Rescue breathing/EAR/CPR/etc

[garyfotodiver]

As I was taught if the victim is breathing it does not matter if you give them "rescue breaths." So we were advised through the SSI method to do them anyway. If the victims heart has stopped rescue breathing won't do any harm, and at worst you are 10s delayed.

Quoting from the SSI Diver Stress & Rescue Manual page 97:
"...in the water, two quick breaths to ventilate the victim and attempt to restore breathing is adequate. Rescue breathing in the water is not only extremely difficult, it may delay your exit to shore or boat, and it may also force more water into the lungs."

On page 69, "Attempt rescue breathing if a pulse is present."

Last Sunday I had a 240lb "victim" during my in-water training. Once I got him out of his gear, rescue breathing every 5 seconds or so, and on to the shore from about 3 ft if water, perhaps 2 minutes elapsed.

The instructor showed me that it was not possible to do chest compressions in the water.

If I ever do this work in real life, I'll first concentrate on getting the victim out of the water.

 

[TheAvatar]

Post made assuming that DrSteve is not actually an MD.

REMEMBER! CPR is to buy the patient time until ALS arrives.

So on page 97 of the book it makes the following statements:
"rescue breathing is very difficult in water...and it may also force water into the lungs."

Excuse me? 6 courses so far have told me that if in doubt perform EAR (expired air resuscitation/artificial respiration). If water is in the lungs, it does need to be drained. But the air you push in will be the difference between a realistic recovery after return of consiousness and a vegetable. BSAC teaches a very effective method of performing mouth-to-nose EAR which is comparatively easy to perform in water.

OK... it depends on who you ask. If you are talking about underwater rescue breathing, I don't think anyone in their right mind would tell you to attempt that.

On the surface? It depends who you ask. EMT's are instructed that "When necessary, artifical ventilation should begin as soon as possible, even before the victim is removed from the water." On the other hand, we are also taught "Rescue before treatment." Then we are instructed to stabilize c-spine in water if there is significant MOI. SSI's booklet makes good points too.

I think you should consider your situation and determine what is best! Open airway and two rescue breaths? Probably if safely possible. Full rescue breathing? Can you safely (and I mean safe for YOU, your fellow rescuers, AND the patient) ventilate the patient in the water? Are there heavy seas? How close is the boat, shore? (20 minutes away in 75F water or 3 minutes away in 40F water?) Maybe you have to rescue breath. Will it delay you? (probably!) Can you get them out of the water without interupting rescue breathing? Rescue before Treatment. But that's just my opinion.

Water in the lungs? You do need to worry about airway obstruction by water or other. Recovery position (lateral recumbant position) if no C-spine worries will help drain the airway (not the lungs). Otherwise, follow your training to clear the airway IF OBSTRUCTED BY FOREIGN BODY. Remember, ~15% of drownings are dry (ie, upper airway swells up keeping water out, but also preventing effective rescue breathing, as the hypoxia gets bad enough they'll go unconcious and the larynx will relax and you can ventilate).

It also claims that in-water CPR should not be attempted as it can "pose the risk of forcing gastric stomach contents into the victim's lungs."

OK once again I am left wondering. First, who could perform chest compressions in water anyway? You can't even perform them on a bed. How would chest compressions cause stomach contents to go up the aesophogus and into the lungs (unless the victim just regained consciousness and threw up)?

You are right that undwater CPR is just nuts.
However, unconcious people can and do throw up.

Finally the book states that if you have to "intensify" your rescue breathing due to proximity of help/shore/boat etc., that you should breath for the non-breathing casualty every 5s. OK once again...every 5s? I am conscious and I breath once every 5s. Are they trying to tell me that an unconscious diver needs as much air as I do?

Rescue breathing, 1 breath every 5 seconds. That should be your rate for adults. I don't know what they mean by "intensify." That's only 12 breaths a second. Unless you are using a BVM or supplimental O2 (and I STRONGLY advice getting an O2 cert), it's not even like 12 normal breaths a second for the patient because you exhale 16% O2 & 3-5% CO2 instead of 21% O2 and >1% CO2 that is normally in the air we breath.

Does the unconcious non-breathing person need to breath as much as you? They are probably hypoxic among other problems. YES YES YES YES. Normal adult breathing rates are ~12-20 times a minute at rest.

(Let's face it the rate for CPR/EAR is 12-15 compressions per 2 breaths, that's slower than one every 5s) If you are attempting to tow and breath I think every 5s is near impossible. If you are stationary maybe. I seem to recall 1 breath every 10 fin strokes, meaning 1 breath every 10 s.

Like I said in the beginning, CPR is to buy the patient time until ALS arrives. 15/2 compressions/breaths is for adults and is not as efficient as the body itself. It buys time. The ratio is to balance ventilations with circulation in the most efficient manner.

-

"It's what I'd do if it were me. It isn't me and neither are you."
W-EMT-B, PSD, RD

 

[TheAvatar]

And I think what I was trying to say earlier is that, IF it were me in warmer water where MDR isn't coming into play, IF they had a pulse, IF it were more than 4 or so minutes to shore or boat and IF I could safely and effectively ventilate someone, I would despite the delay. Brain damage starts after around 4 minutes. Notice there are a lot of IFs and another IF is IF I even have time to think about such things.

So if you are doing the breathing correctly ie. head tipped beack all the way so you don't inflate the stomach you should be relatively OK then?

No, tipping the head back opens the airway, but does not prevent stomach inflation. Short bursts of exhaled air (high pressure) are more likely to cause gastric distension than longer exhalations at lower pressure. Same goes for when using bag/mask ventilation.
Jim

Absolutely. Also remember to allow proper time for exhalation. In that 5second cycle, remember to allow enough time for the patient to exhale (so that you don't try to inflate already inflated lungs and so that CO2 can be properly expelled). (On a similar note, with chest compressions, 50% of it should be compression and 50% of it should be release to achieve maximum arterial pressure and blood flow.)

Secondly, it is impossible to check for a pulse in the water, hence if the patient is in cardiac arrest all your efforts are futile and your energy would be better directed at getting them out of the water fast.

I agree... excecpt it's not impossible to check a pulse in the water, just difficult.

"It's what I would do if it were me. It isn't me and neither are you."
W-EMT-B, PSD, RD

 

[mania]

I'm also doing the Rescue right now. And for the last 2 weekends I'm trying to learn rescue breathing in the water. Guys - it can be done!!!
I don't know if it delays me because my instructor teaches me to do several things at the same time - towing (is this the right word?) a diver, doing EAR and taking his (and mine) gear off (in this case really a good knowledge of your buddy gear is a good thing - not only what we do during the buddy check but also the details that would allow quick and easy stripping). So it's all done more or less at the same time.
It's a very difficult exercise and to be honest after doing it I myself should be resuscitated - first time I did it I barely could stand.
But a week later it was much easier - so it's only matter of practice. Except one thing - please tell me how am I supposed to drag to the shore a guy who weights 91 kilos (more than 200 lb)??? He weights almost twice as much as I do!!!!!

Mania

 

[DrSteve]

Thank you every for some very informative posts. TheAvatar - you are correct I'm not an MD, I'm a chemist (PhD).

Mania - once the person is on your shoulders/across your back you will find out just how strong your legs are. You aren't being required to dead lift this weight (even I'd find that tough and I work out 5 days a week), just drag it out of the water zone. I'd argue that anyone can do this relatively easily, your legs are plenty strong enough and you'll have plenty of adrenaline going through you to help out!

 

[garyfotodiver]

I'm also doing the Rescue right now. And for the last 2 weekends I'm trying to learn rescue breathing in the water. Guys - it can be done!!!

Mania

It can be done, but that is not the point. Will it do more harm than good? I think usually not.

The consensus I've received is to get the person out of the water as quickly as possible. That's what I will do, should I ever need to use my rescue diver training.

Look, I had an instructor once show me that you can breathe from a broken LP hose by adjusting the flow with the tank valve. Doesn't mean that it is a good thing to do.

 

[SubMariner]

I'm also doing the Rescue right now. And for the last 2 weekends I'm trying to learn rescue breathing in the water. Guys - it can be done!!!
I don't know if it delays me because my instructor teaches me to do several things at the same time - towing (is this the right word?) a diver, doing EAR and taking his (and mine) gear off (in this case really a good knowledge of your buddy gear is a good thing - not only what we do during the buddy check but also the details that would allow quick and easy stripping). So it's all done more or less at the same time.

This is the infamous "Rescue Scenario #7" that from Rescue Diver upwards, EVERY level of Dive Pro is required to be able to do this exercise. Even Course Directors (Instructor Trainers).

The main thing about this scenario is that the victim's head must always be supported so that a clear airway can be established and no water gets in. And yes, it CAN be done.

So, while SSI apparently teaches that in water AR cannot be done, PADI teaches the opposite. No judgement; just an observation.

However, everyone agrees that in water CPR is impossible.