Monday, August 08, 2005

Disaster Medicine : Pearls # 2

Disaster Medicine Pearls # 2

The Realities of CPR.

A cardiac arrest, or `code’, is the gravest emergency any responder will ever face. Yet, ironically, with proper training, a responder may save a victim with nothing more than his hands, mouth, and brain. Go figure.

To deal with a cardiac arrest you need to take CPR training. Please don’t assume that, by watching ER, or viewing a website, that you know how to perform BLS (Basic Life Support). CPR requires specific motor skills that can only be adequately learned from practice. This pearl will not, therefore, attempt to teach CPR. You need to take a class for that. Instead, I will focus on what your CPR instructor may not tell you.

In CPR class you will learn how to assess a patient, clear an airway, how to position the head, how to monitor vital signs (pulse, respirations, pupils), and how to properly perform compressions and ventilation. You will learn the mechanical skills needed to provide BLS. If you haven’t taken a class, do so immediately. If you haven’t had a refresher course in a few years, take one.

SAFETY : Electrocutions are a fairly common cause of cardiac arrest. As a BLS provider, ALWAYS inspect the scene before approaching an unconscious patient. Look for wires, water on the floor, or any other hazard that could endanger your life or safety. Don’t endanger yourself while trying to save someone else.

Additionally, some people have been known to attempt suicide by ingesting caustic or poisonous chemicals. DO NOT DO MOUTH TO MOUTH in these cases. If you detect the strong odor of chemicals or pesticides on the patient’s breath , and don’t have an ambu-bag available, accept that the patient got his or her wish.

Please know that working a code is hard work. Two person CPR is easier than one person CPR, but it too can be strenuous. Add to this the adrenalin and stress of dealing with the situation, and a rescuer with a heart condition may be risking THEIR LIFE doing CPR. Sadly, I’ve seen this happen. An ambulance `attendant’ (pre-paramedic days) in his 60’s died in St. Pete doing CPR. Ambulance pulls up to the ER, the driver gets out, opens the back doors, and has a double code on his hands. In that case, neither the patient nor the rescuer survived.

A reasonably healthy person should, however, be able to perform CPR for 20 to 40 minutes without problems. But if you begin to experience chest pains, or difficulty breathing, IT IS TIME TO STOP. Let someone else take over, or call it a day. Don't add to the body count.

EMOTIONS : During a medical crisis, some people panic and flounder about, while other’s rise to the occasion. Everyone reacts differently. Parents are notoriously bad about dealing with an injured or sick child. Their inclination is to hold or cradle a child instead of rendering substantive aid. You have to learn to detach yourself, at least for the duration of the emergency, in order to be effective. Even when dealing with your own children.

You must put aside your emotions, take a deep breath, and deal with the problem at hand. Otherwise, you are simply part of the problem, not the solution. If you can't handle it, get out of the way and let someone else do it.


STARTING CPR: The first consideration for a BLS responder is whether it is appropriate to administer CPR. Here we get into an ethical question, and if Dr. Lou has some additional input, I would welcome that. All I can do is offer my opinion.

Generally speaking, unless the patient has been obviously `dead’ for more than 20 minutes, or you know the patient is in the last stage of a terminal illness, or the patient has sustained obviously mortal injuries, CPR should be started immediately.

Sounds simple, but it isn’t. What constitutes a `mortal injury’? How can you tell if someone has been `dead’ for more than 20 minutes? How can you know the patient’s medical history and/or wishes?

First, if anyone is around who knows the patient (relative, friend), ASK!. They can often tell you if Old Max is in the final stage of liver cancer or not. But understand, you can’t know what you can’t know. Better to err on the side of caution and administer CPR than to withhold it from a potentially viable patient.

Mortal injuries generally involve the head. If the head is some distance from the body, you can forget about CPR. If large amounts of gray matter (brains) are beyond the confines of the skull, cover the victim up and move on. But please know that many other, terrible looking injuries, are survivable. If transportation to a trauma center is possible within the first hour, even devastating injuries can sometimes be salvaged.

When faced with a non-breathing, pulseless patient who has been `down’ for an unknown length of time, there are a few clues that can tell you if the patient is viable. No, there is no surefire way to determine if the patient has been in arrest for 15 minutes or 30. But beyond 30 minutes, changes do occur in the body, which are fairly easy to see.

Skin color and temperature are big indicators. Deep cyanosis (blue coloration) and cold skin are an indication prolonged cardiac arrest or death. If the body is beginning to stiffen, then rigor mortis has set in, and the patient is long gone. And dark pooling of blood at the lowest point of the body (livor mortis) usually does not occur until several hours after death. But in my experience, the eyes are the best short-term indicator. The pupils will cloud over, dry out, and become lackluster begining about 20 minutes after death. They will be dilated and non reactive to light. That, when combined with other signs, can give you a clue.

If the victim’s skin is cooling, deep cyanosis is present, and the eyes are dilated, fixed, and clouding over, then you are probably too late to the party. But unless you are absolutely certain it is too late, initiating CPR is still appropriate. The `code’ can be stopped by the ALS team when they arrive or by the doctor in the Emergency Room.


How long should I do CPR?

Under normal (non-disaster) conditions, help can nearly always be summoned (first step: CALL 911) and should arrive within 20 minutes. During a hurricane, or other disaster, help may be hours away. This will make a difference, on a practical level, for what you can reasonably do. The standard recommendation is that once CPR is begun, it be continued until ALS trained rescuers can arrive. If you are isolated, cut off, and no help can be reasonably expected within an hour, you will have some very hard decisions to make.

CPR alone will rarely re-start a heart. Yes, I’ve seen it happen, particularly with a witnessed arrest, but it is an uncommon occurrence. And if it’s going to happen, it will generally happen in the first few minutes of resuscitation. If no help is forthcoming, and the patient has not responded after 30 or 40 minutes, it’s time to think about calling off the code. Cases involving hypothermia, including drowning, have a better chance of survival than other cardiac arrests, even after a significant amount of `down time’. And the younger the patient, the more likely you are to have a good outcome. But even in those cases, if more than an hour has gone by, it’s time to accept the finality of the situation.

Expectations: Even with ALS equipped and trained personnel on hand, the best we seem to be able to do is a 50% survival rate. In many areas of our country, where response times are long, less than 10% survivability seems to be about average. If ALS is more than an hour away, well . . . let’s just say miracles sometimes do happen.


Liability : We live in a litigeous society, and many people fear that learning CPR will somehow embroil them in legal liability issues. The lay public has no `duty to act', meaning that no-one can legally force you to use your CPR training, nor can you be held liable for not using it. The Good Samaritan laws in nearly every state protect you if you decide to render assistance, as long as you do so in good faith, without intent to cause harm. Even if you do something wrong, if your intent was to help, you are not liable.


Dealing with Death : This is something that is rarely covered during CPR class. And in my humble opinion, ought to be.

The odds are, if you are called upon to do CPR, you are probably fighting a losing battle. If ALS help arrives within the first 20 minutes, and you have done timely and effective CPR, a good success rate would be perhaps a 30%. That’s a best-case scenario. Reality is probably less than 20%. A spontaneous re-start of the heart, without the aid of ALS, will happen perhaps 5% of the time. Still, that’s better than zero.

Patients in cardiac arrest, despite the best efforts of their rescuers, often die. You need to be prepared for that.

Know that, by learning CPR, and using it, you gave your patient a chance. A chance they wouldn’t have had if you hadn’t taken the time and the trouble to learn this procedure. If the patient dies, you did not fail. You did all that you could do. You tried. No one could ask for more.

When the loss involves a friend or a loved one, it is 1000 times more difficult to deal with. There are no words I can give that will mitigate this loss. I wish there were.

All I can tell you is that this is the single best reason to learn CPR. Knowing you did everything possible is the only salve that may someday help heal that wound. Don’t put it off. There are some things in life you will never forgive yourself for.

Don’t let this be one of them.

Final Note: If you are at a public place, a hurricane shelter, for example, and a cardiac arrest occurs, check to see if an automatic defibrillator is available. They are often mounted on the walls of auditoriums and other venues. These are truly lifesaving devices, and are very easy to use. Just follow the illustrated instructions on the cover.


Blogger Docentis Maximus said...

Of course, the new recommendation is to omit the breaths altogether, and just focus on chest compressions.

Great blog! I wish you were still actively posting. I teach students preparing for allied health careers, and they could certainly benefit from your "pearls".

7:26 AM  

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