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    Default New CPR Method Boosts Survival From Cardiac Arrest

    New CPR method boosts survival from cardiac arrest

    Julie Steenhuysen , Reuters
    Published: Tuesday, March 11, 2008

    CHICAGO (Reuters) - More people can survive a cardiac arrest when emergency medical workers use a new resuscitation method that starts with a round of 200 chest compressions before a defibrillator shock, U.S. researchers said on Tuesday.

    Rescue teams in Arizona who used the new approach on people who had a cardiac arrest outside the hospital tripled the survival rate of the standard approach.

    "Cardiac arrest is incredibly common and survival is poor," said Dr. Bentley Bobrow, medical director for emergency services for the state of Arizona and a researcher at the Mayo Clinic in Scottsdale.

    The new resuscitation method, which is not intended for bystanders, increases blood flow to the heart and brain when the heart stops pumping blood.

    "Even if you could improve survival by a few percentage points, you will save thousands of people across the country," said Bobrow, whose study appears in the Journal of the American Medical Association.

    For bystanders, the most important thing is to give chest compressions while waiting for an ambulance, many experts say.

    Cardiac arrest occurs when the heart stops circulating blood. Most often, people with cardiac arrest have a type of heart rhythm known as ventricular fibrillation, in which the heart quivers but does not pump blood.

    If no shock is delivered in the first four minutes of this deadly rhythm, the heart stops altogether and it becomes much harder to get it restarted. During this phase, old-fashioned chest compressions can help push blood back into the heart, making it more likely to restart.

    WAITING TO DEFIBRILLATE

    As most emergency teams do not arrive on the scene in that critical first four minutes, the new resuscitation approach calls for a round of 200 chest compressions given in the first two minutes to improve the odds that the heart will restart.

    "Traditionally, we've told them to defibrillate right away. When they do that, the patient dies frequently," Bobrow said in a telephone interview.

    In 2004, only 3 percent of people in Arizona who had a cardiac arrest outside of a hospital survived.

    Bobrow wanted to improve those odds. He and colleagues studied the use of minimally interrupted cardiac resuscitation, a highly choreographed method of CPR for emergency medical workers that is also called cardiocerebral resuscitation.

    After the first 200 compressions, the victim gets a shock, then another worker jumps in and gives another set of 200 chest compressions. At that point, they may give a shot of epinephrine to stimulate the heart, and then insert a tube into the trachea to ventilate the lungs.

    The approach is focused on continuously pumping blood to the heart and brain. Bobrow's team trained emergency workers in two city fire departments in the state, then compared the survival data before and after in 886 patients with cardiac arrest. The data were collected between 2005 and 2007.
    The rate of people who lived long enough to be discharged from the hospital rose from 1.8 percent before the training to 5.4 percent using the new protocol.

    The benefit was greatest for those who had ventricular fibrillation with a shockable rhythm. Survival in those patients rose from 4.7 percent to 17.6 percent.

    Dr. Mary Ann Peberdy of Virginia Commonwealth University in Richmond said the findings suggest the need for a back-to-basics approach to cardiopulmonary resuscitation.


    We are learning more and more that we can't get sloppy on how we do CPR," Peberdy said in a commentary in JAMA.

    (Editing by Maggie Fox and Doina Chiacu)
    Last edited by backsteprescue; 03-12-2008 at 11:18 AM.
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    Quote Originally Posted by RFRDxplorer View Post
    "Cardiac arrest is incredibly common
    It happens to everyone sometime.
    Even the burger-flippers at McDonald's probably have some McWackers.

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    Hey, I didn't write the article I just posted it.
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    I might be off base here, but I thought it was common knowledge/practice that a minimum of 2 minutes CPR should be conducted prior to initiating defib? At least that is what we've been practicing since I got here, to NoVA.
    If you don't do it RIGHT today, when will you have time to do it over? (Hall of Fame basketball player/coach John Wooden)

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    Quote Originally Posted by MalahatTwo7 View Post
    I might be off base here, but I thought it was common knowledge/practice that a minimum of 2 minutes CPR should be conducted prior to initiating defib? At least that is what we've been practicing since I got here, to NoVA.
    same here. From what I read, they aren't talking CPR, just compressions. So no ventilations. I do remember reading about them wanting to do away with ventilations all together. Who knows. I'll follow my protocol.

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    Being that we are on the subject of CPR ......

    This mack-daddy is worth its weight in gold!

    The Autopulse

    Believe the hype!

    ** Non-compensated supporter. **
    I believe them bones are me. Some say we are born into the grave. I feel so alone, gonna end up a big ol' pile a them bones

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    Quote Originally Posted by JackBauer24 View Post
    same here. From what I read, they aren't talking CPR, just compressions. So no ventilations. I do remember reading about them wanting to do away with ventilations all together. Who knows. I'll follow my protocol.

    There has been a following for this, as the concept is simply that while you are compressing a persons chest, there is some limited amount of air exchange occuring. During my army first aid training (and later as an instructor) we are given some techniques that do not include providing ventilations via mouth-to-mouth. Reason is simple: if you dont know the person, do you really want to be giving a lip-lock of you dont have any form of protective shield between you and him/her? At 100 compressions per minute, there has to be some level of air movement within and out of the lungs, right?
    If you don't do it RIGHT today, when will you have time to do it over? (Hall of Fame basketball player/coach John Wooden)

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    Get it up. Get it on. Get it done!

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    According to chicago ALS SMO's for Pulseless V-Tach or V-Fib you initiate 2 minutes of CPR if unwittnessed arrest and then shock at 200J OR shock immediately at 200J if the arrest is witnessed. Of course you would not withold CPR if there is any delay in the defib for any reason and our CPR is on the american heart standards of 30:2. Just thought i would throw in the Chicago persepctive, not sure if it pertains or not. I'm not sure i understand the advantage of compression based CPR in EMS.
    "As most emergency teams do not arrive on the scene in that critical first four minutes, the new resuscitation approach calls for a round of 200 chest compressions given in the first two minutes to improve the odds that the heart will restart."
    Maybe i'm reading this wrong, but CPR is about manual circulation not "restarting the heart."

    Intersting article but i'll follow my SMO's and ACLS protocols until told otherwise.

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    Quote Originally Posted by MalahatTwo7 View Post
    There has been a following for this, as the concept is simply that while you are compressing a persons chest, there is some limited amount of air exchange occuring. During my army first aid training (and later as an instructor) we are given some techniques that do not include providing ventilations via mouth-to-mouth. Reason is simple: if you dont know the person, do you really want to be giving a lip-lock of you dont have any form of protective shield between you and him/her? At 100 compressions per minute, there has to be some level of air movement within and out of the lungs, right?
    well.... I wouldn't think enough to move new air in and out. of course the air that comes out of our mouth is only what? 15% o2? not enough to sustain. hell I dunno, I put the wet stuff on the hot stuff.

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    Quote Originally Posted by JackBauer24 View Post
    well.... I wouldn't think enough to move new air in and out. of course the air that comes out of our mouth is only what? 15% o2? not enough to sustain. hell I dunno, I put the wet stuff on the hot stuff.
    Our body only uses something like 6% of the O2 it takes in. Normal air- 21% O2
    Air we exhale- 15%. Thats how it works.

    Not sure if that is what you were looking for, and I'm not saying its completely right either.

    Sorry
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    Quote Originally Posted by MalahatTwo7 View Post
    There has been a following for this, as the concept is simply that while you are compressing a persons chest, there is some limited amount of air exchange occuring. During my army first aid training (and later as an instructor) we are given some techniques that do not include providing ventilations via mouth-to-mouth. Reason is simple: if you dont know the person, do you really want to be giving a lip-lock of you dont have any form of protective shield between you and him/her? At 100 compressions per minute, there has to be some level of air movement within and out of the lungs, right?
    According to studies I've seen/heard about if you allow for full chest recoil after compressions there is minimal air exchange without forced ventilations. The service I run with just switched to the new CCR protocols and part of it is to insert an oral airway and place the pt on a NRB at 15L to provide higher O2 levels during those compressions. We are now doing 200 compressions followed by a shock from a manual defib as EMT-B's. We had training on recognizing v-fib and v-tach in order to go manual. After 3 rounds of this is when we finally insert an advanced airway (combi-tube in our case) and begin ventilations. One of our neighboring counties was part of a pilot program and saves increased by 30% plus under these protocols. Haven't had to use the new protocols, but it makes sense, more or less based on the premise that circulating blood to the brain is priority in keeping pts viable.
    Last edited by mvfd27; 03-12-2008 at 03:55 PM.

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    Quote Originally Posted by RFRDxplorer View Post
    Our body only uses something like 6% of the O2 it takes in. Normal air- 21% O2
    Air we exhale- 15%. Thats how it works.

    Not sure if that is what you were looking for, and I'm not saying its completely right either.

    Sorry
    you're right but you're wrong. we require 21%. doesn't matter what we actually use.

    anywho... lol

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    Quote Originally Posted by mvfd27 View Post
    According to studies I've seen/heard about if you allow for full chest recoil after compressions there is minimal air exchange without forced ventilations. The service I run with just switched to the new CCR protocols and part of it is to insert an oral airway and place the pt on a NRB at 15L to provide higher O2 levels during those compressions. We are now doing 200 compressions followed by a shock from a manual defib as EMT-B's. We had training on recognizing v-fib and v-tach in order to go manual. After 3 rounds of this is when we finally insert an advanced airway (combi-tube in our case) and begin ventilations. One of our neighboring counties was part of a pilot program and saves increased by 30% plus under these protocols. Haven't had to use the new protocols, but it makes sense, more or less based on the premise that circulating blood to the brain is priority in keeping pts viable.
    well that's pretty cool. I think. But I don't understand why not use a BVM? Isn't it going to act like NRB until you squeeze? And if you've got two rescuers, surely it's better to get some actual breaths squeezed in there.

    Seriously folks, I'm asking only asking questions, I don't know jack. just a newb Basic.

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    Quote Originally Posted by JackBauer24 View Post
    well that's pretty cool. I think. But I don't understand why not use a BVM? Isn't it going to act like NRB until you squeeze? And if you've got two rescuers, surely it's better to get some actual breaths squeezed in there.

    Seriously folks, I'm asking only asking questions, I don't know jack. just a newb Basic.
    The theory behind no ventilations early on is that until you have an advanced airway, like a combi-tube, ET tube etc you must stop compressions to give breaths. Basically, stopping the 5-10 seconds to give breaths undoes the good of the previous compressions. Kind of like priming a pump....after 30 or so compressions delivered under traditional cpr the prime is just taking hold. So if you stop after 30 you lose what you gained and essentially start over.

    Also, it took a long time for an AED to analzye and charge and deliver a shock so they switched to manual. We charge when the person doing compressions reaches 180 and then charge teh defib, when they reach 200 hands off and check the rhythm on the monitor and deliver or dump the shock as needed. To do this it takes less than 5 seconds to stop compressions decide and shock or no shock. So basically, as I said in the other post there is much more emphasis on moving the blood to the brain and rest of the body to increase survival and reduce brain damage.

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    There was a thread on this a lil while ago it had a whole story behind it with a hiker or a cross country runner and a couple of nurses I believe found him slumped over in the bushes and he did survive. Well the story went on how this is being using by either just Phoenix or all of Arizona im not sure and at the time it was not recognized AHA because there was not enough data to back it up. It was developed at The University of Arizona Sarver Heart Center in Tucson, Arizona.

    Rob

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    Quote Originally Posted by mvfd27 View Post
    The theory behind no ventilations early on is that until you have an advanced airway, like a combi-tube, ET tube etc you must stop compressions to give breaths. Basically, stopping the 5-10 seconds to give breaths undoes the good of the previous compressions. Kind of like priming a pump....after 30 or so compressions delivered under traditional cpr the prime is just taking hold. So if you stop after 30 you lose what you gained and essentially start over.

    Also, it took a long time for an AED to analzye and charge and deliver a shock so they switched to manual. We charge when the person doing compressions reaches 180 and then charge teh defib, when they reach 200 hands off and check the rhythm on the monitor and deliver or dump the shock as needed. To do this it takes less than 5 seconds to stop compressions decide and shock or no shock. So basically, as I said in the other post there is much more emphasis on moving the blood to the brain and rest of the body to increase survival and reduce brain damage.
    I can see the validity in that. The clean oxygenated blood remaining takes a while to lose it's oxygen properties. Therefore you can do 200 or maybe even more compressions without completing an entire circulation of clean blood before you introduce oxygen to the p/t.
    IAFF

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    Quote Originally Posted by eaglesrule1024 View Post
    There was a thread on this a lil while ago it had a whole story behind it with a hiker or a cross country runner and a couple of nurses I believe found him slumped over in the bushes and he did survive. Well the story went on how this is being using by either just Phoenix or all of Arizona im not sure and at the time it was not recognized AHA because there was not enough data to back it up. It was developed at The University of Arizona Sarver Heart Center in Tucson, Arizona.

    Rob
    Rock County (not where I run, but a neighboring county) in Southern WI was also part of a study group using CCR protocols derived from the AZ standards you mentioned. Pretty interesting stuff and sounds like most of southern WI is going to these protocols as well so we'll have to see what if any changes AHA has in response.

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    Quote Originally Posted by mvfd27 View Post
    The theory behind no ventilations early on is that until you have an advanced airway, like a combi-tube, ET tube etc you must stop compressions to give breaths. Basically, stopping the 5-10 seconds to give breaths undoes the good of the previous compressions. Kind of like priming a pump....after 30 or so compressions delivered under traditional cpr the prime is just taking hold. So if you stop after 30 you lose what you gained and essentially start over.

    Also, it took a long time for an AED to analzye and charge and deliver a shock so they switched to manual. We charge when the person doing compressions reaches 180 and then charge teh defib, when they reach 200 hands off and check the rhythm on the monitor and deliver or dump the shock as needed. To do this it takes less than 5 seconds to stop compressions decide and shock or no shock. So basically, as I said in the other post there is much more emphasis on moving the blood to the brain and rest of the body to increase survival and reduce brain damage.
    excellent explanation. Thanks

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    You're welcome, bro!

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    Funny if you're around long enough you see the CPR studies go from one extreme to the other and back. At one point a Boston based study showed that we rarely oxygenated patients enough, so we bagged on 1,3 and 5 during the old two rescuer 5:1 CPR. Now no ventilations are better than stopping compressions. A few years from now we'll be back to the first one, under-oxygenated blood being circulated.

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    Ain't nothing like good quality CPR.

    Good BLS before ANY ALS.
    The Dept with the highest CPR save rate in my area is......


    A BLS Dept!

    Hmm....
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    That sounds a little biased there BLSboy
    IAFF

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    Hahaha!
    It will be ALSBoy in 7 more months.....


    Besides, BLS means less work to do
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    Quote Originally Posted by FDAIC485 View Post
    Being that we are on the subject of CPR ......

    This mack-daddy is worth its weight in gold!

    The Autopulse

    Believe the hype!

    ** Non-compensated supporter. **
    New take on an old idea. We were using thumpers back in the 70's.

    http://www.michiganinstruments.com/r...FQsZHgodJlv_9Q

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    Quote Originally Posted by mvfd27 View Post
    The theory behind no ventilations early on is that until you have an advanced airway, like a combi-tube, ET tube etc you must stop compressions to give breaths. Basically, stopping the 5-10 seconds to give breaths undoes the good of the previous compressions. Kind of like priming a pump....after 30 or so compressions delivered under traditional cpr the prime is just taking hold. So if you stop after 30 you lose what you gained and essentially start over.

    Also, it took a long time for an AED to analzye and charge and deliver a shock so they switched to manual. We charge when the person doing compressions reaches 180 and then charge teh defib, when they reach 200 hands off and check the rhythm on the monitor and deliver or dump the shock as needed. To do this it takes less than 5 seconds to stop compressions decide and shock or no shock. So basically, as I said in the other post there is much more emphasis on moving the blood to the brain and rest of the body to increase survival and reduce brain damage.
    Very good description, but there is one more key element to keep in mind as well when describing the process.

    When we perform compressions, we are only a small fraction as effective as the heart at moving that blood. The 21% o2 in down to 16% o2 out is for a perfectly working circulatory system with 100% flow rate. The blood and lungs are able to transfer the 5% because we are introducing new unoxegenated blood quickly (between 2-3 feet per second in proximity to the heart). If we slow that blood down, we cannot use all the oxygen in our lungs as quickly.

    To use an arbitrary low number (because I can't remember the right one right now ), if we only move 15% or less of the blood around with compressions, we are only allowing 15% or less of the normal exchange of air in the lungs. This means we have to change that air much less frequently. Think of it like your external foam eductor on the pump. Lower flow rate in the line means lower draw rate on the pail of foam concentrate. Your foam lasts longer. Same for a pail (or lung) full of o2.

    Additionally, there are certain schools that also teach that regular ventilation is also far more detrimental than just the delay caused by venting. The theory is that the higher pressure in the lungs after venting actually REDUCES blood flow by compressing the arteries and reducing spacial volume.

    All makes sense to me. Flow and arterial pressure equals perfusion, and perfusion is required before additional oxygen is even needed.
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