Notes From Patrol Director and Other Patrol Members
- Sep 9th, 2008
To:
All OEC Instructors, OEC Instructor Trainers & OEC Supervisors
From: Larry
Bost, Education Committee Chair
There have been some major changes in CPR
this year and as always some major confusion. The chart below provides
an “at-a-glance” look at the current CPR guidelines for healthcare providers
(as presented by the American Heart Association) as well as the NSP policy
regarding NSP-approved CPR providers. I asked NSP medical advisor Michael
Millin, MD and OEC program director, Ed McNamara to look at these changes
and to prepare a informational report on how these changes will affect
Patrollers. Dr. Millin's response is below. I would like to
thank Dr. Millin and Ed McNamara for their quick response to this question.
Dr. Millin’s Analysis
This is actually an interesting
question that is filled with controversy and quite a bit of active research.
The short answer to your question
is that the current recommendation is that CPR preformed by a trained healthcare
provider (including OEC technicians) should include both chest compressions
and rescue breaths in a ratio of 30 compressions to 2 breaths. The long
answer is a bit more complex, so please bear with me. For many years it
has been believed that the keys to survival from sudden cardiac arrest
are chest compressions and defibrillation. The primary initial rhythm in
sudden cardiac arrest is typically ventricular fibrillation, which is best
treated with electrical defibrillation. The purpose of chest compressions
is to circulate blood to the cardiac muscle.
Despite years of community programs
to get bystanders to perform chest compressions, there are still low percentages
of sudden cardiac arrest patients that get bystander CPR. It is believed
that one reason for low bystander CPR is fear of doing mouth-to-mouth rescue
breathing. Therefore, researchers have examined the question of survivability
if CPR is performed by the lay public with only chest compressions. These
studies have clearly shown that when performed by the lay public compression
only CPR is just as effective as standard CPR with compressions and rescue
breathing. It is this research that has evolved to the most recent recommendation
by the American Heart Association (AHA). It is important to understand
that the above mentioned research has all been examining CPR in the hands
of the lay public. At this point in time, the medical literature is not
able to answer the question of standard CPR vs. compression only CPR when
performed by a skilled healthcare worker. This is why the recommendation
for trained healthcare providers is to continue with standard CPR.
If you are ever truly faced with
doing CPR in your capacity as an OEC technician you will notice that CPR
is hard work. You will break ribs on your patient, and after 2 minutes
of pushing hard, pushing fast you will be exhausted. While I have seen
the value of chest compressions in my own clinical practice, this is supported
in the literature as well. The most notable recent study was published
by Wik, et al. that demonstrated for those patients with a down time greater
than 5 minutes, chest compressions before defibrillation were more successful
that just defibrillation. The bottom line is that the current literature
supports compression only CPR when performed by the lay public and standard
CPR when performed by a skilled healthcare worker. When performing CPR,
Push hard and push fast for 30 compressions then perform 2 rescue breaths.
Do five cycles and then using an AED, defibrillate if indicated. After
defibrillation immediately Push hard, push fast. Do not check for a pulse.
Frequently rotate the rescuer doing the chest compressions to minimize
fatigue and degradation of the quality of the compressions. Finally, the
coordination of doing CPR and getting the patient out of the environment
can be quite complex. Exactly how you do this is up to your area. You should
look to your local medical advisors, patrol leadership, and area management
for direction. The fact is that you may have to stop chest compressions
in order to get the patient off the side of a mountain. This is not ideal,
but it is reality. If you do have to stop chest compressions, your area
should develop a protocol that utilizes resources to as much as possible
minimize the time that the patient is without CPR. The reason that this
should be an issue of local direction is that the best way to minimize
time without CPR will be dependent on the local resources and the topography
of the area. I will say that at my local hill we have developed a protocol
whereby two patrollers take the patient down in a toboggan. Other patrollers
are then strategically placed at about 30 second intervals to perform CPR
along the route to the base of the mountain.
While we have not had an actual
case yet with this new protocol, we have practiced it many times and it
seems to work well. Regardless, every area is different so every area should
develop a system before the event that works for the local area. The key
is to have a protocol in place that works before the actual event. In addition,
I can’t stress enough that regardless of the details of your area’s protocol,
it should not put OEC technicians at harm. Your plan should not put OEC
technicians (or the public for that matter) at harm for the purpose of
trying to save the life of a dead person that has a low chance of survival.
Just so that we are clear one more time: 30 compressions with 2 breaths
– Push Hard, Push Fast.
- Michael G Millin, MD, MPH, FACEP
NSP National Medical Advisor
Current CPR Guidelines (for healthcare
providers)
Maneuver
Adult: 8 years
and older
Child: 1 to
8
years
Infant:
Under 1 year
Activate
Activate / call
for AED when victim
found unresponsive
If asphyxial arrest
likely,
call after 5 cycles
(2 minutes) of CPR
Activate after
performing 5 cycles of CPR
For sudden, witnessed collapse,
activate after verifying that
victim unresponsive
Airway
Head tilt-chin lift (suspected
trauma; use jaw thrust)
Breaths
Breath check < 10 secs)
2 breaths at 1 second/breath
2 effective breaths at 1 second/breath
Rescue breathing
without chest compressions
10-12 breaths/min
(approximately 1 breath every 5-6 seconds)
12-20 breaths/min
(approximately 1 breath every 3-5 seconds)
Rescue breaths for CPR
with advanced airway
8-10 breaths/min (approximately
1 breath every 6-8 seconds)
Foreign-body airway
obstruction
Abdominal thrusts
Back slaps and chest thrusts
Circulation
Pulse check (< 10 secs)
Carotid
(can use femoral in child)
Brachial or femoral
Compression landmarks
Center of chest, between nipples
Just below nipple line
Compression method:
Push hard and fast
Allow complete recoil
2 Hands: Heel of 1 hand, other
hand on top
2 Hands: Heel of 1 hand, with
second on top, or,
1 Hand: Heel of 1hand only
1 rescuer: 2 fingers
2 rescuers: 2 thumb-encircling hands
Compression depth
1 ½ - 2 inches
About 1/3 – ½ the
Depth of the chest
Compression rate
About 100/min.
Compression-
ventilation ratio
30:2
30:2 (single rescuer)
15:2 2 rescuers
NSP-Approved CPR Providers
14.3.4.1 All active
NSP members must demonstrate their CPR skills each season, regardless
of the certifying agency’s requirements or the expiration date of the
card. (All active NSP members must hold a current professional-rescuer
CPR certification from the American Heart Association, the American Red
Cross, the National Safety Council, or American Safety and Health Institute,
or Medic First Aid. This training must include breathing and cardiac emergencies,
and adult, infant, child, and two-rescuer CPR techniques.)
- 2007-2008 Polices & Procedures
