A lot of people are praising the AHA (American Heart Association) for their Pit Crew approach to CPR.
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Would praise be appropriate, if this were the AHA approach to monsters in the closet?
When dealing with little children, one of the things we need to do is create a show to ease some irrational fears. This becomes a problem when we do the same thing with adults. The AHA does not appear to have any such problems with entertaining our childish fears about not providing ventilations.
What if we do not provide ventilations during the first 10 minutes, or 20 minutes, of CPR?
There is no evidence of worse outcome when adult patients with cardiac arrest of cardiac origin are treated with continuous compressions, rather than conventional CPR. Conventional CPR is chest compressions interrupted for whatever ratio of ventilations satisfies the urge to provide at least some ventilations.
What about slipping an extraglottic airway in without interrupting ventilations?
The problem is still the same – no evidence of benefit.
There are problems with ventilations.
Interrupting compressions is very bad – unless the interruption is to provide defibrillation.
Excessive ventilation is unnecessary and can cause gastric inflation and its resultant complications, such as regurgitation and aspiration (Class III, LOE B150–152). More important, excessive ventilation can be harmful because it increases intrathoracic pressure, decreases venous return to the heart, and diminishes cardiac output and survival.152 In summary, rescuers should avoid excessive ventilation (too many breaths or too large a volume) during CPR (Class III, LOE B).[1]
Zero ventilations = just right.
Any ventilations = excessive ventilations.
Ventilations can cause gastric inflation
Ventilations can cause . . . regurgitation and aspiration
Ventilation increases intrathoracic pressure
Ventilations decreases venous return to the heart
Ventilation diminishes cardiac output
Ventilation diminishes . . . survival
I agree that all of these are bad and should be avoided.
What we disagree on is the definition of excessive.
All the AHA needs to do is find any evidence that any ventilations improve survival from cardiac arrest of cardiac origin in adults.
As long as there is no evidence that ventilations improve survival, I see no justification for ventilations.
The Pit Crew method is just a way to keep playing Pin the Skill on the Patient.
We need to stop playing games and treat patients appropriately. If we are just providing excellent continuous chest compressions with the occasional defibrillation, we do not need a pit crew.
Or do we have plenty of time to wait for some kind of evidence? The Century is still young.
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Footnotes:
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[1] Rescue Breathing (Box 3A, 4)
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 5: Adult Basic Life Support
Adult BLS Skills
Free Full Text from Circulation with link to PDF Download
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Insane!
Just dumming it down so the general public will be willing to help without having to actually help. Its simple…… CPR without ventilation??? Its trying to live without breathing. No one can live without breathing, duh! Just because everyone has a problem putting their mouth on a stranger, let’s just throw it out. “You don’t “really” ” need ” to breath!”.
It’s training!!! Educate people to save lives not to pretend to do something that is obviously detrimental to the victim, just to make them feel good about themselves by being able to say “I did something”.
What’s next???
“Foot compression only CPR”?
What a great idea, now I can “help” without having to stop texting or putting down my $4 coffee.
JMedik,
Let me dumb it down for you, since you seem to have trouble telling the difference between what you assume and what is real.
There is good evidence for improved survival with Hands Only CPR –
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CPR without ventilation??? Its trying to live without breathing. No one can live without breathing, duh!
Maybe. Maybe not.
Feel free to provide some research that supports what you assume.
There isn’t any evidence that people need ventilations during chest compressions.
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If there were evidence that foot compression CPR provided good outcomes, then it would be worth considering, but I haven’t seen any evidence of that.
Just because you assume that ventilation must go with chest compressions does not mean that you know what you are writing about.
Maybe you should put down your $4 coffee and read some research, so that you actually know what you are writing about.
Why provide worse care by adding ventilations?
Hands-Only CPR works better than CPR with ventilations.
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Causing trouble again, eh?
I think you may be committing your own favorite crime and staking claims beyond the strength of the evidence, scallywag. “Zero ventilations = just right; Any ventilations = excessive ventilations.” is a very strong claim, and although there is little evidence for ventilations at this time, and perhaps insufficient evidence for their routine inclusion in resuscitation algorithms, I think it’s a bit early to say that there is never any situation where they would be beneficial.
In any case, the pit crew model, to me, is not predicated upon the inclusion of ventilations. Rather, it’s a recognition of the fact that even in the most basic code, at least several things need to be done, and the process can be greatly streamlined and improved if there is an effort to train towards coordinated, synchronized, team-based methods of reaching those goals. Even if, as you (and I) advocate for, the typical code is really mostly about compressions and defib, there is ample room for the “parallel rather than linear” approach. While I start compressions, who’s setting up the defibrillator? Clearing the chest, applying pads? Ensuring quality compressions? How are we going to swap out in a coordinated manner? And you can throw in as many or as few other “maybe” interventions as you’d like.
Brandon,
Not me.
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It is almost as if I did not cover that – except that I did cover that –
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No, but ventilations are an important aspect of the pit crew model.
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Continuous compressions and occasional defibrillation. The rest does not seem to matter unless a reversible cause is identified or ROSC occurs.
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Compress until tired, then switch. If defibrillation is indicated, this is the time to deliver the shock.
No pit crew, orchestra, drill team, glee squad, or coffee klatch is needed.
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I see it as specialization of labor, “riding assignments”, etc. We use it in NC as a means of ensuring consistency in care and a focus on uninterrupted chest compression. I haven’t seen it being used to focus on ventilations, beyond establishing some airway to monitor EtCO2. And even then, if you do that you’re not allowed to mess with the “CPR Triangle”.
It also appears to decrease tensions and leads to a calmer code as folks are now assigned singular tasks without room for freelancing. Take this with a grain of salt, as this is merely my experience with the model.
In order to start researching what works beyond CPR, we need a means of helping to ensure consistent resuscitation efforts. I think the Pit Crew concept is a step in the right direction.
Christopher,
Specializing at continuous chest compressions is what is needed.
The CPR Triangle?
No we need more CPR Cowbell!
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This is as simple as – “You do compressions first, when you get tired, let #2 know and he will take over at the next pause.” Add numbers as necessary. Remain calm.
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I think it continues to distract from chest compressions.
More complication for no benefit. It encourages ventilations, which can cause all of the problems I pointed out above.
Continuous chest compressions with occasional defibrillation is as good as we have been able to get with CPR.
Any complication, that does not improve outcomes, is bad.
Ventilations are bad.
Engineering-wise, what do you call something that adds complexity, but does not improve function?
No foul language, please. 😉
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Okay, here are a few things people could do. Tell me if you think any of them might have value.
— Watch the compressor to ensure adherence to proper rate, depth, and recoil, without any unnecessary interruptions.
— Obtain relevant history or information from family/bystanders to assist with post-resuscitation care, and potentially to identify reversible causes.
— To introduce a means (whether an airway, cannula, etc.) of measuring EtCO2, and to monitor this in order to recognize ROSC.
We can start with just those…
Brandon,
I think that we can do all of those without a pit crew style approach.
Even if there are only 2 people on scene, there are enough people to run a code. We only need more if we decide that ventilations should be provided in spite of the absence of evidence of benefit, or IV should be provided in spite of the absence of evidence of benefit, or drugs should be provided in spite of the absence of evidence of benefit, or intubation should be provided in spite of the absence of evidence of benefit, or a dancing voodoo master should be provided in spite of the absence of evidence of benefit.
Uninterrupted compressions = improved survival.
Rapid defibrillation = improved survival.
Therapeutic hypothermia = post-arrest treatment that leads to improved survival.
Everything else is unproven experimental treatment, even if it is considered to be the Standard Of Care.
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Two people can be a “pit crew,” IMO. It’s a matter of how well they’re trained to work together as a complementary team.
Brandon,
I like the idea of a complementary team.
“Blue is your color.”
“It really accentuates the way you do compressions.”
“You look as if you’ve lost weight.”
“The compressions are looking good, too.”
Maybe I just don’t appreciate the possibilities. 😉
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That’s complimentary, silly.
Come on — you know that quality of compressions is routinely poor, even when people try hard or believe they do well.
http://jama.ama-assn.org/content/293/3/305.abstract?ijkey=aafed14171c7109b3fbbf8db9bcf564d65ffe9f8&keytype2=tf_ipsecsha
http://www.ncbi.nlm.nih.gov/pubmed/20044198?dopt=Abstract
http://circ.ahajournals.org/content/112/9/1259.abstract?ijkey=68c752b6a3aefe8722a282ab015bae38d8415183&keytype2=tf_ipsecsha
http://circ.ahajournals.org/content/112/9/1259.abstract?ijkey=68c752b6a3aefe8722a282ab015bae38d8415183&keytype2=tf_ipsecsha
http://jama.ama-assn.org/content/293/3/299.abstract?ijkey=b5868b8ef7104363c0c24a8ad01ca92e9703933d&keytype2=tf_ipsecsha
http://archinte.ama-assn.org/cgi/content/abstract/168/10/1063?ijkey=82484aaa33876434c7d3ae88f99ad06b547510c1&keytype2=tf_ipsecsha
Brandon,
One of the reasons for criticizing the Pit Crew concept is that the Pit Crew takes emphasis off of quality of the chest compressions and dilutes that emphasis among several irrelevant tasks.
Since we know about the problems with chest compression quality and we know that only high quality chest compressions and defibrillation improve outcomes, we need to limit that focus to the continuous chest compressions.
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