THE SHORT FORM:

• Compression-only CPR is at least as good as conventional CPR when performed in response to a witnessed adult arrest.
• If the formatting breaks in your browser, the story can be found on line:

http://nhregister.com/articles/2010/07/29/news/aa7cpr1072910.txt

or http://nejm.org

THE DETAILS:

‘Hands-only’ CPR can save more lives

Associated Press Thursday, July 29, 2010

ATLANTA — More bystanders are willing to attempt CPR if an emergency dispatcher gives them firm and direct instructions — especially if they can just press on the chest and skip the mouth-to-mouth, according to new research.

The two new studies conclude that “hands-only” chest compression is enough to save a life. They are the largest and most rigorous yet to suggest that breathing into a victim’s mouth isn’t needed in most cases.

The American Heart Association has been promoting hands-only CPR for two years, though it’s not clear how much it’s caught on. The new studies should encourage dispatchers and bystanders to be more aggressive about using the simpler technique.

“That could translate into hundreds if not thousands of additional lives saved each year. What are we waiting for?” said Dr. Arthur Kellermann, a RAND Corporation expert on emergency medicine.

An estimated 310,000 Americans die each year of cardiac arrest outside hospitals or in emergency rooms. Only about 6 percent of those who are stricken outside a hospital survive.

When someone collapses and stops breathing, many people panic and believe that phoning 911 is the best they can do to help.

The larger of the two new studies reported survival rates of about 12 percent when bystanders did dispatcher-directed CPR, confirming earlier research that on-scene CPR can dramatically increase odds of survival.

The studies also spotlighted the importance of having forceful dispatchers coaching bystanders, said Dr. Michael Sayre, an Ohio State University emergency medicine specialist who helped update the Heart Association guidelines on CPR.

Previous research has suggested that adults who need CPR get it only about one-quarter to one-third of the time when bystanders are around.

One of the new studies found that when dispatchers told callers to start CPR, about 80 percent attempted it when given hands-only instructions, more than the 70 percent who tried the standard version.

Sayre and others credited the increase on dispatchers who immediately told callers what to do, instead of first asking them if they’d had CPR training or if they’d be willing to try it until medical help arrives.

“This study shows that with great training and motivation, the 911 call taker can make a big difference,” Sayre said.

CPR, or cardiopulmonary resuscitation, is a technique that’s been in use for about 50 years. The standard version now calls for alternating 30 hard pushes on a victim’s chest with two quick breaths into their mouth.

The aim of CPR is to do some of the mechanical work of the heart by forcing at least some blood and oxygen to the brain and other vital organs.

Experts have come to believe that pumping is what’s most important in most adult cases, and advise doing chest pushes continually at a rate of 100 per minute and skipping the mouth-to-mouth. Some suggest using the beat of the old disco song “Stayin’ Alive” as a guide.

Cardiac patients do as good or better when they got hands-only CPR as compared to the traditional version, these and earlier studies have found.

One of the new studies, carried out in London and the Seattle area, involved more than 1,900 people who witnessed someone in cardiac arrest and called 911 or some other emergency number. Emergency dispatchers instructed callers to do either hands-only CPR or an older form of standard CPR that alternates 15 pushes with two quick breaths.

The second study was done in Sweden and included nearly 1,300

In both studies, there was no significant difference in the survival rates of people who got conventional CPR and those who got the hands-only version.

The studies are being published in Thursday’s New England Journal of Medicine.

While there is no good national data on how often hands-only CPR is used, Dr. Ben Bobrow, who directs the Arizona Department of Health Services’ emergency medical system, believes it is catching on.

“We’ve seen a huge trend in hands-only CPR in Arizona and I believe that trend is spreading across the country. I think these findings will further promote that,” he said.

Many people think of traditional CPR as difficult, and to some extent it is. The victim’s head has to be tilted back, the airway cleared, the nose pinched and the mouth completely covered with the rescuer’s. A lot of people have trouble with it, said Don Pederson, a dispatcher in Seattle’s King County, who participated in the U.S. study.

“A lot of the times they weren’t getting air in there correctly,” with oxygen escaping out the sides of the mouth, Pederson said.

Rea and his colleagues believe some bystanders perform mouth-to-mouth so poorly that the interruption reduces blood flow.

Worry about doing CPR correctly was the No. 2 reason many people don’t attempt it, according to a Michigan study published in 2006. The No. 1 reason? People are too panicked.

The “ick” factor of putting lips to a stranger’s mouth — and picking up the stranger’s germs — was cited by only a tiny fraction of people in the study. However, it may be a more significant issue than the study showed, at least in some communities, experts say.

Traditional CPR is still the preferred form of resuscitation for children or adults who have stopped breathing because of choking, drowning or other respiratory problems.

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Online:

New England Journal: http://nejm.org

Link to the class video

OK. You've decided that you need to attend a Bystander CPR course, because you have come to realize that you have a one-in-seven chance of witnessing at least one sudden cardiac arrest in your lifetime and that, when you do witness an arrest, the odds are 85% that the victim will be a family member, a friend, or an acquaintance.

But now you are worried about having to stand there helplessly and watch a family member die, if you see an arrest before you attend that CPR class you just registered for at an American Heart Association learning center or an American Red Cross Chapter.

We have the answer: go to

http://www.slicc.org/ClassVideo/100412_CVschh.m4v and download the class video we used at Sun City Hilton Head. It's not a substitute for attending a class, but it will get you through the tough parts if you see someone arrest before you get to attend that class.

Bob

Interrupting chest compressions

What's the big deal about interrupting chest compressions?

Have you ever pumped water from a well with a hand pump?

• You don't get water from the pump on the first few pumps, but eventually it gets flowing. You don't get blood to the brain with the first 5-8 pumps, but eventually it gets flowing.
• When you stop pumping for a bit, the pump looses its prime. The older the pump, the more the check valves and gaskets start leaking, and the faster the pump looses its prime.

The same thing happens in CPR - the older the patient, the faster the pump looses its prime, and the longer it takes to get the blood flowing to the brain.

If you stop for only a few seconds, it could take as much as ten seconds to restore the blood flow to the brain.

Don't stop - and this is why the S.A.L.T. airway is so important: it permits paramedics to intubate cardiac arrest patients without interrupting chest compressions.

Bob

Practice for CPR with your ears!

Just google Bee Gee's Staying Alive MP3 and you'll find links to the BeeGee's classic - Listen to that several times, and it will stick in your mind.

So why is this a good thing? It's a near-perfect reminder of how fast to pump a chest when doing CPR.

Here's one URL that seems to work:

http://chiron.blogs.psychologies.com/ecrannoirnuitsblanches/files/01_Stayin_Alive_-_Saturday_Night_Fever_-_Bee_Gees.mp3

Bob

Who needs full CPR - breaths & compressions?

The easiest way to remember this is to think about what CPR accomplishes: it causes the oxygen-caring blood to circulate.

...and where does that oxygen come from?

1. There is some residual oxygen in your blood when you die;
2. There is some residual air in your lungs when you finish exhaling;
3. Some air will move in and out of the lungs when you perform chest compressions, particularly if you can get the victim's head into the "sniffing position." [Sniff to see if you can smell something. Freeze. That's the sniffing position.]

So what about the person who drowned? That person used up every shred of residual air in the lungs and nearly every shred of residual oxygen in their blood. They will get a little bit of air in-and-out of the lungs as you perform chest compressions, but not a lot. They could really use a little help in the oxygen department.

And what about the child who arrested, whether or not they drowned? The residual air in the lungs doesn't help a lot, because their lungs are so small. The amount of air that is going to go in and out with chest compressions is very small compared to their need. And children "compensate" very well - they won't have much residual oxygen in their blood stream when they arrest. They also could really use a little help in the oxygen department.

Personally, I don't have a problem doing mouth-to-mouth CPR on any young child I've just pulled out of a pool. You're blowing in, not sucking out, after all. What you really want to watch out for is doing mouth-to-mouth without a barrier device on someone who perhaps bit his tongue when he fell down in cardiac arrest and has blood flowing out of his mouth. That's when - as a bystander - the "If it's not safe, don't do it!" rule ought to occur to you. On the ambulance, we have a duty to respond. When you have a duty to respond, you don't have the protection of a Good Samaritan law, and you don't have a choice regarding whether the victim is going to get mouth-to-mouth or not.

One last point: if you position a toddler on his or her back on the floor, the disproportionately large back of the head will cause the head to tilt "chin-down" and thus effectively pinch off the air path to the lungs. You may have to improvise, but to maintain a viable airway in those victims, a phone book under the shoulder blades will really help, unless you are from a really small town, in which case two phone books might be needed. The nice thing about phone books is that they are not compressible.

Bob

A hard, flat surface and how to get the patient onto it.

CPR saves lives because chest compressions cause blood to circulate in the cardiovascular system until the heart gets re-started. Without the oxygen that the blood caries to the brain, the brain will die.

Chest compressions don't work when the patient is on a "squishy" surface. You cannot do effective CPR on a person who is in bed or on a person seated in a chair. Even if you have a CPR board handy, it's not as effective as getting the patient onto the floor.

(You cannot do effective CPR on someone who is lying face-down, either. This possibility would not have occurred to me, had I not walked into a residence on a 911 call, only to see someone trying this.)

So how do you get a really large patient onto his or her back on the floor? The first step is to get the patient onto the floor, without worrying about the "on his or her back" bit.

If you are alone and if you can't pull the patient out of bed or roll the patient onto the floor, walk around to the side of the bed you don't want the patient on the floor next to, untuck the bottom sheet and throw it over the patient. Walk back to the other side, grab the sheet, and pull it as if you were playing tug-of-war. The patient will roll out of bed and onto the floor. The bigest problem with this strategy is that many people let their fear that they will hurt the cardiac arrest victim interfere with the degree to which they really try. To them, I can only offer this: "That victim is already dead, and unless you get that victim onto his or her back on a hard, flat surface, they almost assuredly will stay dead. Don't worry about hurting the patient. Just do it."

The same holds for a victim who arrests in a chair. If you cannot pull the victim out of the chair, tip the chair over. Use the handle of a broom as a pry bar, if you need to, but get the victim onto the floor.

Victims dumped onto the floor seldom are considerate enough to land on their backs. Here's how to get them there:

1. Straighten the limbs: it's a lot easier to roll someone whose legs are straight and in line with the torso. Ditto for the arms, either at their sides or over their head.
2. Roll the victim unto the back, and start pumping that chest. If you are in a cramped space and there's no room to roll the patient, stand over the patient with one foot on each side of the patient, grab whatever clothing you can grab at the side - not the top - of the patient and using your knees so you don't hurt your back, pick the patient straight up and then set the patient down. You many have to do this several times.

Let me know if this isn't clear, and I'll make a video of it.

Bob

Heart attack vs. stroke vs. sudden cardiac arrest

Heart attacks and the majority of strokes are very similar: a blood vessel gets blocked up, and the down-stream tissue begins to die from lack of oxygen. When the heart stops pumping - either because it is not contracting at all or because it is quivering in a dis-organized manner - we call it a sudden cardiac arrest.

Please see http://www.slicc.org/AMI-CVA-SCA.m4v for a more complete description and some illustrations.

Sudden cardiac arrest is the number one killer in the U.S.A. - it kills more than breast cancer, prostate cancer, motor vehicle crashes, and homicides, combined.

Sudden cardiac arrest must be treated by using chest compressions to maintain the blood flow to the brain until the heart is re-started by electricity or chemicals.

Bob