CPR

[emmbee]

Hi,

Just in case someone's curious...

After a recent CPR refresher, I was wondering, since the latest CPR recommendations from the AHA and the ERC are so emphatic that chest compressions be started ASAP and do not as much as suggest that clothing be removed (except: when wet, in case of hypothermia, specifically to prevent further heat loss), why, when it came to diving, we were supposed to do the opposite.

Yeah, who cares, just do it. I know.

There was a bit of discussion on another forum, but the given justifications were less than satisfactory. For one thing they (mostly) applied just as well to non-diving scenarios where they're obviously wrong. Not what's recommended, anyway. Then the posts got "disappeared" for some reason.

So I asked my AN&DP instructor, FFESSM E4, Swiss CMAS Mon 3, TDI instructor trainer, blah, blah, blah... He then asked rescue hotshots in France (my translation; his words were "Kadors du secourisme") who said the key point was the elasticity of the suit. It makes it impossible to manage the effort of chest compressions. That wouldn't apply to membrane drysuits, but when it comes to drysuits, there's the problem of the inflator getting in the way (d'oh).
A secondary concern is that it allows the use of an AED whenever it turns up and not lose time then (presumably it's quicker to get rid of a T-shirt than of two layers of 7mm, or of a dry suit with underwear).

I'm happy enough with that. At least that doesn't kinda contradict the general recommendations.

Thoughts?

Just in case...

Cheers,

Matthieu

[scuba steve]

hi matthieu .

i am a paramedic and a BLS instructor . the current thinking is that after contact to the emergancy services and are en route compress straight away . dont waste time fannying around trying to get jumpers off . when we get there we just cut them off quickly . so jump straight in if safe to do so

by all means if any clothing is restricting the chest recoil . remove it . but the patient will have a far higher chance of surival with imediate compressions . if there is another person there get them to cut the cloths/suit off while 1 is doin CPR.

also there is a new scheme of cpr tips without the lips ( in case you are un familiar with the patient). which means compression only CPR with continious compressions

doing somthing is alays better than doin nothing

[Stephen McMullan]

I agree with Scuba Steve. I've been trained by BSAC and I'm not an instructor so I've attached our guidelines for you to read for the official club story.

However most of this is common sense Matthieu and what I'd do in practice is as follows:

* Get stuck in quick, hopefully by applying rescue breaths with supplemental 02 and chest compressions they'll come around quick.

* There is no way you will get a diver out of a suit unless its with a shears starting at the neck seal and cutting towards the waist. Chances are you've just dragged them out of the water. Save your time and energy for the CPR - you'll need it.

* I know I can apply chest compressions through any suit and the valve makes no difference. Its actually not a bad reference of where to apply the compressions. We regularly have to ask our trainees to go easy when simulating CPR as they are compressing their "casualties" for real during drills in the heat of the moment.

* Remember the first response of the diver should be kept simple. There will be huge stress and task loading to contend with. We are not EMTs or paramedics nor expected to be. Keep it simple.

[emmbee]

Well, yes, I know, and I agree too.

My problem was, since... what you guys said (thanks, BTW), then why remove the suit, as I was told, instead of just starting compressions right away?

And if someone replies with, for instance, so that you can put your hands in the correct position between the nipples line, that's dubious, because then we'd have to remove, say, a jumper for the same reason, right? But we don't.

Cheers,

Matthieu

Edit: and yes, I know the nipple line stuff is from yonks ago and not current anymore, as well.

[Stephen McMullan]

Again the training I received says not to worry about the "correct position on the chest". Just go straight for the centre of the chest and don't waste time.

Back in the old days you were taught to follow the bottom of the rib cage to the sternum and apply pressure two finger widths above that point. Thankfully thats gone now and the current thinking (according to BSAC) is that is impractical in a diving scenario and wasting time, focussing on unimportant detail.

When you train someone with the advice "just go for the center of the chest and start the compressions" it focusses them on the important stuff and leads to less hesitation. Otherwise they get caught up in detail to the detriment of effectiveness.

[Scubadec / Dec Hanniffy]

I just did the DFR (Diver First Responder) with CFT which also carries PHECC  Pre-Hospital Emergency Care Council accreditation, and found it a great hands on course.
We were told to go for the middle of the chest between the nipples. And that Compressions could be done without Rescue breaths. Anything is better than nothing!

[scuba steve]

when we push on the chest we compress the heart . the suit if a thight fit would restrict the chest raising and thus restrict to heart refilling with blood . i would start compressions/cpr and get someone to cut the suit from the victim .

it IS important to remove / cut the suit off a diver . (also the valve when pressed upon would not be recommended) so cut the suit whilst compressions have been started .

the DFR course that CFT have is the PHECC CFR course with oxygen admin added . as a paramedic when we were taught CPR we were told to " locate the center of the chest ,usually assioated with the inter mamoury /mammary line "
dont get tied down with specifics or nit pick

in short start the compressions center of chest , cut the suit

[Stephen McMullan]

I disagree with cutting the suit or the valve being a problem for various reasons but really thats not important. We can agree to disagree Scuba Steve.

Cut the suit if that is the way you were trained - otherwise don't.

I always advise to stick with the way you were trained and keep up the practice. Consistency is the key and don't worry about how other agencies are doing it differently. I was a PADI rescue diver long before I joined a BSAC club. There were differences in rescue training but I choose my BSAC rescue training procedure not because its better but because for me it was more recent.

On the matter of the new guidelines from EHC 2010. It'll take at least a year for any updates to be incorporated into club training. First each agency has to review the new recommendations, clubs & instructors informed, training materials updated, existing club divers informed or retrained and finally incorporated into the training programs for new divers.

For the purpose of club training, assessments etc just stick with the current brief. Thats what the club has to teach and assess against. It doesn't matter whats coming down the pipeline.

On the practical side of things the club I'm in certainly is happy if the divers informally re-take rescue courses every couple of seasons to keep info and skills fresh. A lot of our divers instruct or assist on rescue tests & drills etc.

[scuba steve]

im not argueing here . but  PHECC / american heart foundation / irish heart foundation courses ( where all diving CPR courses originate)  there is a part about removing /loosening any restrictive clothing . there CPR element of divers training only cover the how to do it  part and not nessarily the Diver related part ie removing the suit etc .

as for the valve it is a hard object that if pressed on repeatly will fracture the sternum . every time iv carrierd out cpr iv broken ribs but to break the sternum wud be a different case as shattered bone could penetrate the lungs or the heart and indeed the pulmonary and micadio sac's .

also you are more likely to have to use CPR on a family member or a passer by on the street than on a dive boat or on a diver . so suit and valve removal is a seconday to the process that you will carry out

as part of my training . we are told to remove all (even as a by stander with out gear) . also we are also told to remove bullet proof vests and the like as it reduces efficency of compressions

to be honest guys . just get stuck in and do somthing .

[Stephen McMullan]

My comments are limited to diving scenarios Steve. I'm sure I'd do something else in a different situation especially if the victim was wearing a bulletproof vest. Running springs to mind 

[emmbee]

I'm perfectly fine with cutting up stuff, just happier if I can make sense of it.

As for the inter nipple line, yeah, this kind of stuff changes every so often.

For instance:

AHA Nov 2005, part 4 http://circ.ahajournals.org/cgi/reprint/112/24_suppl/IV-19:

The rescuer should compress the lower half of the victim’s sternum in the center (middle) of the chest, between the nipples.The rescuer should place the heel of the hand on the sternum in the center (middle) of the chest between the nipples and then place the heel of the second hand on top of the first so that the hands are overlapped and parallel.

The bleeding edge is a bit different; AHA Nov 2010, part 5 http://circ.ahajournals.org/cgi/reprint/122/18_suppl_3/S685:

The rescuer should place the heel of one hand on the center (middle) of the victim’s chest (which is the lower half of the sternum) and the heel of the other hand on top of the first so that the hands are overlapped and parallel.

I guess for one thing there's a continuing drive to simplify the process, and for another there's this paper (reference 68 in part 5 linked above) which suggests that the inter-nipple line may not be optimal in any case...

It just takes a bit of time to diffuse out.

Cheers,

Matthieu

[Neil McLeod]

These are just my thoughts on this matter.

The CPR guidelines we are taught as divers are extrapolated from the European and British Resuscitation Guidelines. These in turn get updated fairly regularly based on reviews of reported outcomes and studies. These guidelines are designed to give the greatest probability of survival in the largest number of cases. They mostly focus on a collapse in adults with a primary cardiac problem (not children). These guys collapse with a primary cardiac arrest and then stop breathing because they have stopped perfusing their brains. They have lungs with enough O2 in them to keep them alive initially. Hence the change in recommendations acouple of years ago to go for compressions first. In a true primary cardiac arrest you are very unlikely to get them back without a defibrillator and so CPR is just buying time. In the latest recommendations it was noted that many people delayed starting compressions while doing other things, that they didn't keep the compressions going or there were delays in restarting them. No compressions equals no delivery of O2 to the brain and heart. Each time they stop the mean pressures generated fall and take several compressions to build up again. Poorer outcomes resulted. The other change was to increase the rate of compressions.
For the guy in the street or on a boat these apply, no argument. A diver in the water could either have had a primary cardiac arrest as above. Or a primary respiratory arrest (drowning, laryngospasm (hypoxia if they get the mix wrong), etc. Compressions where the cardiac arrest is as a result of hypoxia will not circulate much oxygen plus if you are in the water compressions don't work so rescue breaths at this point will do little harm. Get them out of the water Get the compressions going and give O2. Get help and a defib.

The clothing issue depends on the type of clothing if restrictive cut them. If not in the way leave them and just keep going with CPR. Make this decision once you have started the CPR. It never hurts to ensure that their neck isn't compressed, so always worth cutting a neck seal (pressure on your neck can cause slowing of heart rate even cause arrest, this is made worse when hypoxic).

In short don't delay CPR, don't pause for longer than necessary. Start with compressions when you can. Clothing is a secondary issue.

Neil

[Peter McCamley]

Well Neil
Very intresting post. Fair play to you, well written and very factual. Would prefer this anyday over tyre choices (Not thats there's anything wrong with tyres, I love them......... have acturally got 4 on my motor.)
Regards
Peter

[scuba steve]

My comments are limited to diving scenarios Steve. I'm sure I'd do something else in a different situation especially if the victim was wearing a bulletproof vest. Running springs to mind 

when we get there the offender has usually legged it and every Garda in the whole of ireland arrives when they hear of a shooting so little or no danger to us .

my comment was aimed at removing restrictive clothing andindeed as metioned later removing/cutting thight neck seals . so if you hav started cutting just go the extra few inches ( make my life easier when i get there . 

and for all the other lads out there following this thread . if you do ever have the misfortune to be involved in this just try and do somthing . as somthing is better than nothing . the rest Honestly is all prodantics

get stuck in

[pat coughlan]

Here is a useful CPR instructional video on how to perform CPR

Pat

Super Sexy CPR