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CPR Not as Effective as Chest Compressions Alone
patiwat writes "A Japanese study detailed in the New York Times has found that people suffering from cardiac arrest were more likely to recover without brain damage if rescuers focused on chest compressions rather than on rescue breaths. Some experts advised dropping the mouth-to-mouth part of CPR altogether. Interrupting chest compression to perform mouth-to-mouth ventilation might do more harm than good if blood flow to the heart was not properly re-established, a researcher from Tokyo's Surugadai Nihon University Hospital said. According to the article, 'More than 300,000 Americans die from cardiac arrest each year. Roughly 9 out of 10 cardiac arrest victims die before they get to a hospital — partly because they do not get CPR.'"
Sarver Heart Center
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Linux, you magnificent bastard, I read the fucking manual!
No, it is true even if they have stopped breathing. Basically, it does no good to get more oxygen into the blood if it isn't being circulated, and it takes a lot of chest compressions to get it circulated properly. This is an issue that has been slowly unfolding over the last several years. The Red Cross already decreased the recommended number of breaths to chest compressions a couple years ago, and people are debating whether to get rid of the breathing altogether. One additional argument in favor of the breaths is that it allows the person giving CPR a small break, which is important if they are the only one around to provide CPR.
He forgot to also mention its rare (if EVER!) that someone is breathing and their heart has stopped. Definately a not duh.
God spoke to me.
a recent refresher course has really stressed chest compressions over air as well. 30 compressions per two breaths.
MORTAR COMBAT!
As emphasized by someone in the article, which I read when they published it (and I'm also a swim instructor, lifeguard, and first responder) it's VERY important to note that using only compressions is best and useful in the event of a dryland cardiac event. If someone has just been pulled from the water for instance and is not drowning, you need to give them AIR. Rehashing from the article: most people suffering from heart problems and fibrilliation have plenty of oxygen in their blood and it will remain that way for about 8 minutes. They are not generally in danger of losing oxygenated blood flow to their brain and dying that way. Thus, the exec that collapses in the stairmaster you can probably do just fine with giving compressions: and if you're the ONLY one there who can do that, you had probably better do that. Having actually given CPR for more than 2 minutes, it can literally cause you to pass out if you're the only one there: you have to combine forceful compressions (of breaking THROUGH the ribcage to the heart to get it going) with breathing into a person...and then there are people who might know CPR but, as the article points out, are afraid of catching something. In summary: don't forget to breath into the victim if they aren't breathing. Especially if they were drowning.
"As two-person CPR requires a degree of synchronized technique, it is usually more effective for first aid providers to perform individual CPR, and change operators after ten minutes or so." - http://www.fortunecity.com/campus/springbank/973/f irstaid/cpr.htm
This study refers to CPR in case of cardiac arrest only! You should still apply the 30:2 rule to patients that drowned, have airway obstructions or drug overdoses.
In any case, when you approach a patient, most of the time you will not know what the cause of collapse is, unless it is witnessed (someone choking in a lunch room, someone grabbing their chest in case of heart attack). So in this case you have to check for a good airway, by listening and feeling and sometimes by giving a breath mouth-to-mouth to see if the chest rises)
In any case, for people with first aid training i suggest carrying some kind of barrier device like a pocket mask to perform CPR. Some of the smaller device are really cheap and small (fit on your key ring).
I always carry my pocket mask and gloves with me, but then I am also obligated by law to help people because of my first aid ticket, and i want to play it safe.
Also, when i was tought in first aid class, we were specifically instructed never to give mouth-to-mouth unprotected, because the first rule in first aid is to watch out for your own safety!
Thomas Schmid athschmid@gmail.com Skype: athschmid
An easy way to remember the timing was shown to me by a paramedic and diving instructor.
30 compressions is the chorus of "Nellie The Elephant"
NELLie the ELephant PACKed her TRUNK and SAID goodBYE to the CIR - CUS,
OFF she WENT with a TRUMPety TRUMP, TRUMP, TRUMP TRUMP.
NELLie the ELephant PACKed her TRUNK and TRUNdled OFF to the JUN - GLE
OFF she WENT with a TRUMPety TRUMP, TRUMP, TRUMP TRUMP.
If you sing the Toy Dolls version
http://www.youtube.com/watch?v=otBWbVdvxLk
you'll even get the 100bpm about right.
Even the best CPR circulates only a fraction of oxygenated blood to the brain. This study was performed under the old guidelines of 15 compressions to 2 ventilations. A theory proposed by the researchers who did the study is that the delay in properly positioning the patient's airway to provide ventilation actually decreased the effectiveness of the compressions. By the time the rescuer got blood flow going, it was time to stop and ventilate again. Perhaps with the current 30 compressions to 2 ventilations as now taught would change the outcome of the study. In any event, everyone who experiences cardiac arrest who is not successfully resuscitated dies of the same thing, anoxia, or lack of oxygen to the brain. Many people in cardiac arrest vomit, sometimes profusely. Layperson CPR really does not allow such a person to be properly ventilated, as the ventilations would most likely cause aspiration (the vomit entering the lungs). By doing adequate and continuous chest compressions, life saving oxygenated blood is delivered to the brain. This can keep the patient viable until professional rescuers arrive on the scene and are able to provide advanced life support such as defibrillation, intubation and cardiac drugs. Studies have repeatedly shown that early access to CPR and defibrillation provide the best chance for surviving cardiac arrest. Also note thought that this study involved adult patients who usually experience cardiac arrest due to cardiac related events such as heart attacks or lethal disrhythmias. Children usually experience cardiac arrest due to airway problems such as choking. So it is vital that ventilation attempts be made on children to determine whether or not they have a patent airway. If not the Heimlich maneuver should be initiated immediately, as the child's best chance of survival is restoration of a patent airway.
had thought they were dumbing the program down (in the case of choking)so the average person who takes first aid/CPR wouldn't have too many things to remember.
Actually the real reason is that too many patients were surviving their airway obstruction only to die from intraabdominal bleeding due to lacerated livers and spleens. The average joe gets carried away in a panic situation and would put a bit too much energy into those abdominal thrusts. Chest compressions are approximately as effective, and reduce the risk of intraabdominal trauma. Plus as you say, it has the advantage of making this simpler for Joe. Cheers.
Seven puppies were harmed during the making of this post.
I've been a life saver for many years. This year we changed our training to reflect the same idea. The reasoning behind it is that 15 compressions was not enough time to raise the blood pressure to a stable level and allow it to deliver oxygen into the body (the lack of which causes the brain damage over prolonged resuscitation attempts).
The new 30 compressions maintain blood pressure and allows proper delivery of the oxygen. Two exhaled breaths contain over twice the oxygen required during inhalation and the improvised circulatory drive (eg compressions) lowers the amount required due to it's inefficiency (compared to the norm).
Just to be pedantic, as a paramedic, I watched a few people who were breathing while in cardiac arrest. It's not common, but it can happen. The thing is, they won't breathe for long while in cardiac arrest. One guy in a witnessed arrest for 5 minutes, no pulse, not breathing, v-fib on the monitor, grabbed me and screamed "NO!" when I tried to defibrillate him. I almost shocked both of us. After I got his hands pried off my collar, I sparked him and got him back into a decent rhythm. When he woke up a couple hours later, he didn't know why he screamed "NO!" I've always wondered what was going on in his mind.... The ability to move blood decreases dramatically with time when blood isn't flowing. This result may indicate that stopping compressions for anything short of a return of cardiac activity isn't worth it. In the field and in the hospital, it's not uncommon for the person doing chest compressions to stop occasionally to perform an intervention. This result may change how CPR is done by the medical professionals as well. On the other hand, if rescue breathing is being done poorly in the field, perhaps it's complications like air in the stomach that results in vomiting and thus aspiration pneumonia that's causing the problem. More work will definitely need to be done on this question.
This sig seemed like a good idea at the time....
I teach CPR instructors for the layperson as well as for professionals. Yes, I do work in emergency medicine. Here is my take on the findings and from my experience.
First responders (people first on the scene, not medical professionals) historically tend to do a very poor job of ventilating a patient. Often times this renders the rescue breathing almost useless. This has been known about and debated for many years. The "something is better than nothing" attitude as prevailed through the years, even though the majority of the time "nothing" is exactly what the patient gets in terms of oxygen. They often also tend to perform very poor quality CPR compressions (not deep enough, not fast enough).
You are breathing 21% oxygen now. When you exhale into an individual, they are not receiving 21% for part of it was used by the rescuer. The patient is only receiving 16% oxygen. This is a drastic reduction, but it is far better than nothing.
When any patient is determined to not be breathing, there are 3 things a rescuer must remember:
ABC
Airway
It the airway is not clear and straight, no oxygen can get into the lungs.
Breathing
If a person is not breathing, you MUST breath for them or their heart will stop due to lack of oxygen.
Circulation
If a pulse is not detected, you must do proper CPR to circulate oxygenated blood.
These must be maintained in the order ABC. Maintaining circulation when there is no breathing or oxygen is bad.
CPR buys time until properly trained medical personnel arrive. It will not get the heart starting to beat again. You are simply trying to circulate oxygenated blood since the body is not capable of doing that on its own. When there is no pulse in the early stage of a heart attack you see, generally the heart is in an abnormal, but regular rhythm most of the time, but not always. It is basically beating so fast that it cannot circulate blood, and the rhythm at some point becomes very irregular. Defibrillation and cardiac drugs are needed for the heart to return to a normal rhythm. If there is electrical activity still in the heart there is a significantly greater chance of resuscitation. When the heart is in asystole, there is no electrical signal and it is game over. Circulating oxygen is key to survival.
It is also a known fact that most people who take a CPR class forget more than half of what they were taught the day before. As more time elapses, even more is forgotten. If I were having a heart attack, I would prefer that someone tried to give me rescue breaths, even though there is a chance they will do it wrong. It is better to have oxygenated blood circulated than deoxygenated blood. This is just my opinion.
"This is America... where the will of the few outweigh the outrage of the many..." - Unknown
My employers sent me on a CPR course. A while ago, but I remember it well.
Two things in particular that stuck with me:
1. Since you have your hands full, you must nominate somebody to call for help: YOU!!! Call an ambulance! Don't ask for volunteers.
2. Don't be afraid to lean in to it. Nobody ever died of cracked ribs.
I've never had to use what I learned. I hope I never do.
...laura
As a physician who deals with in-hospital cardiac arrests on a regular basis, and whom has RTFA, there are couple important points. First, this study really only looked at bystander-provided CPR. The paramedics/other trained professionals who arrived still intubated and ventilated these patients - as this is standard of care. The authors of the study say that the likely explanation for their finding is likely that bystanders interrupted chest compressions to give rescue breaths. So, we may need to change the training for the lay public regarding CPR, but professional responders will still need to give ventilations, and once an airway is secured simultaneous compression and ventilation can be given. If you don't breath - you don't live. Second, while this is likely one of the better studies that can be done on a topic like this, it was not randomized, it was not controlled, nor was it even comprehensive/population-based. There are multiple types of errors that can creep in and cause erroneous results in these types of studies. Finally, we need to keep results in perspective. While any improvement is important - and should be pursued - the overall statistics they report for outcomes are still pretty dismal. The overall survival rate for out of hospital arrest was 8-9%, and the number of people with only moderate/mild disability afterward (ie able to walk, talk, etc) was ~6% if you only got chest compressions, ~4% if you got compressions and rescue breaths. So, even with the "chest compressions only" strategy, the absolute difference is relatively small.
There might be a slight effect like that, but for air circulation and oxygenation you do the mouth-to-mouth part. The compressions are used to manually provide some kind of heart function by compressing and releasing the heart muscle indirectly through chest compressions, thus keeping some basic blood circulation going to oxygenize the brain and other vital organs (one can also compress the heart directly, but this for obvious reasons is normally only used in an OR setting, never try this at home, kids, even if you got Mom's new bread knife handy !).
Its actually quite substantial if the chest compressions are done properly. You can get a blood pressure of 120/80 (measured directly on an arterial pressure line) with CPR (+ adrenaline to vasoconstrict although endogenous adrenaline may well keep the BP up much the same). In the process of restoring a normal blood pressure, you will shift a fair bit of gas. However, I have observed this mainly in people who have an endo-tracheal tube in place, as its hard to measure otherwise. In the absence of this the airway may well obstruct such that no gas exchange may occur. Although if you are doing good CPR the brainstem will probably have some function and the airway may have some patency, depending on the individual.
Anyway, I can see the rationale for leaving out the expired air ventilation, but it would probably only be good for a short resusicitation. As I have posted earlier, they are the ones that you will probably be able to save anyway.
Michael
There is no cryptographic solution to the problem where the intended receiver and the attacker are the same entity.
that is the optimal, but you don't always have 2 people trained in 2-man CPR available.
since you don't have 2 people, you have to make do with one. the question that is coming up is how best to divide the efforts (ventilation vs. circulation) and it's looking like circulation is more important in the typical length of time you'd need to be using CPR.
when i did my CPR refresher a last year, the instructor (a former military medic) reccomended 80 compressions/2 breaths.
upon the advice of my lawyer, i have no sig at this time