What are the most serious problems with CPR?

FROM 10,000 feet:

1. We're not focusing on training the people who most need to be trained. The people most likely to need to perform CPR are about the same age as - and live alone with - the victim.
2. The technique most commonly taught is something that the vast majority cannot perform for ten minutes.
3. Many of the people who will be called upon to perform CPR weigh too little to perform 2" chest compression on a chest of average stiffness.
4. Even with free instruction, many people who need to know won't take the time to learn.

THE DETAILS:

1. We're not focusing the training on the people most likely to be presented with an opportunity to perform CPR on their spouse. More than 80% of the arrests involve people over 50. Given the ratio of male vs female arrests (2/3 are males) we should be training twice as many females as males, and we should be focusing on persuading both genders over 50 to get trained.Eighty-five percent of all USA Cardiac Arrests occur in a private residence - most are in someone's home, the rest in a nursing home - and the bystander that has to call 911 and start CPR is most likely the victim's spouse.  It's not always the case, but in general the spouse is about the same age as the victim. The CPR in the Schools program that we ran and that the SCA Foundation runs are valuable because it starts to sensitize young people at an early age and should eventually reduce the #4 problem.
2. The CPR method being taught in the vast majority of cases - manual chest compression - is something that fewer than one in six can perform for ten minutes on an adult with an average stiffness chest. We have proven that the use of Heel Compression quadruples the number of people who can perform compression for ten minutes. The study was published in the American Journal of Emergency Medicine in October.
3. Many potential rescuers don't weigh enough to perform guideline compliant chest compressions on their spouse. One's ability to perform guideline-compliant chest compressions is dependent upon the rescuer's weight, the rescuer's weight distribution, the stiffness of the victim's chest, and the method of performing compressions. An adult chest of average stiffness requires that the rescuer using manual compression weigh somewhere between 160 and 175 pounds, depending upon their weight distribution.  If the rescuer were using Heel Compression, the rescuer weight needs to be between 132 and 150 pounds. It's not always the case, but the female in the relationship is generally lighter than the male.
4. Even if the training is available without charge (it is), not everybody who needs to learn will attend. We have trained more than 10,000 in Chatham  County, GA. Given that we know the age distribution of the victims, it would be reasonable to provide free, teacher-less videos (www.slicc.org/ClassVideo) and focus the Bystander Course instructor resource on the people most likely to need to know CPR: the folks over 50.

It worked

The Short Version
An elderly male suffered a cardiac arrest at a meeting. Another elderly male began to perform manual CPR but quickly tired and was unable to continue. The other person present - who had recently read an interview with one of the authors of an article in the American Journal of Emergency Medicine regarding Heel Compression CPR began to perform Heel CPR. The victim's heart was restarted before the arrival of EMS.

That's the whole point of Heel CPR - when you cannot get down on the ground or you have a problem pressing hard enough on the chest to get adequate compression depth, consider an alternative: Heel CPR. Go to www.slicc.org/ClassVideo and click on the Adult CPR video.

Background
Dr. Perez and I wrote a paper about the advantages of Heel Compression CPR. It was promptly published in the American Journal of Emergency Medicine. We wrote the article describing our research so that organizations such as the American Heart Association and the American Red Cross would have a peer-reviewed basis for considering the adoption of the technique in their Bystander course curricula.

Because 85% of cardiac arrests occur in the home - and about half are witnessed - the witness is generally about the same age as the victim. Because of the age distribution of the victims, the witness / rescuer is likely to be unable to perform CPR in the same manner as a medical student or Intern - the typical cohort in a CPR study. Many cannot get down on the floor. Many have arthritis or other afflictions of the hands or arms that reduce their ability to perform Guideline-Compliant Chest Compressions ("GC3's"). It was for this reason that we developed Heel Compression CPR.

Heel Compression CPR enables four times as many people to perform GC3's. Here's the abstract from the AJEM publication:

Heel compressions quadruple the number of people who can perform chest

compressions for ten minutes.

Abstract:

Objective: To evaluate whether chest compressions using the heel provide a more

effective method than manual compressions for bystanders.

Methods: This is a cross-sectional observational comparison study where each subject

acted as his or her own control. A 49-person cohort whose age distribution approximated

that of sudden cardiac arrest (“SCA”) victims, were asked to perform ten minutes of five

cm manual compressions on a CPR manikin at 100 compressions per minute. The

compression rate and the endurance of each subject were recorded. The same subject was

then asked to perform ten minutes of heel compressions at the same depth and rate.

Results: Sixteen percent of the cohort performed compliant manual compressions for ten

minutes versus sixty-five percent using heel compressions. Twenty-four percent of the

subjects were not heavy enough to get compliant depth with manual vs. two percent with

heel compressions, and six percent could not get down on the floor to attempt manual

compressions.

Discussion: Most cardiac arrests occur in private residences. If there is a witness, his or

her age usually approximates that of the victim. Heel compressions are useful in

situations where a lone rescuer cannot get down on the floor, cannot compress the chest

to guideline depth because of an infirmity or lack of weight, or becomes too tired to

continue manual compressions. Heel compressions significantly increase the bystander

population’s ability to provide effective, uninterrupted compressions until EMS arrival.

Heel compressions quadruple the number of people who can perform chest

compressions for ten minutes.

It's happening...

1. Dr. Perez's and my paper that proved that use of heel compression quadrupled the number of people who could perform guideline-compliant chest compression for ten minutes. What makes this even more interesting is that we didn't use the traditional cohort of fifty medical students or 50 interns. Rather, we used a mix of males and females whose age distribution approximated that of cardiac arrest victims. This paper was published online by the American Journal of Emergency Medicine within eight days of their having received it and in print within sixty days! That's pretty speedy turnaround for a peer review journal.

2. The publication of this work gives the AHA what it needs to evaluate publishing the technique in their bystander classes.

3. One medical first responder agency has changed their protocol to include "If a First Responder is alone with the victim and cannot achieve guideline-compliant chest compression ("GC3s") using manual chest compression, the First Responder shall use Heel Compression until someone arrives who can perform GC3s. In any event the LUCAS shall be applied as soon as possible and without any interruption of more than ten seconds."

4. For a demonstration of the technique, see http://www.slicc.org/ClassVideo and click on the adult CPR link.

5. The Abstract of the article in AELM is free and can be found at
http://www.ajemjournal.com/article/S0735-6757%2815%2900560-4/abstract

"Bystander" is more an environment than a level of training

When we hear "Bystander CPR" the image that comes to many minds is a person at home or at the shopping mall who isn't a medical professional but who has just seen someone have a sudden cardiac arrest. (You can thank TV for that shopping mall image - 85% of all out-of-hospital arrests occur in a private residence.)

The bystander environment is usually one where the witness has to call 911 and perform hands-only CPR  alone for an average of ten minutes. The ambulance environment and the hospital environment have other people there to help.

When tested on a manikin exhibiting a chest stiffness at the 32nd percentile - a little less than 65% as stiff as the AVERAGE adult's chest - one-in-six of the subjects tested made it to ten minutes using their hands, but four times as many made it to ten minutes using the heel of their foot.

When talking with EMTs, Paramedics, Nurses, and Doctors about heel compression CPR, the typical reaction I get is "no thanks - I'm CPR certified." The problem is that those medical professionals are certified in a manual technique that that usually cannot be performed on a real adult for ten minutes! When you are by yourself, you are a Bystander, regardless of your training.

Here's where you can watch a demonstration of Heel Compressions. And while you're at it, why not brush up on AED use, choking emergencies, and stroke recognition - they're all in the same folder.

...and to belabor the obvious, after you've watched the videos, you won't be any safer - the folks around you will be safer. So make sure those who are around you frequently watch the videos, too.

Bystanders, use your Heels!

A novel chest compression technique was explored in 1978 and 1980. It was good, but not necessary, because compressing an adult chest one inch wasn't all that tough for the subjects tested in CPR studies.

Time marched on and in 2005 the compression depth guideline went to 1.5 inches. An alarming number of CPR instructors flunked their re-qualification trials, because they were unable to complete five  cycles of 30 compressions and 2 breaths.

Guess what happened when the guidelines went to 2 inches in 2010? You guessed it.

As SLICC began training residents in 31411 - an older community - it noticed that many students either couldn't get down on the floor or couldn't apply much force to the manikin's chest because of problems with their hands or wrists. In those cases we instructed them to take their shoes off, stand over the victim's head facing the victim's feet, place one heel on the CPR point and use the leg / heel to compress the chest a full two inches. In a study published recently in the American Journal of Emergency Medicine Dr. Perez and I demonstrated that use of the heel quadruples the number of rescuers that can perform guideline-compliant chest compressions for ten minutes. Ready for the BIG news? The group of subjects tested had approximately the same age distribution as do cardiac arrest victims!

To see the technique demonstrated, go to www.slicc.org/ClassVideo and select the Adult CPR video. (And while you are there, there are some other useful videos at that site.)

After you watch the Adult CPR video, you won't be any safer - the people you live with and the people you spend a lot of time with will be safer. Hence, it's in your interest that those people watch the videos, too!

Get safer!

A way to make yourself safer in less than an hour!

Eighty-five percent of Sudden Cardiac Arrests occur in the home. Fewer than half are witnessed. For the arrests that are witnessed, the witness is usually about the same age as the victim and off a different gender. The best chance of getting discharged from the hospital with major brain functions intact is immediate CPR and prompt defibrillation.

The way to make yourself safer is to make sure that the person(s) you live with watch the videos at www.slicc.org/ClassVideo/

If he or she is of the thinking type, he or she will figure out that they, too, will be safer if YOU watch the videos, as well.

...and while you're at it, think about the folks you see frequently, too.

And if you want to make the defibrillation happen faster - and that really, really helps - go to www.slicc.org and click on AED Deal in the left column.

A lot of survival depends upon what the other person does!

Bob

It's been a while. My last post was just after presenting our research on the prevalence and magnitude of "leaning" at the AHA's Resuscitation Science Symposium. ("Leaning" is having too much (more than 1.5 pounds) of force on the sternum at the top of the "full recoil" up-stroke when performing chest compressions.

In the past eight months SLICC has...
- Invented a Force Meter that permits the user to:
-- Discover the percentage of the adult population to which a person can administer compliant CPR
-- Measure the instantaneous rate of chest compressions
-- Measure leaning, the residual force on the sternum at the top of the 'full recoil' stroke.
- Invented a device that keeps on clicking when the leaning is within the safe limit (1.5#)
- Been invited to speak at ECCU about how CPR is broken and what we need to do to fix it.
- Had a paper on Heel Compressions vs Manual Compressions published in the AJEM
- Measured the CPR capacity, rate, and leaning of 383 Healthcare Professionals (anonymously)

Currently, we're trying to invent a BVM that cannot be operated more than 10 times per minute.

No offence, but this is so much more fun than playing golf.

...and that's why it's been eight months since I last posted.

Bob