# Rescue breaths



## Ediron (Jan 2, 2010)

When should you give 2 rescue breaths on a patient

when he is apneic and has a pulse??


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## 18G (Jan 2, 2010)

Yes, if during the initial assessment you find the patient not breathing you want to give 2 rescue breaths before continuing to check for a pulse. 

Anytime a patient is not breathing you need to give rescue breaths regardless of pulse or not.


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## Jeffrey_169 (Jan 9, 2010)

18G is precisly correct.


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## jerellem (Feb 15, 2010)

Okay, so when would you go straight to chest compressions?


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## medichopeful (Feb 15, 2010)

jerellem said:


> Okay, so when would you go straight to chest compressions?



After the AED tells you to resume CPR.  Other than that, there is NO time (that I know of) where you would go _straight_ to chest compressions.

You might also go straight to chest compressions on a child with a pulse rate of 60 or below with signs of poor perfusion.  But that would probably be situation dependent.  Hopefully someone more educated could jump in and correct me if I'm wrong.  

You MIGHT (I haven't learned it) go straight to compressions (without breaths) when doing compression-only CPR.  Not sure though.  I'd check another source before doing it.


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## Shishkabob (Feb 15, 2010)

You provide air when your patient isn't getting enough of it on their own... they don't necessarily have to be apneic.  If they are breathing 2 times a minutes, are you going to wait till they stop?


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## emt_irl (Feb 16, 2010)

the only time youd go straight to compressions in my country would be for F.B.A.O if you have tried black slaps and abdominal thrusts with no sucess and they go floppy on you


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## CollegeBoy (Feb 16, 2010)

medichopeful said:


> > Okay, so when would you go straight to chest compressions?
> 
> 
> After the AED tells you to resume CPR.  Other than that, there is NO time (that I know of) where you would go _straight_ to chest compressions.



I do not even go straight to compressions here, my protocols have us check for a pulse and apneic after every shock. Then two more breaths before continuing CPR.


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## jerellem (Feb 16, 2010)

Okay, check this out. Let's say you arrive to find bystanders performing cpr. Do you trust that their CPR was done correctly and instantly hook up AED or immediately begin chest compressions or do you give 2 rescue breaths right off the bat?  Sorry for all the questions but things get confusing when there are so many variables.


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## MRE (Feb 16, 2010)

jerellem said:


> Okay, check this out. Let's say you arrive to find bystanders performing cpr. Do you trust that their CPR was done correctly and instantly hook up AED or immediately begin chest compressions or do you give 2 rescue breaths right off the bat?  Sorry for all the questions but things get confusing when there are so many variables.



In most cases you would ask them to stop and stand back, then begin your assessment from the beginning.  Bystanders have been known to do CPR on people who are breathing and have a pulse, or on someone who has obvious signs of death which EMTs would not work.  Never trust a bystander blindly.


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## medichopeful (Feb 17, 2010)

RuralEMT said:


> I do not even go straight to compressions here, my protocols have us check for a pulse and apneic after every shock. Then two more breaths before continuing CPR.



We were taught to just go straight to compressions after every shock/no shock (within reason.  If they get up and start walking around we wouldn't do compressions ).


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## MrBrown (Feb 17, 2010)

Our clinical guidelines recommend to do 2 minutes of CPR if we have not personally witnessed the arrest.

Now that said if I roll up to a cardiac arrest with somebody doing CPR I'm probably gonna slap on the pads, have a look at the monitor and give the patient a toasting.

An Officer I know was telling us of an arrest he had on Friday, the guy kept flip flopping between sinus rhythm and VF; so "oh we just kept smashing him in the chest with my fist and he would convert back" .... Johnny and Roy would be proud! B)


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## grich242 (Feb 17, 2010)

medichopeful said:


> After the AED tells you to resume CPR.  Other than that, there is NO time (that I know of) where you would go _straight_ to chest compressions.
> 
> You might also go straight to chest compressions on a child with a pulse rate of 60 or below with signs of poor perfusion.  But that would probably be situation dependent.  Hopefully someone more educated could jump in and correct me if I'm wrong.
> 
> You MIGHT (I haven't learned it) go straight to compressions (without breaths) when doing compression-only CPR.  Not sure though.  I'd check another source before doing it.



With kids respiratory problems are usually high up on the list of causes of arrest, or even poor perfusion.


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## Rogue Medic (Feb 18, 2010)

jerellem said:


> Okay, check this out. Let's say you arrive to find bystanders performing cpr. Do you trust that their CPR was done correctly and instantly hook up AED or immediately begin chest compressions or do you give 2 rescue breaths right off the bat?  Sorry for all the questions but things get confusing when there are so many variables.



We should assess the quality of the lay person CPR. It should be obvious pretty quickly if they are doing good CPR. Unless they need to be relieved (bad CPR or too tired), have them continue compressions while we apply the defibrillator pads. We should treat anyone performing lay person CPR with respect. 

*If the patient is resuscitated and survives with an intact brain, it will probably be because of good lay person CPR.*



> _Lay rescuers should continue CPR until an AED arrives, the victim begins to move, or EMS personnel take over CPR (Class IIa). Lay rescuers should no longer interrupt chest compressions to check for signs of circulation or response. Healthcare providers should interrupt chest compressions as infrequently as possible and try to limit interruptions to no longer than 10 seconds except for specific interventions such as insertion of an advanced airway or use of a defibrillator (Class IIa).
> 
> We strongly recommend that patients not be moved while CPR is in progress unless the patient is in a dangerous environment or is a trauma patient in need of surgical intervention. CPR is better and has fewer interruptions when the resuscitation is conducted where the patient is found._
> 
> ...



_"We strongly recommend that patients not be moved while CPR is in progress unless the patient is in a dangerous environment or is a trauma patient in need of surgical intervention. CPR is better and has fewer interruptions when the resuscitation is conducted where the patient is found."_

In other words, there is rarely a good reason to transport dead people.




> _Compression-Ventilation Ratio
> A compression-ventilation ratio of 30:2 is recommended and further validation of this guideline is needed (Class IIa).150,151,180,185–187 In infants and children (see Part 11: "Pediatric Basic Life Support"), 2 rescuers should use a ratio of 15:2 (Class IIb).
> 
> This 30:2 ratio is based on a consensus of experts rather than clear evidence._
> ...






> _When VF/pulseless ventricular tachycardia (VT) is present, the rescuer should deliver 1 shock and should then immediately resume CPR, beginning with chest compressions (Class IIa). The rescuer should not delay resumption of chest compressions to recheck the rhythm or pulse. After 5 cycles (about 2 minutes) of CPR, the AED should then analyze the cardiac rhythm and deliver another shock if indicated (Class IIb). If a nonshockable rhythm is detected, the AED should instruct the rescuer to resume CPR immediately, beginning with chest compressions (Class IIb). Concern that chest compressions might provoke recurrent VF in the presence of a post-shock organized rhythm does not appear to be warranted.25
> 
> AED voice prompts should not instruct the lay user to reassess the patient at any time. AED manufacturers should seek innovative methods to decrease the amount of time chest compressions are withheld for AED operation. Training materials for lay rescuers should emphasize the importance of continued CPR until basic or advanced life support personnel take over CPR or the victim begins to move._
> 
> ...



_"The rescuer should not delay resumption of chest compressions to recheck the rhythm or pulse."_

When a shock is delivered, it is only a single shock, then we immediately resume compressions. _Immediately._


I expect that the next revision of the guidelines, which should come out next year, will discourage initial ventilation in witnessed adult VF/Pulseless VT patients until _after_ several minutes of compressions. The research on compression only CPR is showing much better outcomes for these patients. 

The two important things are continuous compressions and defibrillation - not ventilation. The main objection seems to come from those who think that tradition is more important than science, that tradition is more important than improving patient care.

Respiratory patients, pediatric patients, and other rhythms would not be treated with only compressions, since these patients may actually benefit from early ventilation.




> _*STUDY OBJECTIVE:*
> Assisted ventilation may adversely affect out-of-hospital cardiac arrest outcomes. Passive ventilation offers an alternate method of oxygen delivery for these patients. We compare the adjusted neurologically intact survival of out-of-hospital cardiac arrest patients receiving initial passive ventilation with those receiving initial bag-valve-mask ventilation.
> 
> *METHODS:*
> ...




_"Adjusted neurologically intact survival after witnessed ventricular fibrillation/ventricular tachycardia out-of-hospital cardiac arrest was higher for passive ventilation (39/102; 38.2%) than bag-valve-mask ventilation (31/120; 25.8%) (adjusted odds ratio [OR] 2.5; 95% confidence interval [CI] 1.3 to 4.6)."_

This is just the most recent study by Dr. Ewy. There are plenty of other studies showing similar improvements in outcomes with continuous compressions.


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## triemal04 (Feb 18, 2010)

Rogue Medic said:


> I expect that the next revision of the guidelines, which should come out next year, will discourage initial ventilation in witnessed adult VF/Pulseless VT patients until _after_ several minutes of compressions. The research on compression only CPR is showing much better outcomes for these patients.
> 
> The two important things are continuous compressions and defibrillation - not ventilation. The main objection seems to come from those who think that tradition is more important than science, that tradition is more important than improving patient care.
> 
> Respiratory patients, pediatric patients, and other rhythms would not be treated with only compressions, since these patients may actually benefit from early ventilation.


Offtopic, but what the hell...

I wouldn't be to surprised if this happens; switching to CCR instead of CPR (or just renaming CCR CPR which is more likely) and from the published results of the trials this would actually be a good thing.  BUT as far as I know (and if you or anyone else knows differently then please post it) there hasn't been a study that compares CCR to the new CPR/ACLS standards.  That does need to be looked at before any change get's made.


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## Owenscott (Apr 4, 2010)

Learn something everyday ... passive ventilation ... i like that as a TERM and much better than, for lack of a better term, fumble farting around instead of doing compressions.


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## rescue99 (Apr 4, 2010)

MrBrown said:


> Our clinical guidelines recommend to do 2 minutes of CPR if we have not personally witnessed the arrest.
> 
> Now that said if I roll up to a cardiac arrest with somebody doing CPR I'm probably gonna slap on the pads, have a look at the monitor and give the patient a toasting.
> 
> An Officer I know was telling us of an arrest he had on Friday, the guy kept flip flopping between sinus rhythm and VF; so "oh we just kept smashing him in the chest with my fist and he would convert back" .... Johnny and Roy would be proud! B)



Your guidelines are exactly the current standard. Non wittnessed, or more than 5-6 minutes response time...2 minutes, shock or no shock, 2 minutes then shock or no shock, check the victim...2 minutes and so on. Of course this is BLS, not ALS. Interventions begin when the first 2 minutes of CPR is complete in an ALS setting. ALS still has to get that circulation restarted if they didn't see (or good CPR wasn't being provided) gramps go down.


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## dudemanguy (Apr 4, 2010)

So when do you normally recheck for a pulse? 

You do your first pulse check after giving 2 breaths....then begin cpr or go right to the AED depending on circumstances, but when should you recheck for a pulse?  

After a shock is delivered or theres no shock advised you immediately resume compressions right, so when would be a good time to recheck the pulse, when compressions are paused to give 2 breaths? and how often do you recheck for a pulse, at some point during every 2 minutes and 5 cycles of cpr?

I'm curious what the AHA guidelines are on this, I believe they just tell you to continue CPR until the patient either moves or begins breathing on their own, and dont call for rechecking the pulse unless one of those occurs.


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## Needles17 (Apr 4, 2010)

This is a simple process.  It is ABC for a reason.  Check you airway to see if it is patent.  Look Listen and feel means look in airway and for chest rise, listen and feel for air movement.  Give two breaths if apneic or absent resp.  Then check for a pulse at carotid for 5 to 10 seconds.  If no pulse compressions for 5 cycles if unwitnessed by a healthcare provider.  If you can not fix the airway, does it really matter if you have a pulse or not?  Soon enough you will not have one anyway without a patent airway.  Reassess after every 5th cycle of compressions.  If you get ROSC remember AHA guidelines 2005 state continue compressions for another two minutes.


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## Needles17 (Apr 4, 2010)

This question got blown out of the water and went down the crazy train.  Rescue breaths are for pt's with a pulse but not breathing.  That simple.


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## mycrofft (Apr 5, 2010)

*Agreed. Five is four.*

When someone says "My protocols say" things get dicey.


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## folpak (Apr 24, 2010)

Needles17 said:


> This question got blown out of the water and went down the crazy train. That simple.



Ya that


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## girlyEMT26 (May 12, 2010)

When you walk up to bystanders performing CPR on a patient, you would need to reassess them because sometimes they can be performing CPR when the patient has a pulse, so you wouldnt want to jump to the AED you would kill them or sometimes they arent properly doing CPR.. always re assess your patient if you didnt observe the syncable episode.


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## girlyEMT26 (May 12, 2010)

When you walk up to bystanders performing CPR on a patient, you would need to reassess them because sometimes they can be performing CPR when the patient has a pulse, so you wouldnt want to jump to the AED you would kill them or sometimes they arent properly doing CPR.. always re assess your patient if you didnt observe the syncable episode


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## Owenscott (May 14, 2010)

AED's dont kill people with pulses ....


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## lightsandsirens5 (May 14, 2010)

jerellem said:


> Okay, so when would you go straight to chest compressions?


 
In a witnessed arrest on an adult pt.


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## lightsandsirens5 (May 14, 2010)

RuralEMT said:


> I do not even go straight to compressions here, my protocols have us check for a pulse and apneic after every shock. Then two more breaths before continuing CPR.


 
Your protocols say what now?

I seem to remember AHA says directly following shock you go right back into compressions, do your 2 minutes of CPR, and then reassess. If still pulseless and apnic, check your rhythm and if shockable, blast 'em again, if not, keep going with another cycle of CPR, after two more miutes, reassess........and so on and so forth.


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## joeshmoe (May 14, 2010)

I thought you always immediately resume compressions regardless of whether a shock is delivered. It's my understanding(and im just an emt basic) that even if the heart is shocked back into a normal rythym, you still should do a couple minutes of compressions because the heart is still weak and may not be pumping effectively initially.


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## medichopeful (May 15, 2010)

joeshmoe said:


> I thought you always immediately resume compressions regardless of whether a shock is delivered. It's my understanding(and im just an emt basic) that even if the heart is shocked back into a normal rythym, you still should do a couple minutes of compressions because the heart is still weak and may not be pumping effectively initially.



Do CPR until there's an obvious change in their (the patient's) status.  If they start gagging, moving, etc., then you should probably stop


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## emtstudent04 (May 25, 2010)

If it has been longer then 4-5 minutes since the patient went into cardiac arrest, immediatly perform 5 cycles of CPR at a ratio on 30 compressions and 2 ventilations, which is approximately 2 minutes. Following the 5 cycles of CPR, apply AED and follow the AED protocol. The patient must be unresponsive, with no breathing and no pulse. 

If bystanders or first-responders have already begun CPR, instruct them to stop while you perform an assessment of the air way, breathing, and circulation. Begin or resume CPR while the AED is readied for operation. When the AED enters its analysis mode, Stop any ongoing CPR and clear the patient and hit the analys button, be sure to keep patient clear. If the AED indicates "Deliver Shock" once again make sure everyone is clear, press the shock button to deliver the shock, then resume CPR for 2 minutes. After 2 minutes of CPR pause to check patient's pules for no longer then 10 seconds. If pulse is present, check for breathing. If patient is breathing adequatley high flow O2 via non-rebreather, If patient is breathing inadequetly begin PPV. If no pulse is present reanalyze the rhythm, deliver second shock and resume CPR. If no shocked is advised Check for pulse if no pulse is present the AED could of possibly detected a non shockable rhythm, which in that case resume CPR and transport immediatly. Transport after two (or three shocks) are delivered (with intervening period of CPR) or a total of two (or three) "No Shock" messagesa are received. 

Aed's only shock rhythms in V-Fib or V-Tach.


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