd like to see some hard data on a trial done on ALL cardiac arrests.
> http://www.ncbi.nlm.nih.gov/sites/e...dopt=AbstractPlus&holding=f1000,f1000m,isrctn
> http://web.kshb.com/kshb/pdf/ACurrentOpinionsCCREwy06MCC58.pdf
> 
> The second link is just basic info on what CCR is.  Boiled down it pretty much says that in the initial 8-15 minutes after arrest (which is usually caused by VF/VT...but not always) compressions have a better chance at restoring a rhythm than a combo of compressions/ventilations which reduce the amount of time that blood is flowing.  There's defintely some interesting info out there...like supplemental (non-positive pressure) oxygen having the same effect or better effects than positive pressure in the initial responce.  Helps to make a strong case for the resqpod if nothing else.


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## skyemt (Oct 23, 2007)

you guys are getting carried away with compression only cpr, or ccr, whatever...

there are three phases to an arrest... 
      1-electrical
      2-circulatory
      3-metabolic

in the first phase, electrical (collapse to 4 minutes), research has shown that there is still sufficient oxygen available to cells, and that defibrillation provides the greatest chance for a good outcome... clearly, ventilations in this "witnessed" phase are not as important..

however, after 4-5 minutes up to 10, in the circulation phase, the best chance for a good outcome is at least 2 minutes of CPR PRIOR to defibrillation... in addition, DELIVERING OXYGEN TO THE PATIENT BECOMES IMPERATIVE for a variety of reasons, which we can go into if you want...

the third, metabolic phase, after 10 minutes, outcomes are poor regardless of interventions. the best prospects here seem to be inducing hypothermia.

the point is this... while protocols may change regarding ventilations in a witnessed arrest up to 4 minutes, there is absolutely no way that ventilations will be eliminated in an unwitnessed arrest for rescue personell... to think it would is not understanding the principals of resuscitation, nor physiology of cardiac arrest... simply, it ain't gonna happen.


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## disassociative (Oct 23, 2007)

I posted this the other day in regards to cardiocerebral rescuscitation. This report contains some promising data in regards to CCR.

http://circ.ahajournals.org/cgi/content/full/111/16/2134

(Circulation. 2005;111:2134-2142. American Heart Association. et al. Gordon A. Ewy, MD.)


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## Asclepius (Oct 23, 2007)

skyemt said:


> you guys are getting carried away with compression only cpr, or ccr, whatever...


Gee, I haven't gotten the impression that anyone here has neglected the importance of oxygenation. I think we've had a discussion about guidelines and protocols, but I don't think anyone misses the need to circulate oxygenated blood.


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## skyemt (Oct 23, 2007)

well, then you weren't reading the posts...

compression only = no ventilations = no oxygenation

from medic755 above

"in the initial 8-15 minutes after arrest (which is usually caused by VF/VT...but not always) compressions have a better chance at restoring a rhythm than a combo of compressions/ventilations which reduce the amount of time that blood is flowing."
once again, eliminating ventilations 8-15 minutes after arrest...

these are what i am responding to, i'm not really sure what you are responding to, since compression only means no ventilations.


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## triemal04 (Oct 25, 2007)

skyemt said:


> well, then you weren't reading the posts...
> 
> compression only = no ventilations = no oxygenation
> 
> ...



Actually, that was from me.  If you haven't done it, go through the links that I and dissociative posted; read the entire thing (especially the one dissociative linked).  There is some fairly compelling evidence coming out that favors compressions vs compressions/ventilations vs compressions/ventilations/ACLS during the HEMODYNAMIC stage of cardiac arrest.  (I misspoke a bit earlier; in the intial 4 or so minutes during the electrical phase, some studies have shown equal results with CCR or CPR and ACLS)  That would be 8-15 minutes after arrest.  A lot of the evidence that supports CCR is what drove the changes in CPR; it takes quite a few compressions to build up enough pressure to really perfuse the organs, and the moment you stop to ventilate, that pressue is lost; thus the longer compression cycles and less emphasize on ventilations.  In later stages of arrest (8-15min) good perfusion is being shown to be extremely important.  It won't matter how much O2 you get into the system if the blood itself isn't being circulated.  

Some of the findings from there also tie into the resqpod; to much positive pressure is actually a bad thing, and in at least one study there was no difference when a BVM was used vs a NRB.  Now how's that for shocking?  :wacko:

Now, I don't know if CCR or compressions with free-flowing O2 instead of positive pressure initially is the way to go or not.  I don't know if CCR period is the way to go.  Most of the people running the studies on it don't seem to be sure either.  But what I (and they) do know is that the results of these trials are pretty shocking and food for a lot of thought.  More work definetly needs to be done, and how CCR would mix with ACLS needs to be looked at, but, so far, it's pretty interesting stuff that's being done.  

What I do know is that the new guidelines of 2 minutes of CPR before shocks, drugs, tubes, anything ALS is creating a lot more code saves, and more of these people are making it to discharge than before.  Why is that?  Because their blood is actually being circulated, and good, continous compressions (not ventilations) are being pointed out as extremely important.  More food for thought.

Bottom line...medicine changes.  And sometimes it happens fast, no matter how much all of us drag our feet and kick and scream.  I don't know if this is the way of the future or not, but look back a few years and look at how things have changed.


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