CPR: Compression/Breath Ratio. F'd up ****.

[Ramathorn]

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So, I was talking to this Emergency Medicine doctor the other day about CPR.

He said that research has shown that it's actually better if you do a compression/breath ratio of like 50:1, rather than 15:2 that they teach you in cpr programs. He said they teach 15:2 cause some people would get exhausted much sooner doing 50:1.

Thoughts.... ?

 

[doctawife]

The AHA addressed this to some extent in the new recommendations for CPR/ALS/PALS. Basically, who gives a crap if the blood is well oxygenated if it's not moving? So they recommended more compressions and fewer breaths.

 

[VA Hopeful Dr]

So, I was talking to this Emergency Medicine doctor the other day about CPR.

He said that research has shown that it's actually better if you do a compression/breath ratio of like 50:1, rather than 15:2 that they teach you in cpr programs. He said they teach 15:2 cause some people would get exhausted much sooner doing 50:1.

Thoughts.... ?

BLS (at least the version they teach us as M1s) just changed their recommendations this year to a 30-1 ratio.

 

[BADMD]

In study by Kellum in 2006 (1), they had significant improvements in neurologic outcome in witnessed, out of hospital cardiac arrest in patients with an initially shockable rhythm, against historical controls, if EMS performed only chest compressions at a rate ~100. This has started a campaign entitled "Call and Pump" (http://www.callandpump.org). In "Call and Pump" they advocate switching rescuers every minute to prevent fatigue.

Previous reseach has really only identified coronary perfusion pressure as the factor that influences ROSC (2). Below a certain threshold, about 15 mmHg, patients just don't get ROSC.

The problem is that ventilations increase intratoracic pressure thus lowering CPP. Over ventilation has been shown, at least in animals to lower the rate of ROSC. In addition, CPP builds as compressions go on and falls the moment compressions stop. It can take 1.5 - 2 minutes to actually get a decent CPP. Thus pausing for a breath is bad in it interrupts the build up and allows CPP to start to fall (sorry, but I don't have that reference as handy as the others).

As much as it is counter-intuitive, no one has actually shown that oxygenation improves ROSC (although I'm sure it is a factor, somewhere in there).


1 - http://www.ncbi.nlm.nih.gov/entrez/...uids=16564776&query_hl=15&itool=pubmed_docsum
2 - http://www.ncbi.nlm.nih.gov/entrez/..._uids=2386557&query_hl=10&itool=pubmed_DocSum

 

[MirrorTodd]

BLS (at least the version they teach us as M1s) just changed their recommendations this year to a 30-1 ratio.

They teach us that same stuff in the military.

 

[SolidGold]

In a nutshell, 15-2 is the old ratio. The 2005 updated ratio is 30:2 (hard and fast at 100/min). The updated ACLS emphasizes more chest compressions.

 

[deleted109597]

Push hard, push fast. Don't bother with the breathing unless you've got two people. That's what I've been hearing. The AHA 30-1 is pretty good.

The main problem with CPR is that when people see it on TV, they think they should go that fast (HR=35 or so). I've actually had techs tell me I am pushing too fast, at which point I just stare at them. Seriously, get to 100bpm or don't bother.

 

[doctawife]

In study by Kellum in 2006 (1), they had significant improvements in neurologic outcome in witnessed, out of hospital cardiac arrest in patients with an initially shockable rhythm, against historical controls, if EMS performed only chest compressions at a rate ~100. This has started a campaign entitled "Call and Pump" (http://www.callandpump.org). In "Call and Pump" they advocate switching rescuers every minute to prevent fatigue.

Previous reseach has really only identified coronary perfusion pressure as the factor that influences ROSC (2). Below a certain threshold, about 15 mmHg, patients just don't get ROSC.

The problem is that ventilations increase intratoracic pressure thus lowering CPP. Over ventilation has been shown, at least in animals to lower the rate of ROSC. In addition, CPP builds as compressions go on and falls the moment compressions stop. It can take 1.5 - 2 minutes to actually get a decent CPP. Thus pausing for a breath is bad in it interrupts the build up and allows CPP to start to fall (sorry, but I don't have that reference as handy as the others).

As much as it is counter-intuitive, no one has actually shown that oxygenation improves ROSC (although I'm sure it is a factor, somewhere in there).


1 - http://www.ncbi.nlm.nih.gov/entrez/...uids=16564776&query_hl=15&itool=pubmed_docsum
2 - http://www.ncbi.nlm.nih.gov/entrez/..._uids=2386557&query_hl=10&itool=pubmed_DocSum

See? That's the well-referenced version of what I said! Sheesh!

 

[DropkickMurphy]

Push hard, push fast. Don't bother with the breathing unless you've got two people. That's what I've been hearing. The AHA 30-1 is pretty good.

The main problem with CPR is that when people see it on TV, they think they should go that fast (HR=35 or so). I've actually had techs tell me I am pushing too fast, at which point I just stare at them. Seriously, get to 100bpm or don't bother.

There was actually a competition with a group of we EMT's and medics to see who could achieve the fastest documented "rate" of chest compression (based off of the sine wave produced on the EKG). The EMT who won had a rate of over 130 bpm. The rhythm strip looked like VT. I have no idea how he sustained that for more than a few seconds.

 

[EctopicFetus]

Sarver Heart method involves no breathing at all.

 

[MirrorTodd]

There was actually a competition with a group of we EMT's and medics to see who could achieve the fastest documented "rate" of chest compression (based off of the sine wave produced on the EKG). The EMT who won had a rate of over 130 bpm. The rhythm strip looked like VT. I have no idea how he sustained that for more than a few seconds.

Wait, wait, wait. This was done on a training dummy yes?

 

[The White Coat Investor]

Sarver Heart method involves no breathing at all.

For the first 5 minutes...that is true. The moment your heart stops both your blood and your lungs are full of oxygen, you just need to circulate it.

 

[DropkickMurphy]

Wait, wait, wait. This was done on a training dummy yes?

No this was on an actual patient. We discovered our CPR guidelines for our EMS operation had the admonition "Compression rate >100" and we started pulling strips off of the defibs to check our rates to see how was doing compressions the fastest. Dan won......I was also on the case and can verify he was pumping hard enough to give he patient a easily detectable radial pulse. Interestingly enough the patient had ROSC in the field but died later in the ICU 🙁

 

[LanceArmstrong]

There was actually a competition with a group of we EMT's and medics to see who could achieve the fastest documented "rate" of chest compression (based off of the sine wave produced on the EKG). The EMT who won had a rate of over 130 bpm. The rhythm strip looked like VT. I have no idea how he sustained that for more than a few seconds.

He must've had a lot of practice - on his wife and/or girlfriend - usually I can get to about 115-120 bpm 😎

 

[DropkickMurphy]

He must've had a lot of practice - on his wife and/or girlfriend - usually I can get to about 115-120 bpm 😎

Of course the EMT in question is in exceptionally good physical condition so I think that had something to do with it.....I personally can't get above 120 either and even then I can only pound a chest that fast for a minute or so before I start getting tired.

 

[DropkickMurphy]

Of course the EMT in question is in exceptionally good physical condition so I think that had something to do with it.....I personally can't get above 120 either and even then I can only pound a chest that fast for a minute or so before I start getting tired.

OK....I'm heading to bed....I'm tired. G'night folks.

 

[SouthSideSteve]

chest compressions on someone with an a-line are fun too. Winner is the person who gets the highest SBP.

 

[southerndoc]

chest compressions on someone with an a-line are fun too. Winner is the person who gets the highest SBP.

The best I've seen was a systolic of 130 with chest compressions. Most of the time it's a systolic of 90-100 max.

 

[SouthSideSteve]

I have personally done 130s on a rather large woman. She had a lot of mass up top so I gave her hell and then momentum took over.

Regarding 100+ bpm. One of our CT surgeons was running a code one time and he told the person to slow their compressions his ratioanle being to allow more time for the heart to fill thus increasing CO. Said person was a tad over zealous to begin with and ended up around 85-95 bpm. I know what ACLS says, but it does make sense. Thoughts?

 

[MirrorTodd]

No this was on an actual patient. We discovered our CPR guidelines for our EMS operation had the admonition "Compression rate >100" and we started pulling strips off of the defibs to check our rates to see how was doing compressions the fastest. Dan won......I was also on the case and can verify he was pumping hard enough to give he patient a easily detectable radial pulse. Interestingly enough the patient had ROSC in the field but died later in the ICU 🙁

See that's something we don't get enough practice in with the military-live patients.

 

[southerndoc]

I have personally done 130s on a rather large woman. She had a lot of mass up top so I gave her hell and then momentum took over.

Regarding 100+ bpm. One of our CT surgeons was running a code one time and he told the person to slow their compressions his ratioanle being to allow more time for the heart to fill thus increasing CO. Said person was a tad over zealous to begin with and ended up around 85-95 bpm. I know what ACLS says, but it does make sense. Thoughts?

The heart has no intrinsic contraction (usually, exception PEA), so it doesn't have much resistance to diastolic filling. Unless you're getting rates approaching 150-160, you have adequate filling time. However, it is absolutely necessary to allow for full recoil of the chest.

Remember, cardiac output is equal to the stroke volume multiplied by the heart rate. To get adequate perfusion pressures, you need to have a decent heart rate. Great compressions at a rate of >100 bpm has been shown to offer better perfusion pressures.

Push hard, push fast.

 

[Wackie]

Push hard, push fast. Don't bother with the breathing unless you've got two people. That's what I've been hearing. The AHA 30-1 is pretty good.

The main problem with CPR is that when people see it on TV, they think they should go that fast (HR=35 or so). I've actually had techs tell me I am pushing too fast, at which point I just stare at them. Seriously, get to 100bpm or don't bother.

"Push hard or go home!"

CPR on TV bothers me. Especially seeing the weak slow compressions and the bagger squeezing the bag as quickly as possible as if they're pumping up a raft.

I hope they go to compressions and no breathing. It's safer for the person on scene.
Would the compressions get some air moving in the lungs from compressing them some?

 

[DrMom]

In a nutshell, 15-2 is the old ratio. The 2005 updated ratio is 30:2 (hard and fast at 100/min). The updated ACLS emphasizes more chest compressions.

I've had a couple of nurses/techs lately who were doing slow compressions. Had to kick both of them off cause they refused to speed up. 🙄

Regarding 100+ bpm. One of our CT surgeons was running a code one time and he told the person to slow their compressions his ratioanle being to allow more time for the heart to fill thus increasing CO.

One of our senior residents had a similar conversation with an IM attending who had a cow over fast compressions. The resident eventually told the IM guy that he needed to review the new guidelines.

 

[leviathan]

"Push hard or go home!"

CPR on TV bothers me. Especially seeing the weak slow compressions and the bagger squeezing the bag as quickly as possible as if they're pumping up a raft.

I hope they go to compressions and no breathing. It's safer for the person on scene.
Would the compressions get some air moving in the lungs from compressing them some?

Arhghghg.. I hate that on TV, too. I think they have it backwards, bagging at 100/min and compressing at 12/min. Only once on "ER" do I remember someone (I think it was Dr. Greene) telling a resident to quit bagging so fast because they were making the patient alkalotic.

 

[deleted109597]

I also like how they bag without making a seal. As if the ambu will hold under its own weight.

 

[SouthSideSteve]

I also like how they bag without making a seal. As if the ambu will hold under its own weight.

I have responded to codes and witnessed floor nurses bagging an apneic pt. exactly like this.

 

[Jeff698]

I have responded to codes and witnessed floor nurses bagging an apneic pt. exactly like this.

Back in my paramedic days, I responded to a code where first responders where 'bagging' a patient who was apneic. Turns out, they were squeezing the reservoir bag on a NRB mask. And, to stay on topic here, they were doing it really fast.

Do you have any idea how hard being professional at times like that can be?

Talk about your 'teachable moments'.

Take care,
Jeff

 

[leviathan]

Back in my paramedic days, I responded to a code where first responders where 'bagging' a patient who was apneic. Turns out, they were squeezing the reservoir bag on a NRB mask. And, to stay on topic here, they were doing it really fast.

Do you have any idea how hard being professional at times like that can be?

Talk about your 'teachable moments'.

Take care,
Jeff

I almost don't believe you.

 

[DropkickMurphy]

I almost don't believe you.

If I hadn't seen nursing home RN's doing the exact same thing, I would have trouble believing it too.

 

[leviathan]

I don't feel as bad then when I saw somebody trying to bag a person who was breathing effectively at 16/min.

 

[SouthSideSteve]

Thats still better than someone doing compressions on someone with a perfusing rhythm and that is talking. I think people just get excited and their brains goto ****, sometimes.

 

[leviathan]

Thats still better than someone doing compressions on someone with a perfusing rhythm and that is talking. I think people just get excited and their brains goto ****, sometimes.

The most common idiotic thing someone does in scenarios during EMT classes:
"Your patient [talking to them] does not have radial pulses."
"OK. I'm starting CPR!"

 

[The White Coat Investor]

Thats still better than someone doing compressions on someone with a perfusing rhythm and that is talking. I think people just get excited and their brains goto ****, sometimes.

I'd rather see this 10X than what I saw one day when a patient coded in front of me in the airport, 50 people standing around staring at him dying.