I just finished my CPR/First aid refresher course, and the American Safety and Health Institute teaches to note the coloration of the victim, give a couple of good rescue breaths, and evaluate any changes in color - if the victim seems to start "pinking up", then it's likely there is circulation. In a situation where it's difficult to find a pulse, this seems to be a good way to check.
Rescue breathing when there is no pulse
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I think that pinking up is a good sign if you can see it but in practice, I think that that happens very rarely, certainly after only a couple of breath. Even after putting a patient who is not breathing on a breathing machine with lots of oxygen, it is not often that I see an obvious change in coloration immediately.
I have been in enough situation, even in hospital wtih all the trained staffs in controlled situation (ie enough help, plenty of room to work with, etc) and sometimes the pulse can be detected only with doppler machine and not detectable by touch anywhere. It can be because the blood pressure is low or sometimes atherosclerosis may make the vessels rather stiff etc.
So I think if a doctor cannot always detect a pulse when it is present in a more control environment, I would not assume that if I can't detect a pulse in a rescue situation in scuba diving that there is absolutely no pulse.
ssra30, that's interesting to know. I'll have to give the instructor that info and ask the question of her. too.
I guess they try to generalize so much in these courses, that it's hard to know what the reality would be.
So, it sounds like it's safest to assume circulation, and do rescue breaths. If there is adequate assistance to get the victim advanced care within 4 minutes, then all the better. If there's a beach or dock, or boat within a couple of minutes' tow sprinting without stopping to give breaths, then....??? Don't do it, and wait to do full CPR on a solid surface?
Yes, it's hard to know what the right course of action would be.
I guess they try to generalize so much in these courses, that it's hard to know what the reality would be.
So, it sounds like it's safest to assume circulation, and do rescue breaths. If there is adequate assistance to get the victim advanced care within 4 minutes, then all the better. If there's a beach or dock, or boat within a couple of minutes' tow sprinting without stopping to give breaths, then....??? Don't do it, and wait to do full CPR on a solid surface?
Yes, it's hard to know what the right course of action would be.
I've been involved in cardiac arrest research and I'm also a medical student as well as a Cardiac Arrest Management instructor trainer...so here is my 2 cents...
If your patient is in cardiac arrest, your number 1 priority is getting acces to EMS and getting access to an AED. Research has shown that the chances of succesful defibrillation is reduced by 10% for every minute of the the first time to shock. In other words, If the person is in cardiac arrest, they have approx. 10 minutes of possible defib time (some more some less), if they have a shockable rythm. However, if it's been 5 minutes, they have 50% chance of regaing a normal rythym, 8minutes; 20% etc..That being said, if your in the water with a diver and you've determined that he or she is pulsless or has no signs of circulation, get them to an AED and EMS fast!!! If giving rescue breaths while reaching a point of safety slows you down, don't. Don't forget, you don't want to compromize the patients airway (ie. water in the mouth). Another problem with rescue breathing in the water is dealing with complication. If the diver swallowed some water, ventilating may cause the patient to throw up, possibly compromising his or her airway. Standards are one thing, reality is another. Hope you never have to use these skills, but if you do, make sure you're prepared, physically, mentally and emotionally. Best of luck
If your patient is in cardiac arrest, your number 1 priority is getting acces to EMS and getting access to an AED. Research has shown that the chances of succesful defibrillation is reduced by 10% for every minute of the the first time to shock. In other words, If the person is in cardiac arrest, they have approx. 10 minutes of possible defib time (some more some less), if they have a shockable rythm. However, if it's been 5 minutes, they have 50% chance of regaing a normal rythym, 8minutes; 20% etc..That being said, if your in the water with a diver and you've determined that he or she is pulsless or has no signs of circulation, get them to an AED and EMS fast!!! If giving rescue breaths while reaching a point of safety slows you down, don't. Don't forget, you don't want to compromize the patients airway (ie. water in the mouth). Another problem with rescue breathing in the water is dealing with complication. If the diver swallowed some water, ventilating may cause the patient to throw up, possibly compromising his or her airway. Standards are one thing, reality is another. Hope you never have to use these skills, but if you do, make sure you're prepared, physically, mentally and emotionally. Best of luck
I'd agree w/ the posters who suggest it's often difficult, even in optimal situations, to say w/ 100% certainty if a victim has a pulse or not. I can't recall the citation right now, but there was a neat study done several years ago where EMTs were taken into the operating rooms of patients undergoing cardiac surgery involving circulatory arrest (technique which completely stops blood flow). They were not told whether the patient was at a point in the procedure where pulse should be present or absent. The EMTs were asked to assess for a pulse....results were abysmal.
I know from experience having performed CPR/ACLS multiple times in the hospital setting, often one is wondering whether or not a weak pulse is felt or if you are experiencing a "tactile hallucination!"
So, if I need to be rescued in the water one day & my rescuer isn't sure if I'm pulseless or not, please give me a couple good rescue breaths & then get me to a defibrillator quickly!
I know from experience having performed CPR/ACLS multiple times in the hospital setting, often one is wondering whether or not a weak pulse is felt or if you are experiencing a "tactile hallucination!"
So, if I need to be rescued in the water one day & my rescuer isn't sure if I'm pulseless or not, please give me a couple good rescue breaths & then get me to a defibrillator quickly!
You do have a good point but the problem is that there is a variation of scenarios and various things that could happen. I don't have the statistic but of the pulseless unconscious person found in water, how many of them actually have a shockable rhythm. In various code situation that I have been involved in a hospital, I would say probably about 50%. So ignoring rescue breath because you may or may not detect pulse accurately and rush a victim to a defibrillator while doing nothing else is not the ideal solution either.
I agree that you should get the victim to the closest help as fast as possible but at the same time, provide whatever assistance you could as best you can. If rescue breathe hinder too much, such as in extremely rough water where it could jeopardize the rescuer as well then it is best avoided but generally it is still a good idea to provide rescue breath as you can't be 100% sure what you are dealing with, pulse or no pulse etc.
GoBlue! once bubbled...
I'd agree w/ the posters who suggest it's often difficult, even in optimal situations, to say w/ 100% certainty if a victim has a pulse or not. I can't recall the citation right now, but there was a neat study done several years ago where EMTs were taken into the operating rooms of patients undergoing cardiac surgery involving circulatory arrest (technique which completely stops blood flow). They were not told whether the patient was at a point in the procedure where pulse should be present or absent. The EMTs were asked to assess for a pulse....results were abysmal.
I know from experience having performed CPR/ACLS multiple times in the hospital setting, often one is wondering whether or not a weak pulse is felt or if you are experiencing a "tactile hallucination!"
So, if I need to be rescued in the water one day & my rescuer isn't sure if I'm pulseless or not, please give me a couple good rescue breaths & then get me to a defibrillator quickly!
The success rate in that study was 30%. This is one of the reasons why a concensus was reached at the Emergency Cardiac Care conference in San Diego in September of 2000 that lay rescuers would no longer be taught to check for a pulse but rather "signs of circulation". Targeted rescuers would be taught the puls check as well as to look for "signs of circulation". The Amercian Heart Association, the European Council on Cardiac Care and the Heart and Stroke Foundation of Canada have implemented this change to their training. However, not all training agencies (ie. PADI) have adopted these changes.
twatto
Registered
As with all courses - ABC's is the usual way to start anything (with some variability depending on situation).
I'd say most importantly is to get advanced life support ASAP.
Much of the time a pulse cannot be felt - in which case cardiac compressions, defib, etc is usually commenced... however this is somewhat situation dependent. Pulse would be checked after rescue breaths are given, then the decision made to continue EAR or CPR. If you can't feel a pulse it doesn't necessarily mean there is no cardiac output.
Please comment if you feel otherwise, but I think when you take into account:
1. unlike the general community where the underlying principles for CPR exist for all sorts of cardiac/respiratory arrests usually in those people with multiple comorbities and medical conditions - it may be possible to focus the possible cause of an arrest in a diver - ie drowning (near drowning depending on the outcome), barotrauma, etc.... where the airway is the primary point of compromise - which can ultimately lead to cardiac arrest secondary to other causes (eg hypoxia).
2. effective Cardiac compressions needs to be exactly that - effective. There is some discussion now about maintaining greater numbers and rates of effective cardiac compressions so that circulation can be built up and not lose too much energy when stopping to give breaths. Effective compressions may be difficult when in the water.
it could possibly be concluded that maintaining airflow in a situation where effective full CPR may be difficult. Hopefully there will be some remaining circulation - even if a pulse can't be felt - to see the injured diver until they get further help.
I'd say most importantly is to get advanced life support ASAP.
Much of the time a pulse cannot be felt - in which case cardiac compressions, defib, etc is usually commenced... however this is somewhat situation dependent. Pulse would be checked after rescue breaths are given, then the decision made to continue EAR or CPR. If you can't feel a pulse it doesn't necessarily mean there is no cardiac output.
Please comment if you feel otherwise, but I think when you take into account:
1. unlike the general community where the underlying principles for CPR exist for all sorts of cardiac/respiratory arrests usually in those people with multiple comorbities and medical conditions - it may be possible to focus the possible cause of an arrest in a diver - ie drowning (near drowning depending on the outcome), barotrauma, etc.... where the airway is the primary point of compromise - which can ultimately lead to cardiac arrest secondary to other causes (eg hypoxia).
2. effective Cardiac compressions needs to be exactly that - effective. There is some discussion now about maintaining greater numbers and rates of effective cardiac compressions so that circulation can be built up and not lose too much energy when stopping to give breaths. Effective compressions may be difficult when in the water.
it could possibly be concluded that maintaining airflow in a situation where effective full CPR may be difficult. Hopefully there will be some remaining circulation - even if a pulse can't be felt - to see the injured diver until they get further help.
In general, a person who goes into cardiac arrest will, most often than not, initially go into V-Fib (the most commom arrythmia for cardiac arrests and shockable). If no defib occurs while the heart is in V-Fib, they will most often deteriorate into Asystole or possibly even PEA (non shockable rythyms). That being said, it will be difficult to determine if the person does or does not have adequate circulation and tissue perfusion. However, if it is determined by the rescuer (pulse, general apperence, skin colour, cap refill, patient history etc..) transport to shore/boat should not be delayed! Obviously scenarios will vary, but keep the PRINCIPLES of ABCDs in mind at all times and make sure you can deal with complications as they arise. If you can ventilate and transport a diver as efficiently as not providing ventilation and transporting, than by all meens...
This is a great discussion topic and should be part of your pre-dive preperation (ie. AED available? Distance to shore? Trained rescuers? etc...). Best of luck to all.
ScottNY
Contributor
I need to amend my earlier post...
Having just hopped into the Rescue Diver course and read the book, it seems there is a protocol of sorts for this. They recommend that if you can't tell if there's a pulse, to just assume there is and try the breaths.
PADI Rescue Diver Manual, c. 2001, p. 158.
After thinking about what I'd said, my personal experience with patients with hard to find pulses and my personal lack of experience in the water, etc. and what others have said, I'd have to say it was probably wrong to suggest just learning to try to get a pulse better is a good solution.
I don't supose it could hurt to do the resuce breathing if your not sure about the pulse. (other than the usual concerns for the rescuer regarding hygiene if not using a pocket mask or other barrier.) Of course, I'd stand by the thought that if for any reason you yourself become exhausted or at risk during a rescue, you do need to abandon the effort.
Scott
Having just hopped into the Rescue Diver course and read the book, it seems there is a protocol of sorts for this. They recommend that if you can't tell if there's a pulse, to just assume there is and try the breaths.
PADI Rescue Diver Manual, c. 2001, p. 158.
After thinking about what I'd said, my personal experience with patients with hard to find pulses and my personal lack of experience in the water, etc. and what others have said, I'd have to say it was probably wrong to suggest just learning to try to get a pulse better is a good solution.
I don't supose it could hurt to do the resuce breathing if your not sure about the pulse. (other than the usual concerns for the rescuer regarding hygiene if not using a pocket mask or other barrier.) Of course, I'd stand by the thought that if for any reason you yourself become exhausted or at risk during a rescue, you do need to abandon the effort.
Scott
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