I have been teaching CPR for more than 20 years and have seen it evolve. Years ago much of the emphasis was on opening the airway and delivering breaths. As we learned more about what happens to the heart in arrest we began to concentrate on delivering more effective compressions and administering an early effective shock to stop the heart and help it correct the abnormal non-productive (no blood being pumped) rhythms [Ventricular Fibrillation (quivering), Ventricular Tachycardia (beating too fast)] as an essential part of saving a victim. The defibrillator (AED) only recognizes and shocks those two rhythms.
As time went on the art of delivering effective high quality CPR became more and more important to the victim’s survival. Today it is not unusual to expect that immediate high quality CPR and early defibrillation will save approximately 30% of the victims, and result in minimum in-hospital and post recovery rehabilitation after the event. This is true for more and more victims of all ages, especially those between 40 and 65 years old.
The ECCU 2015 guidelines stress beginning CPR as soon as possible after recognition of cardiac arrest. If the victim is unconscious and does not respond to (shake and shout), shout for help. Then check for breathing and a pulse at the same time. If you don’t feel / see breathing and don’t feel a pulse, shout for help. If you have a cell phone, call 911. Calling 911 is the most important thing you can do to activate emergency services. By calling 911 you alert the emergency response teams and they are on their way to bring you the life – saving equipment you need. If you know exactly where the AED is then turn the victim on their side in the recovery position and leave the victim to go and get it, or better yet, if someone responds to your shouts send them to get the AED and you start compressions. Remember you can’t leave the victim alone for more than 4 minutes (that gives you 2 minutes to go and 2 minutes to come back). The brain will start to die if it is deprived of oxygen for more than 4 minutes. After approximately 10 minutes the brain is almost dead. The only time this changes is in the case of a drowning or if used in cold weather.
The purpose of CPR is to pump oxygen rich blood to the brain to keep it alive. The main focus should be on delivering effective compressions to a depth of at least 2 inches but not more than 2.4 inches. Most rescuers are hard pressed to deliver compressions to a depth of more than 2 inches consistently over time. The 2015 guidelines have also determined that the rate or speed of compressions should be more than 100 per minute. The 2015 guidelines recommend a speed between 110 to 120. Compressions delivered faster and effectively are even more beneficial to the victim’s survival if delivered at approximately 110+ per minute.
In my experience, most rescuers can consistently deliver compressions at approximately 110 compressions per minute. Going faster than that could affect the depth of compressions or chest recoil. Chest recoil is very important because it is the recoil that allows the ventricle to fill back up with blood and be ready for the next push. I searched for a song that you might put in your head to keep you in the proper rhythm. The one that I came up with is Beyonce’s “Single Lady”, especially the chorus portion of the song. If you can match your compressions to it, they will be around 110 per minute.
The new guidelines stress checking the pulse and looking for chest rise at the same time. If you can’t detect a pulse, and don’t see visible chest rise, call for help. If no one responds and you know where the AED is, go and get it. If not and you are alone and have a cell phone on you, put it on speaker and dial 911 while starting compressions and yelling for help.
If someone or two responds to your shouts before you finish assessing the victim send one bystander to call 911 and the other to get the AED. The quicker you call 911 the better. The quicker you get the AED in use the better the chance of the victim’s survival. If you can use the AED within the first 3 minutes you have an excellent chance to save them. If you have to, place the victim in the recovery position and leave to call 911 and get the AED if you know where it is. Then return to the victim immediately and begin compressions.
WHAT DO YOU DO WHEN THE AED ARRIVES?
As soon as the AED arrives take the rescue mask out and begin to administer 2 breaths. The person arriving with the AED should immediately put it down next to the victim’s head and turn it on (see figure 1 and 2) and listen to the prompts. It will tell you to apply the pads while the original rescuer continues compressions. Figure 1
Remember the AED pads go on bare chest. If the victim is a female, you must remove the bra at this point. There should be scissors in the AED kit.
If the victim has a hairy chest you need to shave the chest in the area of pad placement.
If you notice a lump in the chest (could be pacemaker) you need to make sure the pads are at least one to two inches away, moving them toward the heart.
If the person has a patch on their chest you should remove the patch (use gloves) and make sure you wipe the chest clean before placing the pads on it.
Once you are sure the chest is clean and dry place the pads according to the diagram on each pad. Only place one pad at a time. Peel the pad and place it and then peel the other pad and place it.
NEVER BARE TWO PADS AT THE SAME TIME. IF THEY TOUCH, THEY WILL STICK AND THE PADS WILL BE RUINED.
LISTEN TO THE PROMPTS. If the AED says to apply the pads, then you should apply the pads according to the picture on the pad. The wire usually enters the pad at the bottom edge (knob). Typically the Right pad is placed on the right chest with the knob opposite the right nipple making sure the pad is just below the collar bone. The left pad is placed under the left breast with the knob at the bottom under the left nipple. Once the pads are in place and the cord is plugged in the AED will analyze. Everyone should stop what they are doing and move back from the patient. This is also the opportunity to switch positions. All of the rescuers can reposition themselves by moving around the head of the patient. Try not to step over or go around the victim’s feet. Switching allows the compressor/ compressors to rest and take on another task. If it is necessary to switch before the AED analyzes then one rescuer can tell the compressor: “I’ll take over after 30”. It is always best to switch compressors after 30 compressions have been completed. If able, the responding rescuer will take over compressions while the original rescuer delivers breaths and operates the AED.
Remember there are different types of AED’s. Some AED’s are already plugged in and have only one size pads. So if you are dealing with a child you will put the pads on them and plug in the DOSE ATTENUATOR (see Figure 3) to lower the shock voltage for them.
The normal shock voltage is 360 jewels while the shock voltage for a child is usually one quarter of that or 90 jewels. That is the purpose of the DOSE ATTENUATOR. If there is no dose attenuator then you will use the pads the way they are (see figure 4).
If the AED has them, Pediatric pads are recommended for children (LESS THAN 8 YEARS OLD) or Infants (LESS THAN ONE YEAR OLD) but If all you have are ADULT PADS you can use them, making sure they don’t touch each other. The main way you can make sure the pads don’t touch each other on a child or an infant is to place one pad on the front and the other on the back (see Figure 5).
Every time the AED analyzes the rescuers should switch or if there is another rescuer present they should take over compressions while the other rests.
In the new teaching materials, there is more of an emphasis on team dynamics, which I will cover in the next section of the presentation. Everything is geared to providing high quality CPR and advanced treatment in a smooth professional manner for the ultimate benefit of the victim. Delivering High Quality CPR and working smoothly as a team decreases the amount of time between compression cycles, increases the chance of survival and Return Of Spontaneous Circulation (ROSC) by a factor of 300%. In other words, the chances of survival if all the steps are followed, is 3 times greater than it would have been previously. That is quite an improvement.
One other aspect of the new guidelines deals with Opioids. Today there is an epidemic of heroin and opioid use. A good number of people are overdosing on pain killers and using heroin. Overdosing on Opioids complicates the resuscitation process. Many times it is the opioids and their side effects that cause people to go into Cardiac Arrest.
The emergency responder has to be aware of it being a factor. One of the main things to look for is whether the pupils are dilated or constricted. If they are constricted and you are trained to administer Naloxone (Narcan) in any fashion, you should do so according to your local approved protocols. Ideally one person will deliver the Naloxone while the other rescuer continues performing high quality CPR. The aim is to bring the unconscious person to the stage where they can breathe on their own. High quality effective CPR restores circulation and the Naloxone helps restore breathing. If you are administering Naloxone under protocol directives previously approved by your Medical Director, you should try and bring the person to the point where they are breathing on their own, but are not completely awake. Once you have ROSC, the victim should be transported to the nearest appropriate hospital.
I can personally attest to the fact that the new guidelines do help save lives at a more improved rate. Since the new guidelines went into effect this year, my squad has had 3 medically related CPR calls and all three resulted in saves.
If you have an AED that tells you to continue compressions while the AED is charging, then continue compressions until the AED tells you to stop compressions and then press the shock button.
IF YOUR AED DOES NOT TELL YOU TO CONTINUE COMPRESSIONS WHILE IT IS CHARGING, DON’T.
If you do continue compressions and your AED is not equipped to accommodate it, the AED will interpret your compressions as a heartbeat and will not administer a shock.
WHEN YOU BUY AN AED CHECK WITH THE MANUFACTURER TO MAKE SURE THE AED WILL ALLOW YOU TO CONTINUE COMPRESSIONS IN BETWEEN CHARGING AND SHOCK.
WORKING AS A TEAM TO DELIVER HIGH QUALITY CPR
The only way to improve the outcome even better than working alone is to deliver high quality CPR as a team. There are several aspects to working as a team. Depending on the number of team members, one essential requirement is having someone to relieve the compressor every 2 minutes or sooner if possible (2 rescuers).
Another advantage is having someone to deliver breaths (3 rescuers) and finally if possible someone to operate the AED and coordinate the efforts of each rescuer (4 rescuers).
If you are fortunate enough to have more than four responders one can keep time and coordinate the moves of each team member and another can keep other people away from the scene.
The coordinator provides constructive feedback to each rescuer according to their assigned task. The coordinator makes sure the compressions are deep enough and fast enough with proper chest recoil. They make sure the breaths are making the chest rise and are not being administered too fast or slowly. They also coordinate the continuation of compressions (if allowed) while the AED is charging and stop them before the shock is delivered, and assures that compressions are started immediately after the AED delivers the shock or pauses.
The coordinator makes sure all the steps are followed to the letter to insure the absolute best high quality CPR to the victim. Comprehensive Effective Team CPR assures the victim the greatest chance of survival.
DO YOU NEED ANY ADDITIONAL HELP?
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