Has CPR Changed Again?????????

Monica RN,BSN · Oct 3, 2004

I am a certified CPR instructor, and I have never heard of such a thing as 4 breaths and 8 compressions. Yes it is 15 to 2 though, not 15 to 1 point is, as long as you are moving air and moving blood, it is effective (within the limitations of the victims chance for survival anyways)

explorer · Oct 3, 2004

:) First of all I'm starting with a happy face because I helped save a life today. I was leaving work and saw a lady lying on the ground in the parking lot. One of our doctors was in the parking lot also and we both ran over to her. She was not breathing, no pulse, and blueish around the mouth. Dr. H began to do the breathing and I began the chest compressions. He said "stop, stop" He said 4 breaths, then 8 compressions. I thought, huh? It's been almost 2 years since ACLS but that just didn't seem right to me. While he was doing his second set of 4 breaths I got my cell phone out and quickly called the ER. (cardiac arrest in the front lot, come now please!) They were there in about 2 minutes. By the time they arrived she was breathing on her own but we couldn't feel a pulse. They hooked her to the pack and she had a junctional rhythm. They whisked her away on the stretcher. I went on home. Just curious, 1 to 15 hasn't changed has it? The important thing was that we were able to revive her but I just need to know. Dr. H just happened to go to that ACLS class with me and was my partner. I will razz him next time I see him if he was wrong! He's got a great sense of humor. There are some doctors, you know what I mean, who you don't try to explain anything to! Dr. H is a jewel !!!

You are right!

kathy_79 · Oct 3, 2004

you did great job,

i agree with monica, 15 to 2

and i know about 5 to 1 if i am not wrong you do this way when you are alone so above is for two people doing cpr

you are very good person, i bet you save more lifes, :)

Audreyfay · Oct 4, 2004

Yup....15:2. I am a CPR Instructor also. There have been some changes, but that is not one of them. The doc must have been rattled! :rolleyes:

zambezi, BSN, RN · Oct 4, 2004

I agree with the 15:2...however, "no ventilation" cpr is now the new thing if you do not have a protective airway device with a one way valve to protect you, the rescuer. Remember rule number one is protect yourself. The body has extra oxygen molecules that can be relesed when necesary so doing more compressions and getting that circulation going is key...What is the point of blowing in oxygen if you can't circulate it?? With longer compression times, the blood has a chance to get moving, if you are stopping too frequently to give breaths, that bloodflow that is bringing the oxygen to the tissues that you worked so hard to initiate stops. I was at an interesting conference this weekend and the speaker, who is quite well known, stated that he thought that in the next couple of years we will see a change from ABCs to CABs...just food for thought...

Of course if you have airway managment techniques to keep you safe, by all means, get that airway, give your breaths and do the standard 15:2

It seems that even the 5:1 (cpr with two rescuers) is out the door now unless there is a secure airway (ie: et tube) ...because of the whole circulation of blood flow concept...

Audreyfay · Oct 4, 2004

Thanks for the update Zambezi. Can't wait to hear what comes up. Some of those thoughts haven't trickled down to us yet. CAB...........and here I thought that was a coronary artery bypass. :chuckle

zambezi, BSN, RN · Oct 4, 2004

Thanks for the update Zambezi. Can't wait to hear what comes up. Some of those thoughts haven't trickled down to us yet. CAB...........and here I thought that was a coronary artery bypass. :chuckle

Just to clarify...the Circulation/Airway/Breathing (CAB) is not a part of the BLS protocol yet...the ratio for compressions and breaths is 15:2 or about 100 beats a minute...unless the patient is intubated, then it is 5:1 but compressions are not stopped -> the bagger/airway management person just times the breath with the upstroke on the fifth compression...

of course, early defibrillation is key too!!!

http://www.findarticles.com/p/articles/mi_m0BPG/is_9_16/ai_78801558

From: the journal of critical illness, sept. 2001

Update on the American Heart Association Guidelines for ACLS

(I cut the article off, but the rest of it is it posted on the attached link!)

ABSTRACT: Consistent with the continuing trend to simplify advanced cardiovascular life support protocols, the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care are based on critical reviews of published data on various procedures and medications. Using an evidence-based approach, a panel of international experts has developed a hierarchical system of recommendations for both basic life support and advanced cardiovascular life support. Major changes include elimination of the pulse check by lay rescuers, renewed emphasis on the importance of uninterrupted chest compressions, practical recommendations for mouth-to-mouth ventilation, de-emphasis on the use of many cardiac medications, and new emphasis on the early recognition of shockable cardiac rhythms and the use of automated external defibrillators whenever possible. (J Crit Illness. 2001;16(9):416-420)

For many years, the American Heart Association (AHA) has helped bring together experts from the United States and other countries to develop evidence-based guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC). The culmination of these efforts was the convening of The First International Conference for Guidelines on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care in February 2000. One of the objectives of this conference was the development of evidence-based guidelines for CPR and ECC. These new guidelines represent several major changes in the recommendations for basic life support (BLS) and advanced cardiovascular life support (ACLS). [1]

In this article, I will review the major recommended changes in BLS and ACLS protocols and the reasons for these changes. In upcoming issues of The Journal of Critical Illness, I will review in more detail the recommendations for the use of cardiac drugs in the emergency setting.

BASIC LIFE SUPPORT

Pulse check

For BLS initiated by laypersons, the pulse check step has been eliminated. The basis for this change is the substantial evidence that laypersons are not very proficient at checking the pulse. Previously, laypersons and health care providers were taught to judge within 5 to 10 seconds whether a pulse was present. However, clinical data have shown that laypersons can make such a decision within 10 seconds only 15% of the time. Also, it has been demonstrated that lay rescuers mistakenly identify a pulse in 10% of unconscious, pulseless patients and fall to detect a pulse in 45% of unconscious patients who have a pulse. [2 3]

Instead of checking the pulse, laypersons will be taught to look for signs of life, such as if the victim starts moving when chest compressions are initiated or the presence of normal breathing. [4] For health care providers, the pulse check will continue to be recommended as a component of BLS.

Chest compression-to-ventilation ratio

The BLS sequence for chest compressions has been simplified. Previously, slightly different compression rates were recommended for infants, children, and adults. The new recommendation for both children and adults is 100 chest compressions per minute. [4]

The compression-to-ventilation ratio for 1 and 2 rescuers has been changed to 15 compressions to 2 ventilations if the victim's airway is unprotected. Once an endotracheal tube has been placed and its position verified, the recommended ratio for 2 rescuers is 5 compressions to 1 ventilation, which is interposed on the upstroke of the fifth compression. [4]

The reasons for the change in chest compression rate and the compression-to-ventilation ratio are based on data obtained during the last decade. Transesophageal echocardiography has identified 2 mechanisms responsible for blood flow during closed chest CPR in adults. With the first mechanism, compressing the sternum squeezes blood directly out of the ventricles by compressing them. This mechanism was postulated in the 1950s and confirmed by studies in the 1960s. [5]

However, a second mechanism has been identified and may, in fact, be the dominant mechanism in adults. It is the so-called thoracic pump, whereby significant changes in intrathoracic pressure rhythmically compress the great vessels, as well as the heart, causing blood to stream forward, provided that the major arteries remain patent. [6-10] Patency of the great vessels depends on the maintenance of vasomotor tone, which typically is enhanced with medications such as epinephrine and vasopressin. A backwash of appreciable amounts of blood does not occur during closed chest CPR because the veins typically collapse as they enter the thorax. [11]

After 1 or 2 chest compressions, blood begins to move through the right side of the heart. However, it takes 4 to 6 chest compressions before a significant quantity of blood starts moving through the left atrium and ventricle. [11-14] With the initial chest compressions after cardiac arrest, blood flows very rapidly through the right ventricle (RV) because, in virtually all adults, compression of the sternum causes direct compression of the RV.

However, in most adults, blood flow through the left side of the heart depends predominantly on the thoracic pump, and 4 to 6 cardiac compressions are needed before blood clears the pulmonary circulation and starts to move through the left atrium and left ventricle (LV). Pausing momentarily after 5 compressions to allow ventilation in a person with an unprotected airway--which was the previous recommendation--is counterproductive. Just as blood is beginning to flow through the LV, the force promoting blood flow through the left side of the heart--the thoracic pump effect created by chest compressions--is interrupted. [11-14]

In summary, the new recommendation is that if the airway is unprotected, 15 compressions should be followed by 2 ventilations. This sequence will initiate and sustain the momentum of blood flow. However, if the patient is intubated and correct placement of the endotracheal tube has been verified, 5 compressions with a ventilation on the upstroke of the fifth compression will not interrupt blood flow significantly [4]

Mouth-to-mouth ventilation

The use of chest-compression-only CPR (that is, chest compression without mouth-to-mouth ventilation) is now recommended in the following circumstances [4]:

* In dispatcher-assisted or phone GPR.

* If the rescuer is unwilling or unable to perform mouth-to-mouth rescue breathing.

Several surveys have shown that health care providers (physicians, nurses, and emergency medical technicians [EMTs]) and even BLS instructors often are unwilling to perform mouth-to-mouth ventilation on adults, particularly those in whom infectious disease is suspected. [15-18]

About 10 years ago, a study in Belgium of more than 3300 patients found that if laypersons performed both mouth-to-mouth ventilation and chest compressions and were judged by trained rescuers who arrived on the scene to be performing BLS well, the survival rate of the patients was about 16%. [19] If chest compressions were being done without mouth-to-mouth ventilation, the survival rate of neurologically intact patients was 10%. The difference between the 2 groups was not statistically significant. However if CPR was not being performed or was being performed poorly, the survival rate was less than 4%, a statistically significant difference compared with either of the other groups.

Another study confirmed that mouth-to-mouth ventilation is not necessary if chest compressions are being done properly and the airway is patent. [20] Several studies have indicated that for the first few minutes following cardiac arrest in an adult, chest compression alone, without mouth-to-mouth ventilation, is associated with a reasonable chance of survival provided that the airway is patent.

The oxygen concentration of exhaled air (not supplemented by oxygen) that a rescuer blows into a victim's lungs during mouth-to-mouth ventilation is 16% to 17% [21] This value compares with an oxygen concentration in room air of 20% to 21%. Thus, during the phase of passive recoil of the chest during chest compressions, the patient is receiving a higher concentration of oxygen with chest compression alone than during mouth-to-mouth ventilation without supplemental oxygen. The key to chest-compression-only CPR is to maintain a patent airway. [22]

Therefore, mouth-to-mouth ventilation is no longer a requirement for BLS performed by laypersons, particularly if trained first-responders are expected to arrive within 5 to 7 minutes. [4'23] After this time, the muscle tone of the respiratory muscles diminishes and the tidal volume with chest compression decreases.

zambezi, BSN, RN · Oct 4, 2004

While I was looking for info, I found this neat acls practice site:

http://www.netmedicine.com/open/benefits/madsci/codeteam/show_pro.htm

another article:

http://www.emedmag.com/html/pre/cov/covers/071501.asp

acls provider manual online:

http://www.emedmag.com/html/pre/cov/covers/071501.asp

mattsmom81 · Oct 4, 2004

As a former CPR instructor, I'm glad to see these changes. I used to teach lay CPR and the public still tends to gets all hung up on the 'mouth to mouth' when they should be calling 911.

Thanks for the info Zambezi, I had wondered for years about the point of ventilating without adequate circulation.

Funny/awful story: remember the days before barriers/AMBUS were on every unit; where nurses WERE expected to start 'mouth to mouth' without protection. I was 8 mo pregnant and had to do 'mouth to mouth'...the patient vomited, so did I, that baby turned somersaults for hours and I'm surprised I didn't go into premature labor. LOL. Ahh the good old days...this is an example of NOT.

zambezi, BSN, RN · Oct 4, 2004

Matts mom--that is gross...I can't imagine doing mouth to mouth on someone that I don't know (well, I can imagine it and I would want to to help the person, but I just couldn't do it...)

It seems that most people tend to vomit with cpr...ick...it would only make me vomit on them, and then what good would I be??--certainly not thinking about early defibrillation or chest compressions that is for sure!

It was interesting that in the article that they are not even teaching lay persons the pulse check anymore...more food for thought!