MonkeyArrow
Forum Asst. Chief
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@Chewy20 Is your head really stuck so far up... into the clouds that you think no one has ever survived an in-hopsital cardiac arrest or a transported cardiac arrest? Your little personal anecdote does absolutely nothing to further any side of this discussion, and yet, you call me out on being academic.
@triemal04 I understand that 1 provider will not provide as effective BLS as 2 providers. However, I am also saying look at the bigger picture. There really is no study out there, that I know of, that will show difference in survival between 1 person CPR to hospital transport or 2 person CPR to ALS intercept, which is really at the heart of the question. I believe the answer is a continuum, with time to hospital, time to intercept, provider training/ how good can they do CPR, and other variables all have to be factored in to find a time when transporting will induce better outcomes than working on scene. Right now, all anyone is doing is drawing extrapolations from independent aspects of the survival cascade and attempting to apply it to the overall scene. No matter how good your CPR is, unless you defibrillate, the patient probably won't survive.
But since you would like to continue to throw studies into my face that really do not show what we need it to show, I will continue to tell you why each of these studies is not applicable. For ease of reference, I will go in order, referring to them by the number in which they appear in your post.
I think the peri-shock pauses that you brought up, while valid, is starting to split hairs a bit. If we're talking about a delay of minutes vs. seconds for one vs. the other, I would understand the argument. However, I highly doubt that the extra 30 seconds it would take for a single provider to deliver a shock, and the 5-10 seconds of additional peri-shock pause will affect outcomes. All the literature that I have read states to limit total pauses to less than 20 seconds, and pre-shock pause to less than 10 as blood will still flow for a little while when you stop compressions. Getting a pre-shock pause time of 1 second, while feasible, is fairly rare and probably will not happen in the context of this resuscitation. Therefore, I think the effect of having a single provider deliver the electricity is negligible in this instance. More and more of the recent studies actually demonstrate that hands-on defibrillation/compressions, while they decrease the total interrupted compression time and decrease the coronary perfusion pressure restoration ratio, do not affect ROSC, indicating that we have probably reached a plateau at which 1 second vs 3 seconds is not clinically significant.
@triemal04 I understand that 1 provider will not provide as effective BLS as 2 providers. However, I am also saying look at the bigger picture. There really is no study out there, that I know of, that will show difference in survival between 1 person CPR to hospital transport or 2 person CPR to ALS intercept, which is really at the heart of the question. I believe the answer is a continuum, with time to hospital, time to intercept, provider training/ how good can they do CPR, and other variables all have to be factored in to find a time when transporting will induce better outcomes than working on scene. Right now, all anyone is doing is drawing extrapolations from independent aspects of the survival cascade and attempting to apply it to the overall scene. No matter how good your CPR is, unless you defibrillate, the patient probably won't survive.
But since you would like to continue to throw studies into my face that really do not show what we need it to show, I will continue to tell you why each of these studies is not applicable. For ease of reference, I will go in order, referring to them by the number in which they appear in your post.
- 1: talks about CPR on a moving stretcher, which does not provide as stable as a platform to work off since there isn't, oh, I don't know, a floor? Also, the baseline rate for correct compressions was 54% indicating a lack of provider training.
- 2: I don't understand how kneeling on the bed can be extrapolated to CPR in an ambulance. You have chairs and you can stand where the patent will actually be at optimal height for compressions.
- 3: Nothing to do with a moving ambulance. Said standing is less effective than in a supported position. Kneel on the stretcher.
- 4: The study is comparing a mechanical CPR device to humans, first of all. (Not that this study hasn't been addressed in a previous post) The rate of compressions was good and the depth was .3mm off of the recommended depth. If I'm less than 1/100 off of my target depth, I think I deserve a pat on the back. There is no control with the same humans doing compressions not in an ambulance. Actually, this study supports the notion that effective CPR can be done in a moving ambulance, if you are willing to accept compressions an average of .3 millimeters too shallow.
- 5: 80% of compressions by males were effective irrespective of position, compared to 40% of females. Kneeling requires more energy but is more effective. Again, training is needed to increase 40% effectiveness in all positions, because that is dismal. Kneel on the cot if you so please while doing compressions.
- 6: What the hell is the relevance of a study detailing mechanical devices to humans. Yes, the LUCAS is better than me. Do you want me to buy one now? None of these studies, that are reputable, have any control group with human rescuers not moving vs. moving.
- 7: Finally, you give me a reputable, conclusive study. It shows that hands-off time does increase with transport and average BPM falls approximately 10 compressions. However, note that the fractions of compressions on scene deemed effective would have been very low because it did not meet the 100 BPM threshold. Also, the conclusion says transport with CPR in progress is not futile, as everyone here is saying is.
- 8: Single person CPR is not effective n=3 in a moving ambulance, anecdotally speaking of course.
I think the peri-shock pauses that you brought up, while valid, is starting to split hairs a bit. If we're talking about a delay of minutes vs. seconds for one vs. the other, I would understand the argument. However, I highly doubt that the extra 30 seconds it would take for a single provider to deliver a shock, and the 5-10 seconds of additional peri-shock pause will affect outcomes. All the literature that I have read states to limit total pauses to less than 20 seconds, and pre-shock pause to less than 10 as blood will still flow for a little while when you stop compressions. Getting a pre-shock pause time of 1 second, while feasible, is fairly rare and probably will not happen in the context of this resuscitation. Therefore, I think the effect of having a single provider deliver the electricity is negligible in this instance. More and more of the recent studies actually demonstrate that hands-on defibrillation/compressions, while they decrease the total interrupted compression time and decrease the coronary perfusion pressure restoration ratio, do not affect ROSC, indicating that we have probably reached a plateau at which 1 second vs 3 seconds is not clinically significant.
