Is it ( FINALLY! ) time for a change in protocol?

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DeepSeaDan

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I have opined for many years on this board that in-water rescue breathing is a mostly futile ( though well-intentioned ) effort that actually works against the chances for successful resucitation ( I say "mostly" because there are circumstances where several initial breaths would be indicated; eg: a witnessed drowning with quick recovery ).

There is growing case-history in the field to support the new "cardio-cerebral" method of emergency resucitation; consider:


CPR alternative

By Nate Legue
ROCKFORD REGISTER STAR
Click here for more information about Nate Legue

ROCKFORD — Howard Erickson can’t remember how fast he ran the annual Turkey Trot last Thanksgiving.

The 59-year-old jogger can’t remember much at all from that day.

That’s because when the Beloit, Wis., man finished the 5K race at Reuben Aldeen Park and turned to see the clock, he dropped dead.

It wasn’t a full-blown coronary that felled him, but the electrical disturbance in his ticker was enough to bring down the robust former Rock County sheriff.

He survived because several doctors were nearby to give first aid and Rockford firefighters rushed to the scene from a station less than a mile away. Forgoing traditional CPR, they resuscitated Erickson with a different method, a protocol that is saving three to seven times more coronary victims than CPR, according to medical studies.

Thankfully for Erickson, some local paramedics and medical directors are among the first emergency responders in the country to switch to the new protocol, dubbed continuous chest compression or cardiocerebral resuscitation. But the method still has not gained wide acceptance in the medical community because it means abandoning mouth-to-mouth resuscitation in favor of nonstop chest thrusts — and re-examining 40 years of conventional wisdom about first aid guidelines for heart attacks.

Dr. Robert Harner, a Rockford cardiologist, and Dr. John Underwood, SwedishAmerican Hospital’s emergency medical director, prompted a 13-month study of the method with the Rockford and Byron fire departments. By using only continuous chest compression and automatic external defibrillators, they found that 28 percent of heart attack victims lived and 82 percent of those survivors suffered little or no ill effects to brain function. Under normal CPR protocol, which also uses AEDs, the local medical community saved only about 3.7 percent of its heart attack victims, a standard survival rate, said Bob Vertiz, training coordinator for emergency medical services at the Rockford Fire Department.

“Because of the improved survival rates we’ve been seeing in the field, we’ve put all our faith in this new method,” Vertiz said.

With evidence from tests like Rockford’s study popping up in medical journals, emergency responders in almost two dozen regions, including major metropolitan areas like Kansas City, Mo., are launching their own trials. The biggest proponent of the method, Dr. Gordon Ewy, a university medical professor, is advocating for it statewide in Arizona.

What makes continuous chest compression effective? When a person’s heart stops, it leaves between six and nine minutes worth of oxygen in the bloodstream. That oxygen can be circulated with rapid chest thrusts and keep the brain alive. When paramedics or bystanders stop to blow air into the victim’s mouth, it interrupts the flow and starves the brain for 10, 20 and even 30 seconds — enough time to do damage during cardiac arrest.

“We feel breaths are detrimental,” Underwood said. “I think they do more harm than good. If we can get people to stop doing them, we can see an increase in survival rates.”

Erickson credits the resuscitation method for his very life. Six days after his Thanksgiving heart episode, the retired police officer checked out of the hospital. Three weeks later he was back to work as a marketing director for a travel bus company.

“I’m just as good as I was before,” Erickson said. “I can certainly tell you what they did worked.”

In addition to rapid chest thrusts, paramedics used an AED to shock Erickson’s heart three times during his collapse. While medical experts agree that AEDs improve survival, the electrical devices are still not widespread even with state laws requiring them in many public places. And continuous chest compression is simple. It can be taught to a bystander over the phone by a 911 dispatcher. In fact, since 2000, dispatchers have been doing just that when callers say they can’t do CPR.

The problem is that many bystanders don’t do CPR, sometimes because they’re panicked and afraid to mess up or sometimes because they don’t want to kiss a complete stranger.

And many experts are reticent to endorse the experimental method because it could do harm to some patients who need mouth-to-mouth. While continuous chest compression works well on adult heart attack patients, it could hurt drowning or drug overdose victims who have exhausted bloodstream oxygen and need air.

Still, many physicians who subscribe to the rapid compression method are agitating for a change in training guidelines for first responders and laypeople. The American Heart Association allows for emergency personnel to use high-frequency chest compressions but says “there is insufficient evidence to recommend for or against its use,” according to the guidelines it published last year.

“What they’re saying is, ‘You guys are telling us that what we’ve been doing for 40 years is wrong. You’ve got to really prove it to us,’ ” said Dr. Michael Kellum, a Janesville, Wis., physician who spearheaded a similar study supporting cardiocerebral resuscitation. “You’ll see over the next year or two more people report this (in medical journals), and the experts will say, ‘Now we have enough data to say this is the way we should do it.’ ”

Staff writer Nate Legue can be reached at 815-987-1346 or nlegue@rrstar.com.

By the numbers
3.67 Percent of local patients who survive a cardiac arrest
2 to 5 Percent of heart attack survivors considered normal by emergency responders
28 Percent of patients who survived cardiac arrests in 13-month study of continuous chest compression by Rockford and Byron firefighters
82 Percent of those survivors who suffered little or no brain damage
48 Percent of heart attack survivors found in a similar study in Walworth and Rock counties in Wisconsin
Sources: Rockford Fire Department, American Journal of Medicine


So I ask you - is it not time for a complete review of diving rescue / resuscitation in light of this new information?

Regards,
DSD
 
You still can't do compressions in the water, so this is pretty much moot for dive rescue scenarios. The new CPR and ACLS standards both emphasize the importance of "Push hard, push fast, don't stop!", so as people recertify or take new original courses, the new procedures will spread.
 
Is this really any different from the new CPR standards? I just did my recertification on the new standards. I suppose it is if they are saying that you should not do the initial 2 rescue breaths and go straight to the chest compressions. And what do they mean by "rapid"? Does that mean more than 100 compressions per minute, which is what we are doing now?
 
I think the reporter who wrote the article is just writing about the new emphasis on effective compressions without really understanding what the changes mean.
 
rongoodman:
You still can't do compressions in the water, so this is pretty much moot for dive rescue scenarios. The new CPR and ACLS standards both emphasize the importance of "Push hard, push fast, don't stop!", so as people recertify or take new original courses, the new procedures will spread.

...that there is still too much emphasis on teaching in-water rescue breathing ( specifically while towing ). PADI has taken the step of given the rescuer an option ( the :5 distance rule ), but I don't think that goes far enough ( & I think they actually have it backwards! ). The bottom line is that in most instances, the casualty needs circulating blood, & the best way ( & the only way, as you've indicated ) is to get them to a flat, hard surface at all possible speed.

DSD
 
divingjd:
Is this really any different from the new CPR standards? I just did my recertification on the new standards. I suppose it is if they are saying that you should not do the initial 2 rescue breaths and go straight to the chest compressions. And what do they mean by "rapid"? Does that mean more than 100 compressions per minute, which is what we are doing now?

...similar to the new lay-rescuer standard, but altered to take advantage of the new research. Lay-rescuers will continue to follow the new 30:2 ratio. "Rapid" still means 100 cpm.

The new lay-standard is based on the emerging philosophy of "more compressions are better", but falls short of eliminating them altogether in the protocol. I suspect the next major protocols review might just do that.

You can bet that the chap in the article was intubated a.s.a.p.

Regards,
DSD
 
In the SDI Rescue course they ask for 2 breaths every 10 seconds, rather than 1 every 5, which seems more manageable to me for towing and equipment removal(if necessary).
 
rongoodman:
In the SDI Rescue course they ask for 2 breaths every 10 seconds, rather than 1 every 5, which seems more manageable to me for towing and equipment removal(if necessary).

...but in your SDI training, did you ever actually "breathe" for someone in the water? Of course not. In all honesty, do you think you can deliver ( proper, effective ) rescue breaths in typical open water conditions in scuba? I work on vital signs absent people ( v.s.a. ) regularly in the dry, as part of a team of professional rescuers, & we find it tricky in such "ideal" environments! ( thats why we intubate a.s.a.p. - it guarantees a patent airway ).

The in-water rescue-breathing skill is, & has been, ( IMHO ) for many years, a "feel-good" process for the rescuer trainee. In reality, it would be tremendously ( read: mostly impossible! ) to do effectively in typical open water conditions, particularly while towing.

As I said, the whole process WORKS AGAINST a successful out come ( again in most, not all situations ), as it delays the much needed blood circulation, & should be reviewed.

Regards,
DSD
 
The company I work for as a programmer developed Trauma software for tracking the success rate of any given response to a medical emergency, so although I am not in any way a medical person I do know that this is not just a fad ... BUT ... please note the caveat mentioned. This pertains to other than drowning and drug overdose victims, who may already have depleted blood oxygen levels. This method is primarily endorsed right now for instances where there is an observed event and can be assumed to involve retained blood oxygen. I believe there has been a tendency already to extend the number of compressions and decrease the frequency of breaths.
 
DeepSeaDan:
And many experts are reticent to endorse the experimental method because it could do harm to some patients who need mouth-to-mouth. While continuous chest compression works well on adult heart attack patients, it could hurt drowning or drug overdose victims who have exhausted bloodstream oxygen and need air.

DSD

It looks like more study really is in order in specific regards to drowning and near drowning incidents. There is emphasis in an instructor newsletter I received on artificial ventilations and how over inflating a victim's chest can impair blood flow from the thoracic (sp?) area. Hopefully there will be a more definitive answer soon and then all the different training agencies, not just SCUBA will have to revamp their training doctrine as well as support materials.
 
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