30:2 - Gold standard or just a suggestion?

[MedicSchrute]

Good evening, I had a question I would like to run by you guys if you had a minute. I'll try to keep it short and sweet.

Just started working for an EMS agency. Every code I've been on so far has surprised me. Not the patient or the situation, mind you, but the choice of treatment. Essentially, the medics seem to regard the old 30:2 ratio as hogwash (with or without an advanced airway placed). Twice now I've paused compressions to allow ventilations and been told "No, no - we don't do that here".

When I asked for the reasoning behind it, basically I've been told that it's more of the "book vs. the real world", and "this is how things are really done".

I've tried researching the efficacy of this method and haven't had a whole lot of luck finding evidence to back it.

So please, please enlighten me. I don't care who's right, I just want to know WHY.

Thank you in advance guys, I've learned a lot from these forums already.

 

[Wheel]

Studies are showing that continuous compressions are the most important thing in a cardiac arrest. I'm on my phone or I'd try to link some.

 

[MedicSchrute]

Oh don't get me wrong, I agree. However, why try to ventilate at all if you aren't going to pause chest compressions? In that case it seems like you're taking a greater risk with gastric inflation.

 

[Ecgg]

Are you talking about just at arrival that 30:2 is not followed? Are you running the entire code without rescue airway or ET? How long does it take for them to place some sort of airway device?

2010 AHA Guidelines for CPR and ECC continue to recommend
that rescue breaths be given in approximately 1 second. Once
an advanced airway is in place, chest compressions can be
continuous (at a rate of at least 100/min) and no longer cycled
with ventilations. Rescue breaths can then be provided at
about 1 breath every 6 to 8 seconds (about 8 to 10 breaths per
minute). Excessive ventilation should be avoided.

 

[medicdan]

OP, is it possible your service is doing a trial with CCR (Cardio-cerebral resuscitation; Look it up for more info...)?

 

[Arovetli]

So, some of the rational behind continuous compressions is as follows:

You inhale bout 21% O2 concentration and exhale around 13-16%. When someone arrests there is still air in the lungs and the gradient is such that the remaining o2 can continue to diffuse for a few, also there is O2 still in the arterial blood, and by mechanical compression of the chest you mildy ventilate the patient by contracting and recoiling the chest.

Plus it takes a bit of time doing compressions to get the blood moving, so starting and stopping isn't the most effective way to circulate and the heart needs to the good flow to get its bio mechanical processes ready to restart, so to speak. It's a mindset focused on heart and brains, hence the name cerebrocardial resuscitation.

Back in the early 2000s there was a doc out west, maybe Texas?, that was doing alot of research on it and it all looked promising. Then AHA started pushing it for lay rescuer and now the research is being laid to expand it.

AFAIK all the research of continuous compressions looks favorable over the old way.

Edit: prior to airway placement

 

[Handsome Robb]

OP, is it possible your service is doing a trial with CCR (Cardio-cerebral resuscitation; Look it up for more info...)?

What's what I was thinking.

We're part of a CCR trial and do 50:2 or continuous compressions with an OPA and NRB mask.

 

[Arovetli]

What's what I was thinking.

We're part of a CCR trial and do 50:2 or continuous compressions with an OPA and NRB mask.

Are you just looking at outcomes in this trial or are they looking at chemistries too? Pm if you don't want to go specific on the open forum.

 

[troymclure]

both cpr classes and my emt course brought up this very thing.

the aha is looking to drop the breaths completely, and go strait to compressions at 100+/min.
apparently the full rise and compression allows for sufficient air to move in and out of the lungs for adequate gas exchange.

there are several places running trials, and we were told the aha should announce the findings by the end of the year.

 

[cprted]

My service, one of the largest EMS agencies in North America, performs a 10:1 continuous compression CPR. We we start a code, compressions are started at a rate of 100 per minute, at the same time the pads are getting placed. Once we have good compressions and we have rhythm analysis and defibrillation happening, then we start delivered breaths after every tenth compression or so (without pausing compressions). Per our guidelines, we can start to think about advanced airways after our third rhythm check.

 

[Sandog]

So, some of the rational behind continuous compressions is as follows:

You inhale bout 21% O2 concentration and exhale around 13-16%. When someone arrests there is still air in the lungs and the gradient is such that the remaining o2 can continue to diffuse for a few, also there is O2 still in the arterial blood, and by mechanical compression of the chest you mildy ventilate the patient by contracting and recoiling the chest.

Plus it takes a bit of time doing compressions to get the blood moving, so starting and stopping isn't the most effective way to circulate and the heart needs to the good flow to get its bio mechanical processes ready to restart, so to speak. It's a mindset focused on heart and brains, hence the name cerebrocardial resuscitation.

Back in the early 2000s there was a doc out west, maybe Texas?, that was doing alot of research on it and it all looked promising. Then AHA started pushing it for lay rescuer and now the research is being laid to expand it.

AFAIK all the research of continuous compressions looks favorable over the old way.

Edit: prior to airway placement

What he said...

 

[sdadam]

So far as I can tell your question is why are the medics you work with doing this. That is a question that I can't answer. But the fact that you said:

When I asked for the reasoning behind it, basically I've been told that it's more of the "book vs. the real world", and "this is how things are really done".

...worries me. See, the number one way to tell if someone knows what they are doing or talking about, and I mean really KNOWS, is to ask them two questions: why and how.

This is the great divide between people who do things "Because that is how we were taught" and people who do things because they understand the physiology of what is happening to their PT and arguably more importantly the empirical data supporting their actions.

Once you get an answer to why and how keep asking how, over and over.

Eventually you will get to the bottom of everyone's knowledge because the answer at the bottom of the rabbit whole for most things is "we don't entirely know how" even things a simple as osmosis. But a good clinician should at least be able to tell you a few levels down, hopefully to the molecular if not at least the cellular.

Now why are your crews are doing that? I hope the answer is not because some other person told them to and they took their word for it.

I'll take a shot at explaining to you the why with sources below.

There are several layers to your issue and you will need to clear up the exact circumstances in order for people on here to give you real detailed information. I'll try to cover as many as I can.

The ratio of 30:2 is still recommended prior to the establishment of an advanced airway.

Compression only CPR is for lay rescuers, not recommended for professionals.

The goal behind compression only CPR for lay rescuers is not actually that CPR is more effective without respiration. It is recommended because it was shown that the biggest hurdle to bystanders doing something in a CPR situation was fear.

The respiration part of CPR was removed in order to simplify the process of lay rescuer intervention so that it was not as frightening and thereby might increase the prevalence of bystanders doing ANYTHING rather than, well, standing by.

This is why compression only CPR is not taught in BLS for Healthcare Providers or ACLS.

Now specifically with ACLS, it is only a concern until an advanced airway is placed as at that point 30:2 goes out the window anyway.

All that being said I'm going to assume that your crews are following the proper ACLS guidelines once an advanced airway is placed. However prior to that airway placement they are having you forgo the 30:2 ratio.

Now, that's not great because there is a lot of misinformation about compression only CPR. The studies and reports of it's "effectiveness" are both greatly over stated and almost always in relation to LAY rescuers preforming compression only CPR PRIOR to the arrival of professionals.

Findings summarized in a 2010 study: "For prolonged OHCA of cardiac origin, conventional CPR with rescue breathing provided incremental benefit compared with either no CPR or compression-only CPR, but the absolute survival was low regardless of type of CPR.". Showing that classic CPR was incrementally better!

To be fair another study from AZ came up with "A significantly greater percentage of cardiac arrest victims survived in the chest-compression-only CPR group (13.3 percent) compared to those in the conventional CPR group (7.8 percent).".

As you can see not all the data has shown that compression only CPR is the way to go just yet. (I'm not saying that it's not I'm just saying that we don't really know yet.)

What is clear is that people are significantly more likely to preform compression only CPR than they are to preform traditional CPR, which is what we, as professional rescuers want!

So all this being said many professional rescuers who get most of their knowledge from talking with other EMT's and Paramedics got the idea that compression only CPR had something to do with us. It does not.

This is illustrated by the fact that our AHA guidelines have not changed.

The AHA even states on it's website:
"Hands-Only CPR (CPR with just chest compressions) has been proven to be as effective as CPR with breaths in treating adult cardiac arrest victims." (emphasis added by me) As effective, not more, the data isn't there yet.

As far as I know there has only been one study that attempted to have ALS providers switch to a compression only, no matter what protocol rather than standard ACLS and it found that:

"The findings of the present study suggest that when CCC CPR is integrated into an EMS protocol, patients are no more or less likely to survive than if they had been treated with standard ACLS cardiac arrest procedures."

So, what people are doing when they deviate from standards is anybodies guess.

Might they be helping, and it will turn out that compression only CPR is better? Maybe. But at this point it is just as likely that they are doing damage as the studies about compression only CPR never took in to account Paramedics thinking they were supposed to abandon ACLS guidelines (with the exception of the one I posted).

This is dangerous not because of this particular instance but because it illustrates what really boils down to a lack of scientific literacy in EMS. There is no reason for a paramedic to think that they should be preforming compression only CPR, other than misunderstanding that is.

I hope this has shed some light on your situation. There is no “real world” vs. “school”, those kinds of statements are a form of anti-intellectualism that have no place in medicine. They are a throwback to the time when experience trumped all, but now we live in a time where empirical evidence trumps all and things are going to continue to change.

 

[Arovetli]

So, there are no great over statements regarding compression only resuscitation, outside of the puffery normal to scientific inquiry perhaps.

In the patient populations most likely to survive an out of hospital arrest, in the time frame most likely to achieve rosc, compression only is more effective.

Although the improved outcomes may not be entirely physiological, rather CCR is easier and gets performed more correctly.

However when we say more effective, that means barely statistically significant, there is no real raising of the dead going on.

The issue with the study cited above is that it uses neurological outcomes and stratifies by the 15 minute mark and by CCR/CPR. This really tells us nothing about the types of patients enrolled. Though it cites an overall impressive number of patients enrolled. When your dealing with 2% of 10,000, or 200 patients, the outcome could well be altered by having an inordinate amount of healthier pts in shockable rhythms with quicker times to BLS and quicker times to ALS become concentrated in one group, distorting the outcome.

The multivariate nature of medicine should give us pause when trying to make inferences from abstracts, and too many try to do just that. Even in the study you cited, it links to comments published in Circulation than raised some questions about the outcomes and methods.

All we can say from the study posted is that in arrests greater than 15 minutes, or prolonged arrests, more attention should be given to ventilations.

So, what if we did CCR for 15 minutes, then switched to CPR for the remainder? How would outcomes change? The study doesn't answer that, so well have to experiment to find out.

In studies which stratify patients by age, underlying rythym, underlying disease, in home/out of home, time to start of resuscitation efforts, witnessed vs. nonwitnessed, etc. CCR still shows an edge in the populations likely to be helped by said efforts, in the short run.

This makes sense and fits in with everything, not refuting it. As I said above, In the initial period following arrest it is hypothesized that ventilations can be disregarded for a few. Logically, as the arrest prolongs the hypoxia and acid/base derangements worsen, remaining o2 is depleted, thus ventilating becomes more important.

Which is why some are using OPA and NRB in conjunction with CCR to study how this changes things.

Studies are merely a single step in a given direction, you have to take a lot of them to get anywhere.

As to OPs original question of gold standard vs. suggestion...the answer is that it is a work in progress, like everything else in medicine.

 

[Christopher]

Compression only CPR is for lay rescuers, not recommended for professionals.

It is important to state that the recommendation is AHA's from 2010 and not from the available body of current evidence.

The respiration part of CPR was removed in order to simplify the process of lay rescuer intervention so that it was not as frightening and thereby might increase the prevalence of bystanders doing ANYTHING rather than, well, standing by.

And the fact that layperson and HCP ventilations have both been proven to decrease survival to discharge.

I don't think you'll find any disagreement in the importance of removing barriers to layperson CPR, nor in the efficacy of CCR for bystander CPR.

This is why compression only CPR is not taught in BLS for Healthcare Providers or ACLS.

You've shown why CCR is preferable for laypersons, instead of why CCR is not preferable for HCP/ACLS.

Now, that's not great because there is a lot of misinformation about compression only CPR. The studies and reports of it's "effectiveness" are both greatly over stated and almost always in relation to LAY rescuers preforming compression only CPR PRIOR to the arrival of professionals.

Except for anything out of SHARE or Hennepin or Wisconsin (I forget their project's name). All three areas use CCR both in the community, pre-hospital, and sometimes in-hospital.

SHARE actually has shown that CCR is superior to standard ALS.

Research out of Hennepin has shown that you can actually have good standard ALS care, but that CCR is consistently able to drive higher survival to discharge while CPR has heterogeneous results. If you think about it, this makes sense.

If you wanted a study which you could use to favor 30:2, it would be the Wake County Experience which clearly shows if you strive to me reaaaally good at resuscitation, you can make it work.

Is it because they used 30:2? Not likely.

Is it because they placed an increased emphasis on chest compressions and a decreased emphasis on interruptions? Very likely.

Findings summarized in a 2010 study: "For prolonged OHCA of cardiac origin, conventional CPR with rescue breathing provided incremental benefit compared with either no CPR or compression-only CPR, but the absolute survival was low regardless of type of CPR.". Showing that classic CPR was incrementally better!

You left out, "...was incrementally better for prolonged OHCA of cardiac origin."

Later studies from SHARE have shown that CCR is superior for all downtimes and most age groups (<80). Interestingly enough though, the <40 and 65-80 crowd see's a huge benefit from CCR over standard-ALS.

To be fair another study from AZ came up with "A significantly greater percentage of cardiac arrest victims survived in the chest-compression-only CPR group (13.3 percent) compared to those in the conventional CPR group (7.8 percent).".

As you can see not all the data has shown that compression only CPR is the way to go just yet. (I'm not saying that it's not I'm just saying that we don't really know yet.)

It is pretty much leaning this way...

What is clear is that people are significantly more likely to preform compression only CPR than they are to preform traditional CPR, which is what we, as professional rescuers want!

I think we can all agree on that.

So all this being said many professional rescuers who get most of their knowledge from talking with other EMT's and Paramedics got the idea that compression only CPR had something to do with us. It does not.

A large number of high performing EMS systems have switched to CCR for the initial resuscitation...so I'm not sure what you're getting at here.

This is illustrated by the fact that our AHA guidelines have not changed.

The AHA even states on it's website:
"Hands-Only CPR (CPR with just chest compressions) has been proven to be as effective as CPR with breaths in treating adult cardiac arrest victims." (emphasis added by me) As effective, not more, the data isn't there yet.

So if it is AS effective and ventilations are not superior...why would you include ventilations? Consider that if they are used inappropriately it has been absolutely proven to be harmful.

As far as I know there has only been one study that attempted to have ALS providers switch to a compression only, no matter what protocol rather than standard ACLS and it found that:

"The findings of the present study suggest that when CCC CPR is integrated into an EMS protocol, patients are no more or less likely to survive than if they had been treated with standard ACLS cardiac arrest procedures."

SHARE has definitely shown that they are more likely to survive. See the above studies.

So, what people are doing when they deviate from standards is anybodies guess.

AHA is great as a literature gathering body, but pretty poor as a standards body. Everything is "consider this" or "consider that". They serve to provide guidelines for implementation based on the available pooled literature. If anything, AHA guidelines represent the minimum level of care acceptable. They certainly do not represent the best care available.

Might they be helping, and it will turn out that compression only CPR is better? Maybe. But at this point it is just as likely that they are doing damage as the studies about compression only CPR never took in to account Paramedics thinking they were supposed to abandon ACLS guidelines (with the exception of the one I posted).

ACLS is exactly that, a guideline. Besides, you've missed the point of CCR vs CPR.

Interruptions in chest compressions are bad.

Hyperventilation during cardiac arrest is bad.

You must limit these two in order to effectively resuscitate individuals. Once you've done that you can go back to playing with ventilations or medications (unproven witchcraft when compared to CCR).

This is dangerous not because of this particular instance but because it illustrates what really boils down to a lack of scientific literacy in EMS. There is no reason for a paramedic to think that they should be preforming compression only CPR, other than misunderstanding that is.

This seems out in left field considering the bulk of literature and systems implementation which supports CCR over traditional CPR for cardiac etiology.

I hope this has shed some light on your situation. There is no “real world” vs. “school”, those kinds of statements are a form of anti-intellectualism that have no place in medicine. They are a throwback to the time when experience trumped all, but now we live in a time where empirical evidence trumps all and things are going to continue to change.

This statement I can agree with. Typically the confusion is in what AHA supplies. They do not supply the "gold standard" but rather a guideline for implementation. It is full of considerations that each system must make during their implementation.

You've missed the mark on CCR vs CPR, and adopted the wrong end of the literature debate on this issue.

Resuscitation of adults from OHCA is based upon a very simple triad, which has extremely strong literature support:

1. Uninterrupted, high quality chest compressions
2. Early and appropriate defibrillation
3. Integration of therapeutic hypothermia and coordinated post-arrest care

The only time you can deviate from these 3 and not adversely affect survival to discharge is if you have a known reversible etiology and the equipment/medications to do so on scene.

New support for ECMO and very interesting work out of Hennepin on ischemic post-conditioning / sodium nitroprusside/adenosine assisted CPR may change this triad; but until then you ignore CCR at your own peril.

 

[Christopher]

So, what if we did CCR for 15 minutes, then switched to CPR for the remainder? How would outcomes change? The study doesn't answer that, so well have to experiment to find out.

Most "CCR" systems actually do this, but not for n=15 but instead n=T+6, where T is "time of first chest compression".

What you actually want to research is whether initial continuous chest compressions keep the body from its own natural protection: ischemic post-conditioning. (STEMI care may move to include ischemic pre-conditioning)

Stutter CPR with sodium nitroprusside and adenosine will likely enter the arena in the next 5 years, so will a resurgence of impedance threshold devices and other intrathoracic pressure regulation devices.

Dr. Keith Lurie gave a great lecture recently on where we're going in cardiac arrest, and last year Dr. Weingart had Drs. Lurie and Yannopoulos on emcrit talking about the next generation of cardiac arrest care.

 

[Arovetli]

I was merely making a hypothetical to illustrate to the previous poster that the study he cited raised additional questions, and that his philosophy of asking why and how should be applied to the evidence he provided.

 

[Aidey]

Compression only CPR is for lay rescuers, not recommended for professionals.

Christopher pretty much covered everything, but I want to add that you should google "pit crew CPR". This is a "style" of resuscitation that is specifically designed around continuous compression CPR with minimal interventions.

 

[Christopher]

Good evening, I had a question I would like to run by you guys if you had a minute. I'll try to keep it short and sweet.

Just started working for an EMS agency. Every code I've been on so far has surprised me. Not the patient or the situation, mind you, but the choice of treatment. Essentially, the medics seem to regard the old 30:2 ratio as hogwash (with or without an advanced airway placed). Twice now I've paused compressions to allow ventilations and been told "No, no - we don't do that here".

When I asked for the reasoning behind it, basically I've been told that it's more of the "book vs. the real world", and "this is how things are really done".

I've tried researching the efficacy of this method and haven't had a whole lot of luck finding evidence to back it.

So please, please enlighten me. I don't care who's right, I just want to know WHY.

Thank you in advance guys, I've learned a lot from these forums already.

Their reasoning is dumbed down as sdadam pointed out. Basically they're either:

1. Not telling you why because they don't think you'd understand
2. Not telling you why because they don't understand

The book met The Real World(tm)--with a lot less racial tension--in Wake County as they implemented the 2k5 AHA Guidelines with a huge boost in survival to discharge.

You see, most people have been missing the gold nuggets lying around in the AHA guidelines all of these years.

All they have done is increase their forcefulness in saying, "chest compressions are proven, the rest is not". You can find support for decreasing or de-emphasizing ventilations and medications going all the way back to the 2000 guidelines.

The honest answer is we've not yet established the best ratio, just that 30:2 is superior to 15:2 and 5:1. Nor have we established whether we even need to ventilate at all (this does not contradict my earlier statements on CCR; I'm now talking about 0 positive pressure ventilations until ROSC).

The book is pretty great actually, crack open the ECC guidelines and realize just how little evidence supports anything that you're doing. If somebody points to ACLS as to why amiodarone should be used for Cardiac Arrest, you know they have not read the guidelines.

If you were surprised by CCR, you'd be stupefied to see how our arrests run. Sub 5 second peri-shock pauses, hands-only CPR until 3 cycles are complete, OPA+NRB during initial resus, apneic oxygenation during intubation attempts, intraarrest hypothermia, a de-emphasis on ACLS medications...the list goes on.

 

[Aidey]

If you were surprised by CCR, you'd be stupefied to see how our arrests run. Sub 5 second peri-shock pauses, hands-only CPR until 3 cycles are complete, OPA+NRB during initial resus, apneic oxygenation during intubation attempts, intraarrest hypothermia, a de-emphasis on ACLS medications...the list goes on.

I really hate that your service is in NC. How much money do you think it would take to hire your medical director away?

 

[Ace 227]

Just took a "High Performance CPR" inservice which states that current studies are showing that we over oxygenate arrest victims and that compressions without respirations improve circulation due to the increased intrathoracic pressure caused by ventilation pushing blood out of the heart.

I don't have the studies available to back this claim but if you are an EMS provider in the state of PA, you have probably seen the memo about the inservice as it is required by the beginning of July.

The 1.5 hour long presentation was very interesting and certainly strays from the "30:2" guidelines, advocating that the first 10 minutes of an arrest be non-stop compressions. If you can get the IV/IO with compressions going on, great. IF you can tube with compressions going on, great. But if you can't they've shown it to be detrimental to stop compressions for those interventions.