What is the current thinking about proper CPR procedure?

Glenn MacGrady

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An interesting tangent about CPR came up in a recent paddling technique thread. Especially important for a canoe site, I thought, is that there seem to be different recommended procedures for drowning CPR vs. non-drowning cardiac event CPR.

I'd like to ask yellowcanoe, a retired paramedic; pblanc, a retired doctor; and yknpdlr, a NYS licensed guide and SAR team member, to repeat their information, as well as anyone else to share their knowledge or experience with CPR.
 
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Succintly, in drowning the heart stops because it is deprived of oxygen. So rescue breathing is essential and may actually help restart the heart. Likely done in a timely fashion the heart is ready to go when provided with fuel ( oxygen)

Non drowning; it is likely there was a heart attack ( loss of blood supply to the coronary arteries due to a block in one or more of them). the only definitive cure is in a hospital (most likely a cath lab) In this case you do CPR just to keep whatever blood is oxygenated circulating while the heart itself is on strike. This can't sustain life forever. ACLS providers have to be there within 8 minutes with cardiac drugs.
Things can get messier.. You can have a heart attack and have a rhythm called ventricular fibrillation. Multiple sites in the heart are trying to run things. The defibrillator can shock the heart and stop all the electrical activity and hopefully the one true captain ( the Sino Atrial Node) takes over. Again ACLS providers are needed in case the rhythm remains none or without a pulse

Now the scenario can overlap. A person can have a heart attack and drown at the same time. We had such an instance on a group trip some 12 years ago on the St George River here in Maine.

Don't try to figure out what happened. Time is of the essence. Call for help right away. Do what you can to supply oxygen and supply that external heartbeat.

And the final word: the are not dead until they are warm and dead. Remember that in cold water.
 
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I would encourage anyone to take a BLS and first aid course. Pediatric specific as well if you are around kids as the methodology/techniques are slightly different. AHA and the Red Cross offer these. Many ACS affiliated institutions offer hemorrhage control for lay people.
 
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I had to take First Aid regularly as part of work, and CPR changed so often, I couldn't keep up. In a WFA course, I was told that when dealing with extreme hypothermia, the only thing that should be done is rescue breathing, because compressions could kill the person. What are the thoughts on that?
 
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I am not a medical provessional, but the reason, as I was told, is the same reason as taking care in not rewarming the body core of a hypthermia victim too quickly, If the chilled blood residing in the limbs is circulated with compressions before it is sufficiently warmed, then when it reaches the heart it can cause heart or other organ failure.

As I am told by professionals, the frequent changes to CPR guidance are the result of constant study of successful sufvival cases and reactions by care givers and with what works in the majoriity of situations that marginally trained care providers can effect. The recent compresssions only advice is the result of understandable hesitancy by lay persons, who do not have the training or PPE equipment to provide safe (to themselves) rescue breathing to random strangers in medical need. It has been found that compressions only to circulate the oxygenated blood already persent within in the body may delay death long enough until advanced EMS arrives. Obvioiusly not effective or productive in a remote WFA situation.
 
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I had to take First Aid regularly as part of work, and CPR changed so often, I couldn't keep up. In a WFA course, I was told that when dealing with extreme hypothermia, the only thing that should be done is rescue breathing, because compressions could kill the person. What are the thoughts on that?
Anyone who suffers cardiopulmonary arrest from extreme hypothermia has a nearly zero chance of survival whether CPR is done or not. The success rate of CPR in profound hypothermia is exceedingly low. I doubt that there is enough real world survival data to support a position for or against chest compressions in that setting.

In a profoundly hypothermic person in a field setting without electrical monitoring equipment, a peripheral pulse may be very difficult to perceive.
 
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I am not a medical provessional, but the reason, as I was told, is the same reason as taking care in not rewarming the body core of a hypthermia victim too quickly, If the chilled blood residing in the limbs is circulated with compressions before it is sufficiently warmed, then when it reaches the heart it can cause heart or other organ failure.

As I am told by professionals, the frequent changes to CPR guidance are the result of constant study of successful sufvival cases and reactions by care givers and with what works in the majoriity of situations that marginally trained care providers can effect. The recent compresssions only advice is the result of understandable hesitancy by lay persons, who do not have the training or PPE equipment to provide safe (to themselves) rescue breathing to random strangers in medical need. It has been found that compressions only to circulate the oxygenated blood already persent within in the body may delay death long enough until advanced EMS arrives. Obvioiusly not effective or productive in a remote WFA situation.
The recommendation for no rescue breathing CPR is not only because of reluctance of bystanders to perform mouth to mouth resuscitation but also for a couple of other reasons.

First, in our modern mobile phone world it is increasingly common for bystanders to receive coaching remotely from a medical dispatcher by phone in instances of out of hospital cardiac arrest (OHCA). It is very difficult for individuals who have never received any on-hands education in rescue breathing to be able to assess airway patency and perform mouth to mouth breathing even minimally effectively.

Even those who have received hands-on instruction who have not actually performed rescue breathing in a real world situation would sometimes waste a lot of time trying to assess the airway and deliver even a few rescue breaths before initiating chest compressions.

While it is true that in most cases of OHCA, the vast majority of which are cardiac in origin, assuming that chest compressions can be initiated promptly the blood remains adequately oxygenated for some minutes and circulating that blood with chest compressions is beneficial. That is not the case in a drowning victim who has sustained cardiac arrest as a result of asphyxiation. In most of those instances the drowning victim had a healthy heart that was circulating blood up to the time that the blood oxygenation level dropped to the point that unconsciousness ensued followed by cessation of cardiac activity. In those instances the blood is desaturated to the point that circulating it with chest compressions without rescue breathing is basically pointless.

The success rate of any type of CPR for OHCA has improved slightly over the years but remains lower than many in the general public appreciate. One has to be careful in defining what constitutes "success". Many victims who receive CPR and have return of spontaneous circulation (ROSC) (which many would consider success) do not survive to hospital discharge, and some do not even survive to hospital admission. In one large world-wide meta-analysis looking at the survival of individuals receiving bystander CPR the survival rate in North America to hospital discharge was only 7.7%. Overall world-wide survival to discharge did improve from the period 1976-1979 to the period 2010-2019 but only very modestly, from 8.6% to 9.9%.

One thing that has been significant in increasing survival of individuals receiving bystander CPR is the wider availability of automated external defibrillators (AEDs). Many witnessed OHCAs are the result of a malignant, non-perfusing cardiac dysrhthymias. These individuals will generally not see a return to a perfusing cardiac rhythm unless defibrillated. Prompt defibrillation greatly enhances the chance of survival. It may well be that the modest improvement in survival of OHCA victims who have received bystander CPR over the preceding decade is due to the wider availability of AEDs alone.

As for the issue of chest-compression-only CPR versus conventional CPR, a meta-analysis appeared some years ago in the Lancet that analyzed three studies of dispatcher-assisted CPR in which the technique was randomized to one or the other method. The outcome was survival to hospital discharge. When these three studies were pooled in the meta-analysis the chest-compression-only technique showed a very modest survival benefit of 14% versus 12%, but when looks at the 95% confidence interval for the risk ratio between these groups (1.01-1.46) one sees that the difference barely achieved statistical significance. In the same paper the authors did a meta-analysis of seven other observational, non-randomized studies comparing the two techniques. In that meta-analysis no difference in survival to hospital discharge was observed between the two cohort groups, 8% versus 8%.


There may be more recent data demonstrating evidence for a greater benefit for chest-compression-only bystander CPR for OHCA that I am not aware of.
 
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I had always heard that the success rate of survival and full recovery after receiving CPR is lower than one would expect.

So from Pblanc's post above, it appears that as a licensed guide, specializing in wilderness canoe travel and BSA waterfront activity, that the requirement that I maintain an active certification in CPR is nearly pointless.
 
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I had always heard that the success rate of survival and full recovery after receiving CPR is lower than one would expect.

So from Pblanc's post above, it appears that as a licensed guide, specializing in wilderness canoe travel and BSA waterfront activity, that the requirement that I maintain an active certification in CPR is nearly pointless.
nope. Kids do better. We had kids immersed in a van for 45 minutes in freezing water. The van had gone through the ice.
The kids survived because they got pertioneal rewarming quickly.

The real point is that you learn some skills and practice them ; skills are very relevant to working with clients. As in how to handle a drowning victim whose heart has been starved for oxygen. You will be able to help the client that ate too big a piece of your great steak.
No you won't be able to save a client in the wilderness who did not know they had a 100 percent coronary artery blockage.

But you tried to the best of your ability. You would not feel well about doing nothing.

Nothing in life is perfect.
 
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But you tried to the best of your ability. You would not feel well about doing nothing.
And I think that is the point. Without checking all the boxes, and increasing expectations of reliance on high technology in tjhe field vs traditional methods (navigation and direct communication means, for example), law sjuits are alway a great risk.
 
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I had always heard that the success rate of survival and full recovery after receiving CPR is lower than one would expect.

So from Pblanc's post above, it appears that as a licensed guide, specializing in wilderness canoe travel and BSA waterfront activity, that the requirement that I maintain an active certification in CPR is nearly pointless.
I would never say that CPR is pointless or not to try it, but I think one has to have realistic expectations regarding likely outcomes. I have had patients brought into emergency departments basically dead on arrival accompanied by bystanders who had attempted CPR and were distraught because they thought they had done something wrong, or demanding an answer as to why CPR did not work.

A variety of observational studies have looked at survival to discharge for CPR done in a hospital setting where presumably resuscitative drugs, defibrillators, intubation equipment, and perhaps advanced cardiac life support measures are immediately at hand. Those studies have shown a wide range of survival rates but survival to discharge has generally been only 15-35%. I have been present at quite a few cardiopulmonary arrests in hospitals where CPR was done. I can recall only a very few individuals who survived to leave the hospital.

I have seen salt water drowning victims successfully resuscitated with conventional CPR. These individuals were relatively healthy prior to the event. The results of CPR for freshwater drowning victims has been pretty poor, IME, but certainly worth trying. For OHCA of a cardiogenic nature the success of CPR is going to be lower but AEDs are increasingly being taken by outfitters on guided wilderness expeditions and can make all the difference in an arrest resulting from a malignant dysrhythmia.

If one witnesses a OHCA in normal civilian setting, the first thing to do should always be to phone 911 if you have a phone. If not, if another person is available send them to get help or access to a phone. The second thing I would do is ascertain whether or not an AED is locally available. They are increasingly available at schools, auditoriums, public recreational venues and the like.
 
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An interesting tangent about CPR came up in a recent paddling technique thread. Especially important for a canoe site, I thought, is that there seem to be different recommended procedures for drowning CPR vs. non-drowning cardiac event CPR.

I'd like to ask yellowcanoe, a retired paramedic; pblanc, a retired doctor; and yknpdlr, a NYS licensed guide and SAR team member, to repeat their information, as well as anyone else to share their knowledge or experience with CPR.
For the last 15 years or so I guided kayak tours and maintained certifications in First Aid and CPR. Overtime, CPR instruction moved to compression only training. However, all those years of compressing those plastic torso dummies paid off when I found myself outside a hotel performing compressions on a man laying on the street. After about 200 compressions, he started gargling, first once and then again and his heart resumed pumping and all the color came back to his face. I could hear the sirens of EMT coming as I was doing compressions. I‘ve always wondered if that guy survived and what his outcome was.
 
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I've reported on this tragic event here recently, but I think it may bear repeating in light of this current discussion. A dear freind of mine for the past 32 years, a fellow wilderness guide and instuctor of BSA adult wilderness trek leaders, passed suddenly without warning. We frequently visited and camped together in the wilderness in all seasons, as well as in annual preparation for the upcoming 8+ days as instructors of BSA wilderness trek leader training. So anyway, He suffered from increasing arthritis, making it difficult to get in and out of his canoe and to hike long distances. Otherwise no known major illness that he spoke of. He even had his first EKG just six weeks prior as we discussed his procedure. Nothing of note showed up in the results.

He and his wife were on an easy uphill trail near their home when he sat down in the grass, unable to go further, not even to a nearby bench a few yards away. He then laid down as his wife immediately called 911. She had been trained in CPR many years ago as the 911 dispatcher guided her through chest compressions. EMS, based about a mile away arrived within minutes, shocked him with a defib to no avail. No autopsy was performed, so we shall never know the real cause.

He and I were due to go together on another training outing just next week. I simply cannot imagine how I would have handled it if the same happened to him with me deep on the wilderness trail together, or when in a canoe.
 
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but AEDs are increasingly being taken by outfitters on guided wilderness expeditions

I was going to ask about this. We have AEDs at work and the field crews have them in the trucks. Our drill sites have been over an hour drive down a dirt road past a locked gate; we are our own first responders out there.
 
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