Cardiopulmonary Resuscitation as an organized act of mercy is now 50 years old, and like most 50 year olds it’s not what it used to be.
The expectation of CPR is that there are a number of persons who get a heart attack, they are not dead, the heart is still beating, it is beating inefficiently in ventricular tachycardia or fibrillation, but with appropriate attention it may be possible to save their lives. This has in fact, as reasonably as possible, been shown to be true. Seattle, a relatively small city on the West Coast, has made a point of educating its citizens in both the physical and attitudinal concepts of CPR, whereas New York City has yet to do so. If you plan to have a heart attack, go live in Seattle where because of this education your chances of survival are 30% compared with less than 2% in NYC.
The underlying issue is a heart that has not stopped, is not dead, that if more adequately perfused with oxygen may live long enough for normal beating to be restored, possibly spontaneously, more probably by electric shock with the automated defibrillator.
Basic Life Support, an overall system in which CPR is one component, used a very convenient ABC mnemonic. Airway, Breathing, Chest Compression were the words. The training was to inspect the mouth to determine whether false teeth or other object were blocking the intake of air, blow air into the lungs by “mouth to mouth,” and then start rhythmic compression of the chest to pump blood actively out and passively into the heart.
A decision was reached in 2010 by the authorities who lay down rules for best procedures, the current American Heart Association Guidelines for CPR have been changed from ABC to CAB – Compression first, then Airway clearance and then Breathing by mouth to mouth.
The change is based on a recognition that 50% of those who might reasonably have been given CPR did not receive it. Bystanders stand by. They did nothing, except worry they might do the wrong thing or in some way become involved only to wish they hadn’t tried it. In particular there is a (literal) distaste for mouth to mouth (ugh! maybe even the same sex! and my picture will be in the papers! And who knows, maybe she’s got AIDS!) and since the mouth to mouth preceded the chest compressions, there were in consequence no chest compressions attempted.
Another change has been to remove from the protocol the testing for a pulse. Competent experienced persons often find this difficult, inexperienced persons are by definition incompetent and shouldn’t waste valuable time trying to decide whether a pulse can be found. If there is no pulse, then CPR is appropriate. If there is a pulse, and the CPR that was given was not necessary, no harm was done.
Judgement has to be used in calling for help. Logically, get another person to call 911. If that isn’t possible, and you can do it immediately on your cell phone, possibly that is best. The alternative of going down the street to look for a phone is not logical.
A hard surface behind the person’s back is better but not essential. Compressions are given at the rate of 100 a minute, the person doing the work should kneel at the subject’s side, one hand over the other, placed on the center of the chest, and with his body weight over his arms. The chest should be depressed a couple of inches – yes! it’s hard work!
If it doesn’t seem like hard work you aren’t doing it right. It is recommended that a ratio of 30 compressions to two mouth to mouth air breaths be instituted in the adult or 15:2 in the child, and so much easier if two persons are doing it. If there is an overwhelming distaste for the mouth to mouth thing, compressions alone are still of value.
Key to any success is the AED. If there is Vtach or Vfib it is unlikely that normal cardiac rhythm will be restored. The function of the CAB is to keep the brain alive until the heart can be shocked with the AED, so another person should be fetching it, which it is to be hoped will be available, and used before the paramedics arrive.
If the paramedics are among the best trained they will intubate the patient (put in an endotracheal tube), bag him (give rhythmic ventilation), continue with compressions until they get him to hospital where more complicate d treatment might be indicated using drugs and other electrical measures following the Advanced Life Support (ACLS) protocol. Even in hospital, the chest compressions are continued until heart beat is restored spontaneously, or by an electrical pacemaker, very similar to the defibrillator, or the patient is declared, the local argot for regretfully deciding life cannot be restored.
Where do you get checked out on CPR?
It isn’t necessary to have a Basic Cardiac Life Support (BCLS) certificate, but it does give confidence. Organizations are strongly encouraged to see their members are competent in CPR and the use of the AED. Your local hospital probably has BCLS course, usually run by the respiratory therapists, enquire there. The firefighters are trained, as are the paramedics, ask them. The Heart and Stroke Foundation, of Canada and the American Heart Association, USA, will help you to find a course and they have a wealth of information on their websites.
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