CPR priorities

Melclin

Melclin

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In our service we have had a relatively recent revision to the way in which a team of two paramedics is supposed to work an arrest.

Going through the changes as part of my internship, I had a rather different interpretation of the instructions than did the educators and after a long discussion I wasn't really happy with the outcome. Not at all saying he was wrong just that I think we were getting our wires crossed and I really didn't wanna risk it descending into an argument.

The procedure, in essence, is as follows.
Paramedic ONE: Response, Checks and clears airway including suction, checks for breathing and administers vents accordingly.
Paramedic TWO: "Immediately" checks for a pulse and in its absence commences compressions.

I really liked this change when I first read it because I felt it was taking into account the evidence that compressions are supreme. To my mind this meant instead of waiting for the airway paramedic to finish their business (approx 30-50seconds), then do a pulse check and start compressions, that compressions would be started concurrently while the airway was managed. Its gets the compressions going earlier and I don't see that anything that the airway paramedic might find would affect whether or not compressions are done in a pulseless pt.


I'll be seeking clarification from someone within the service, but I was interested in what thoughts the forum might have on the matter.
 
I think the only caveat is how long after the person goes down CPR is started.

If the person has been in arest more than 8 minutes prior to any attempt at CPR, I am not sure that the time saved managing the aiway is going to matter.

When I worked codes in the street, and currently in hospital, airway and compressions are done simultaneously, so no time is ever lost there.

If bystander CPR is already underway, short of "signs of life" or as I like to say, some guy reaching up and asking you to stop, there seems no reason to interrupt compressions in order to reassess.

How were you guys doing it before?
 
They way ive done it:

Paramedic 1# goes to head, checks response and clears airway, inserts OP and 2 vents with BVM
While this is going on:

Paramedic 2: Remove/cut shirt, apply pads/check pulse and start compressions

In 2 minutes of compressions, Paramedic 1 should be preparing to insert LMA

Ideally LMA in before end of 2 minutes of CPR

Counter shock if required/

Back to CPR/ IV access adrenaline hopefully by 3-4 mins in

I dont see a reason to pause during suctioning and OPA placement, but i have paused for intubation or insertion of LMA
 
Part of the new 2010 guidelines is a discussion of "New Blood/Old Blood", and thinking about the etiology of the arrest (asphyxial or cardiac), and allowing that to guide your actions.
 
We discussed this change recently in class. It was made clear that compressions are the highest priority due to it continuing circulation and the smallest lapse decreases survival rate.
 
We've got the highest priority on compressions. In our system, there is only one medic on the scene, so in the first minute or so of the arrest, there's a lot of getting stuff out, finding out what the story was, hooking up to pads...it's actually a lot easier starting with compressions. We don't typically delay for any reason; the first person at the patient's side starts CPR, and the others cut the shirt from the side, hook up the monitor, etc.

These new guidelines, combined with ETCO2 monitoring, make for some extremely short cardiac arrests. Which is a good thing, because I'm in better shape than most around here and can only do 4-6 minutes of good CPR (not in a row) before I know I'm not doing a great job anymore. With 3-4 people present on the scene, that gets the patient 12-24 minutes of a great effort, and then I'm on the phone, depending on what's going on.
 
abckidsmom said:
We've got the highest priority on compressions. In our system, there is only one medic on the scene, so in the first minute or so of the arrest, there's a lot of getting stuff out, finding out what the story was, hooking up to pads...it's actually a lot easier starting with compressions. We don't typically delay for any reason; the first person at the patient's side starts CPR, and the others cut the shirt from the side, hook up the monitor, etc.

These new guidelines, combined with ETCO2 monitoring, make for some extremely short cardiac arrests. Which is a good thing, because I'm in better shape than most around here and can only do 4-6 minutes of good CPR (not in a row) before I know I'm not doing a great job anymore. With 3-4 people present on the scene, that gets the patient 12-24 minutes of a great effort, and then I'm on the phone, depending on what's going on.
Click to expand...

That's how we do it, too, and it does seem a whole lot comfortable. Starting with A in an arrest simultaneously with compressions is good in theory, but It neglects the whole taking out stuff stage that isn't mentioned in the ABC algo'. Given compressions is the highest priority now, focus should be on pulse check and compressions without delay.
 
Good to know I'm not going nuts.

abckidsmom said:
We've got the highest priority on compressions. In our system, there is only one medic on the scene, so in the first minute or so of the arrest, there's a lot of getting stuff out, finding out what the story was, hooking up to pads...it's actually a lot easier starting with compressions. We don't typically delay for any reason; the first person at the patient's side starts CPR, and the others cut the shirt from the side, hook up the monitor, etc.
Click to expand...

I agree with this and that's the way I interpreted the wording of our update.

Vene: We used to do it exactly how negro puppy describes. Paramedic TWO: cut clothes, applied pads, checked pulse etc. The change involved removing most of that work load and giving it to the airway guy, so compressions could be started earlier. It also removed all of the ALS stuff as a priority. Eg questions were asked if adrenaline wasn't on board early and LMAs weren't in, but now the focus is completely on compressions and vent and in most cases your back up can do the ALS stuff.

Basically the situation came down to me arguing simultaneous compressions and airway management. The counter argument from the instructor involved a "but A comes before B, then C" like I hadn't ever come across the idea of a primary survey. He was super concerned that I would kill all of the chocking PEA arrest (apparently they are very much more common than primary cardiac arrests) because I skipped A, no matter how many times I said I wasn't advocating skipping A, just that I wanted to do a little multitasking. He then proceeded to loudly criticize my ability to apply evidence based medicine which got me to feeling a fraction cranky. A MICA guy or two I've talked to has agreed with everything you guys have said so I'm relatively certain I'm not going crazy.
 
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