Wrong is right CPR question

Editorial Team / Admin · May 27, 2017

Recommendations change. Once the person becomes unconscious, we now begin chest compressions rather than abdominal thrusts. The Heimlich is only for those who remain conscious.

AceOfHearts<3 · May 27, 2017

Rose Queen is right, but here is some other things to think about:

Kids are not just little adults, so what you do for adults is not always what you would do for pediatrics.

If you WITNESS a pediatric become unresponsive you IMMEDIATELY start compressions.

Sorry for all caps on the words I wanted to emphasize- the option to bold or italicize is missing.

dishes, BSN, RN · May 27, 2017

Recommendations change (often based on research or expert consensus), the reasons why the changes were made are often in the current American Heart Association Guidelines.

WKShadowNP, DNP, APRN · May 27, 2017

Plus consider that the chest compressions will also potentially dislodge the foreign object obstructing the airway.

Floor_Nurse · May 27, 2017

Ok, thanks. I guess I have difficulty with that recommendations change" thing. At least CPR is still 30:2 ....until it CHANGES again.

AceOfHearts<3 · May 27, 2017

Ok, thanks. I guess I have difficulty with that recommendations change" thing. At least CPR is still 30:2 ....until it CHANGES again.

30:2 if alone, 15:2 with peds if there are 2 or more people present to assist

HermioneG, BSN, RN · May 27, 2017

I recently took CPR class and got a question wrong concerning a choking child: The question portrayed a child eating, then coughing, then falling down unresponsive. My response... I would do the Heimlich maneuver to dislodge the food item which is likely obstructing the airway.
They say to go ahead and start chest compressions (CPR) with no mention of Heimlich.
Once, in real life, I had something similar happen to an adult. I did the Heimlich first and it saved the patient's life.

I teach CPR, and I've had many questions on this. This is how I rationalize it to my students (keep in mind, I am not an expert, but anything that can help people remember is game in my book!):

If a child starts choking, then coughing, and then falls down unresponsive, it's probably from lack of air. This child is a strong candidate for cardiac arrest. We know that "cardiac arrest in children frequently results from respiratory failure" (Pediatric Respiratory Failure: Practice Essentials, Background, Pathophysiology).

Let's imagine how long the child has been without adequate air before falling unconscious. In this case, falling unconscious is a strong indication that the brain is already starting to feel the negative effects of the lack of oxygen. This is concerning because the brain can last mere minutes without adequate oxygenation before sustaining some form of permanent brain damage. Say we start a timer from the time that the child falls unconscious until the time that we get through some quality Heimlich maneuvers and we check their mouth to see if anything is there. How long has the time been from them falling unconscious to finishing a round of Heimlich maneuvers? One minute? Two? More? What's happening to the brain in those precious minutes? What's happening to their heart? Is it still beating? What if they went into cardiac arrest from lack of oxygenation when we were spending time on Heimlich and we didn't catch it immediately?

Then there's the thought that if someone was already choking, someone has already probably tried to do the Heimlich on them. If it didn't work while they were standing, whose to say it's going to work now? If it didn't work the first time, do we really think it will work this time around? And are we willing to spend precious minutes trying (yet again) to make it work if during that time the child is a high risk for cardiac arrest?

In the case where the child falls unconscious from choking, we can assume that we have exhausted all other measures (aka coughing, Heimlich while they were awake) and they did not work. So it must be lodged in there really well. Now our main focus is to keep the child's heart moving because the airway has a very low likelihood of being cleared without more advanced and invasive treatment. Heimlich (to my understanding) has little to no effect on the heart. If we spend time doing that instead of compressions and it doesn't clear the airway, we are taking a huge gamble. Research shows the child will probably go into cardiac arrest from lack of air, so if the status of the airway does not change, cardiac arrest is inevitable. If they fall unconscious and we were so focused on Heimlich that they went into cardiac arrest and we didn't catch it right away, then sweet Jesus we've just wasted precious minutes. See what I mean?

It's really hard to write it out, and I've had a lot more success just explaining it verbally, but the bottom line is that if someone falls unconscious from a blocked airway, the status of the airway may very well not change with BLS. If Heimlich didn't work while they were awake, then it may or may not work while they're unconscious. And the stakes are too high. If it doesn't work while they're unconscious, the child will most likely go into cardiac arrest (remember, one of the main reasons a child goes into cardiac arrest is from inadequate ventilations) then that means that if Heimlich doesn't work and that airway doesn't clear immediately you're going to be doing compressions anyways. I understand that it worked for you and it saved someone's life (that's awesome by the way!) but the most recent curriculum doesn't' want you to take that risk. Go straight into compressions.

So, hop on compressions immediately and just check the mouth to see if the compressions pushed the object up into the mouth, before giving ventilations and possibly pushing it back down into the airway. Anticipate that CPR will most likely be needed, and treat it immediately before the heart stops on its own.

TLDR: Compressions have a dual purpose here. First, they can act as a mechanism to try and push the object up and out of the airway (which is why we look before giving the two breaths in this situation) and second, they act as a protectant for the heart. The heart is struggling from lack of oxygen, and because one of the leading cause of cardiac arrest in peds patients is respiratory insufficiency, we are directly addressing the massive risk of cardiac arrest that this child has. We see this same thing in peds patients when their heart rate is under 60 beats per minute and they're showing signs of inadequate oxygenation... when that happens we also begin CPR because we anticipate imminent cardiac arrest. The only difference here is that we take a quick peek in their mouth for an object before giving the breaths.

ProperlySeasoned · May 28, 2017

Great conversation - love that teaching is being backed up by sound physiological reasoning.

Floor_Nurse · May 28, 2017

Yes, thank you very much.

morte, LPN, LVN · May 28, 2017

if you don't have an air way, you have a dead person. all the pumping in the world is not going to help.

HermioneG, BSN, RN · May 28, 2017

if you don't have an air way, you have a dead person. all the pumping in the world is not going to help.

I agree, except we can't just do nothing. We still have to try and do what we can until more advanced medical resources are available, or someone who has advanced airway in their scope of practice comes to help.

Also, the hope would be that chest compressions could potentially force the object out, so you both clear the airway and address the potential circulation risk. But I do agree. This really would be a dire calamity in real life. No airway=very little hope.