CPR Right Now

I helped teach CPR to our latest EMT class this past week. This class is always a good reminder of how fast emergency medicine changes.

Here in their first week, the new students are beginning to hear our warnings.

“You are going to hear about many different ways to perform this skill. Some are older methods than the ones we are teaching you today. Some are newer. Some things you are learning will quickly go away. New methods, new machines and new research are all in progress. That doesn’t mean what you are learning right now is wrong. It is an imperfect method. Prepare for change.”

Some students get stressed over the idea that CPR isn’t a gold standard technique handed down unchanged for decades. I worry for their future. Like the banner says, “Medicine moves fast.” …You know the rest.

When you consider everything that needs to happen for changes to occur in the CPR techniques of EMS providers around the globe, it really is remarkable how fast this single skill adapts and morphs over a period of relatively few years. When you consider the logistics of it, change really should take decades.

Have you ever wondered where these changes come from? Here’s a fly-by of the process:

  • Research looking at survival rates and outcomes of our current CPR and resuscitation techniques is funded and conducted at various centers around the globe.
  • The current research is prepared, published, vetted and deemed to be relevant and worthy of consideration or unhelpful.
  • Various committees and groups convene at regular intervals and review all the latest research.  These groups include;  Australian Resuscitation Council (ARC), European Resuscitation Council,   New Zealand Resuscitation Council, American Heart Association (AHA) and the big boy on the block, International Liaison Committee on Resuscitation. They discuss and debate the research and form official recommendations for CPR education.
  • Local medical directors and program administrators look at the recommendations and decide how and when it would be best to implement new guidelines, methods and techniques.
  • Then … every EMS professional on the face of the planet gets retrained.

Read that last bullet point one more time and consider the scope of it. Consider the challenge of accomplishing just that one final, necessary objective.

If you’re wondering what’s new in CPR, here are some of the things we’re teaching right now that may be different from what you learned in your last CPR class. I hesitate to call any of these recommendations new because they’re not. We’re actually at the end of a recommendation cycle.

That’s right; most of this stuff comes from the 2005 flurry of activity. There’s a new ILCOR conference getting ready to convene in 2010 and the whole cycle will kick into high gear again.

But for now:

  • There is a huge emphasis on hard, fast, effective compressions. We do compressions poorly and slowly … and we stop too much. 100 per minute on everyone.
  • Change the compression rescuer every two minutes.
  • Lay rescuers aren’t feeling for pulses. They keep going until they see signs of life, or an AED says stop, or we tell them to stop.
  • Some guidelines are suggesting compressions alone for primary cardiac arrest in adults or if the rescuer is untrained or not-confident in their CPR.
  • Everyone who does get compressions gets a 30/2 compression ventilation cycle except for two rescuer kid and infant CPR.
  • AED users should jump right back on compressions after one shock and turn off the machine if it hasn’t been reprogrammed for this yet. (No pulse checks or rhythm checks here. Just get back on it.)

For us professionals, a few other considerations:

  • We stop compressions even more than lay rescuers. The current recommendations are to not stop compressions for anything. (Including airway interventions.) If you can do it while the compressions are going fine. If not, don’t stop compressions.
  • Do on-like-Donkey-Kong compressions for 2 minutes then shock immediately.
  • Don’t delay the continuation of compressions for post shock pulse and rhythm checks.
  • Do that 5 times.
  • Adrenaline is the front line drug for cardiac arrest pharmacology. (Or Vasopressin.) All other drugs are a lower priority.

That’s the major nuts and bolts for now. I’m sure we’ll be back to talk about it again after the 2010 ILCOR conference. Everything changes. It’s as it should be.

Now it’s your turn: What CPR guideline is your agency currently following? Do your protocols reflect the latest recommendations? Do you think we change our CPR standard to frequently or not fast enough? Leave a comment before you move on. I’d like to hear from you.

Related Posts:

The Art of The Pulse Check

The Art of The Nasopharyngeal Airway

Six Techniques to Nail The IV Every Time

EMT Skill: Observation

Comments

  1. I did my Occupational First Aid here in BC (one step below basic EMT, so it’s pretty low-key) just last year, and we were told two different ways to do CPR alone – one was the 30/2, and the other was continuous compressions.

    The instructor mentioned a rule for which one to go with, but I honestly can’t remember what it was – I’m going to stick with 30/2.

  2. Timothy Clemans says:

    I’m looking forward to seeing if there is a significant improvement in survival to hospital discharge for bystander witnessed VF/VT due to heart disease in Seattle/King County after the implementation of the 2010 AHA guidelines. In 2005, Seattle/King County’s survival to hospital discharge rate for bystander witnessed VT/VF due to heart disease increased by 11% over the previous year after they eliminated stacked shocks, post shock reanalysis, and post-shock pulse check from it’s CPR protocol and increased CPR time from one to two minutes in January.

    My prediction is there will not be more than a 5% increase in the survival to hospital discharge rate for bystander witnessed VF/VT due to heart disease over the previous year after implementation. I will be amazed if the yet unreleased Seattle/KC 2009 rate is higher than 53%, see http://en.wikipedia.org/wiki/File:King_county_vf_cardiac_arrest_survival_rates_chart.png

    It seems to me the secret to getting ROSC has been found. I will be totally stunned if future CPR guidelines are nearly as important as the 2005 AHA guidelines.

  3. I am not sure about how often we should be changing but in my opinion implementation of the 2005 standards was dreadfully slow. I heard about them 11/2005, received a BLS instructor update in 6/2006, then was not able to actually teach new guidelines until 9/2006, and then protocols were not updated to use new guidelines until 1/2007.

    This article, “A look at the 2005 guideline implementation and uptake and adherence to these guidelines” was discussed on the last episode of the EMSEduCast journal club. Very interesting read about experience of implementing new guidelines. http://www.emseducast.com/journal-club

    My expectation is that the 2010 guideline implementation will be dreadfully slow. In the last 2 months I have been to training sessions where we reviewed the “new guidelines” and by new the instructor meant the 2005 guidelines.

  4. Steve: I’m really curious to see the new changes implemented. I worked a code last week that was as close to perfect as one could hope for, There was great citizen CPR and a valiant effort by all involved and we still didn’t get ROSC. Some are just beyond saving,

    I’ve been hearing for ages that ALS should stop focusing on ETI as the primary airway and I’ve come across some some anecdotal evidence that shows ROSC and positive outcomes are similar with a supraglottic airway (King LT) to that that of ETI. It just makes sense, doesn’t it?

    Of course, I’m still a student, but an airway that doesn’t require direct laryngoscopy, has the ability to pass a gastric tube to decompress the stomach and and has the ability to accept a bougie for ETI if needed, sounds like a great ‘first line’ airway in a code situation. i know that MEDIC in Mecklenberg County has moved to supraglottic airways in all of their codes (unless ETI is the only way to protect the airway). I’m sure they’ll publish research on the outcomes. Can’t wait to see it.

    And Steve, I love the blog. I always see something that makes me think. Thanks.

  5. Medtech21 says:

    I too am a student (Medic), and just today went over every type of basic airway from OPA to LMA, as next week we begin ET Intubation. We were introduced to a relatively new type called the SALT airway, and as you mentioned with the switch to King airways, Im wondering if these wont catch on as well. For those who dont know it is basically and oversized OPA type device that funtions like an LMA, and you can pass an ETT through it as well. This way BLS can insert the device and ventilate efficiently during a code, and as ALS shows up, intubate with almost no setup or problems at all.

  6. Steve: This could be merely a small pet peeve of mine, but in every facility I have worked (about 6), every time a patient is in cardiac and pulmonary arrest, bagging is done concurrently with compressions, and often not even on the up-stroke of the compression (during chest recoil.) I am a certified BLS instructor through the AHA and am enrolled in an ACLS lab now for RT school. Also, in the past I held a cert in ACLS.

    Never in any of these courses (BCLS or ACLS), or in any handbooks or guidelines issue by the AHA has it ever been stated that compressions and bagging are to be done at the same time– I’m talking a BVM here, not once an advanced airway is present (ETT, Combitube, etc). Yet every time I’ve been in on a code, bagging is always done continuously throughout the cycle of compressions. Even ACLS guidelines state 30:2. I often wonder why this is done this way.

    Just my 0.02.

  7. Bruce Saunders says:

    This is the first time I’ve posted here, although I’ve been a long time reader. Thanks for a great blog Steve. I’m an RN, but also involved in prehospital care, and I’ve always found the content informative and interesting…
    Trauma Junkie, I’m an ALS instructor in the UK, and I see BMV ventilation being performed while chest compressions are done a lot of the time here too, despite the guidance.
    I guess that it’s partly/mostly panic on the part of the ventilator, and partly the “need” to be seen doing something. Also do the people doing the compressions count out loud to assist the person ventilating geting it right?
    I really try and reinforce this when teaching, and point out if the air isn’t going into the lungs effectively (and it isn’t) then some of it has to be going into the stomach… and a distended abdomen isn’t good for venous return, plus increases the risk of regurgitation/aspiration.
    I’m fairly sure there was some recent research that showed anaesthetists attempting ETI actually resulted in worse outcomes in cardiac arrest. Often people take too long trying (skill fixation- “I HAVE to get the tube in..”) and there are prolonged interuptions in CPR while making the attempt. That’s why I prefer the use of a supraglottic airway if at all possible.
    I have also noticed there’s a tendency to hyperventilate patients whatever airway is obtained.

  8. Steve Whitehead says:

    @CarzyNewt Yes, and both ways were correct, depending on which standard your system is using. I know it can be confusing but we’re going to have to get used to CPR techniques being a moving target.

    @Timothy Hey brau, I agree that those extraordinary results are going to be hard to beat but there’s a lot of smart folks out there trying to figure out something better. I’m optimistic.

    @Greg. I think we’ve become accustomed to the slow roll-outs. It is a complex process. could we do it faster? For sure. Hopefully we’ll get better at that too. for CPR instructors like yourself it must be very frustrating.

    @Medic22. Hey thanks. I’m not deeply attached to my ET tube. I’ve tubed a bunch of people in my career and it’s not a perfect intervention, but we could do it way better. With All of our devices for esophageal detection, ETCO2 monitoring etc. we just shouldn’t have unrecognized esophageal tubes, and yet we do. To many if the research is to be believed. I’m not opposed to the idea of something better. If it is really better.

  9. Steve Whitehead says:

    @MedTech21 Hum. The SALT airway. I’ll have to check this out. Thanks for keeping me in the know.

    @TraumaJunkie I see your point. And, as an RT, I can see why poor ventilation techniques would irk you. But the more we research, the less we tend to emphasise the airway and the more we tend to emphasise good, continuous, uninterrupted compressions. Bag on the upstroke? Sure. But I don’t think the future of cardiac arrest management will be better airway management. It will be better compressions, earlier defibrillation and management of body temperature. (But, then again, I’ve been wrong before.)

  10. Steve Whitehead says:

    @Bruce Thanks for jumping on the comment bandwagon. I really feel like the added contributions of the readers make these posts immeasurably better.

    I agree that we do chronically hyperventilate people. Perhaps one of the reasons I’m not a huge advocate for more effective ventilation. (That may be a cop-out.) But I love…absolutely love, capnography. it should be a standard on all our intubated patients. As a nurse, maybe you could shed some light on this, why don’t the ERs use continuous wave-form analysis? maybe care providers would have less of an excuse for forgetting the capnogram if the hospitals considered it essential.

    I tend to plug in the capnography and tell the airway dude to keep the ETCO2 between X and Y. No more rate counting needed.

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