Mounted search and rescue

["Jeff Hasse" <jhasse@comcast.net>]

MSAR Members,

 

    I thought I would pass on some background on the changes in CPR.  I have been employed as a Paramedic for over 26 years and seen standards change several times throughout my career.  I have also used cardiac resuscitation skills many, many times during that time.

 

    Ever since I was first trained in CPR in the late 70's the thinking was that there were two separate mechanisms that caused blood to flow throughout the circulatory system during CPR:  1) mechanical compression of the heart between the sternum and spinal column and 2) bellows effect.  Bellows effect is caused by the compression and relaxation of the thoracic (chest) cavity during CPR.  When the chest is compressed and the lungs evacuated during compressions, a positive pressure is created in thoracic cavity and blood flows out of it.  During upstrokes, especially when the lungs have little air in them, a negative pressure exists in the thoracic cavity and blood flows towards this negative pressure.  Throughout much of the history of CPR research, mechanical compression was thought to be the primary mechanism of blood flow and bellows effect a distant second.  However, research in the early 2000s (especially in Europe) has shown that bellows effect is the primary way blood is moved throughout the body during CPR.

 

    A little sidebar on how these changes came about:  The US medical research system has historically been quite xenophobic on research from outside the country.  The American Heart Association (AHA)--the principal leader in establishing CPR standards (the Red Cross usually lags behind but eventually follows AHA guidelines)--is no exception until recently.  Several European countries have some outstanding data on CPR research and the AHA finally conducted an international conference (in 2005, if memory serves) and new guidelines were born.

 

    When a person suffers cardiac arrest, blood flow ceases or is so diminished that the heart can no longer move enough oxygen to sustain normal life activities.  Tissues throughout the body begin to become hypoxic (starved of oxygen).  While some tissues tolerate this well (muscles and bone), others do not.  The brain is the most sensitive and will suffer irreversible damage in 4-6 minutes.  In earlier CPR standards, we tended to hyperventilate patients in an effort to provide the body with much-needed oxygen.  Thus, the Airway-Breathing-Circulation priority model.  Makes sense, right? 

 

    Unfortunately, ventilating a patient interferes with the bellows effect and dramatically decreases the efficacy of CPR.  Every time you fill the patient's lungs with air, you create a positive pressure within the thoracic cavity and blood flow nearly ceases.  The research graphs are very dramatic.  During pig studies, you can see that after a single breath, it takes approximately 12 compressions to begin moving blood effectively again.  In old-style CPR, we would then stop at 15 compressions and give another breath.  So only 3 compressions out of every cycle actually effectively moved oxygenated blood--not enough to sustain life.

 

    With the new standards coming out, the lay public will be taught compressions-only CPR.  This isn't primarily about the "Yuck Factor," although that is a side-benefit that they are promoting.  The thought is that there is enough dissolved oxygen in the blood during the initial minutes during a cardiac arrest that compressions alone will move it effectively around until other measures are initiated (electricity and drugs).  However, this oxygen will not last very long and ventilations must resume fairly quickly.

 

    When First Responders and/or medical professionals arrive on scene to a cardiac arrest, we will begin ventilations with compressions.  However, the priorities have changed.  Good strong, fast (100/minute) compressions with complete upward stroke (hands off the chest) are the first priority.  This exhausts rescuers quickly, so mechanical CPR devices are making a comeback such as the Autopulse and Lukas device.  We will only pause compressions for less than 10 seconds at a time and as infrequently as possible.  We will place an advanced airway.  Once it is in, we don't even attempt to synchronize breaths to compressions and simply do compressions continuously.  There are other changes to advanced cardiac resuscitation that came with the new standards such as use of an Impedance Threshold Device (ITD) to increase negative pressure in the thoracic cavity.

 

    Have all of these changes made a difference?  While I haven't seen the results of any definitive studies yet, in my personal experience they sure have!  I saw it save a life very early in the changeover.  A 65 year-old gentleman dropped from cardiac arrest while bullfloating concrete at work.  The concrete truck driver was a firefighter and began CPR.  When we arrived (approximately 6-7 minutes after the arrest), we witnessed good compressions but no rescue breathing.  None of the guys at the scene could bring themselves to do it.  The patient was in ventricular fibrillation and was defibrillated multiple times.  We stabilized him long enough to get him to a nearby hospital where he arrested several times again.  He stabilized long enough to transfer him to a hospital 40 miles away for interventional angiography where they fixed the occlusion that was causing his heart attack.  During this whole time, I defibrillated him a total of 13 times.  I would not have bet a nickel on his chances for survival, but he did.  He actually went home with very little neurological deficit (slight short-term memory loss which was improving).  I would have bet that the initial CPR without rescue breathing would have killed him, but it didn't--it improved his chance of survival.

 

    Since then, I have seen numerous examples where a life was saved when they would have likely perished five years ago.  We routinely obtain good blood pressures from patients during CPR, which was unheard of years ago.  The changes work and I would encourage anyone to obtain updated CPR training if they haven't already.

 

    One last thought.  I emphasized that compressions-only CPR was being taught to the lay public for a reason.  When we are on a search, we are most often (if not always) operating under the authority of a Sheriff's department (or other governmental authority having jurisdiction).  This may mean that you are operating under a higher standard of care than what is expected of the lay public, so compressions-only CPR may not be an appropriate standard for your group.  In addition, if you have to use CPR on a search, the chances are pretty high that you will be doing it for a while and ventilating the patient will become necessary.  I would encourage everyone to speak to their Medical Director for guidance on the appropriate level of CPR training for your organization.

 

Respectfully,

 

Jeff Hasse

Midwest Technical Rescue Training Associates

Search, Rescue, and Recovery Resources of Minnesota

Jon Francis Foundation

 

Note: These opinions are my own and may or may not be the official position of the organizations to which I belong.

----- Original Message -----

From: IRVIN LICHTENSTEIN

To: Hoosierhorsemen@yahoo.com ; 'Mounted search and rescue'

Sent: Friday, October 08, 2010 3:23 PM

Subject: Re: [MSAR] Have a heart!

Red Cross position is some CPR is better than no CPR (Yuck factor) but until next revision comes out in 2011 we still do ventilation.

 

Irv Lichtenstein

 

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From: msar-riders-bounces@lists.ibiblio.org [mailto:msar-riders-bounces@lists.ibiblio.org] On Behalf Of Yvette Rollins
Sent: Friday, October 08, 2010 2:06 PM
To: Mounted search and rescue
Subject: Re: [MSAR] Have a heart!

 

Thank you Karen, great article to share.

Happy Trails!

Yvette Rollins, Indiana

‘Tread Lightly upon the Land and Leave No Trace!’

--- On Tue, 10/5/10, Karen Nesbitt <spanishequines@yahoo.com> wrote:

From: Karen Nesbitt <spanishequines@yahoo.com>
Subject: [MSAR] Have a heart!
To: "MSAR" <msar-riders@lists.ibiblio.org>, "Mounted search and rescue in Illinois USA." <msar-il@lists.ibiblio.org>
Date: Tuesday, October 5, 2010, 11:13 PM

 

Thought this would be a good link to share on CPR.–  Apparently hands-only CPR doesn't just eliminate the "yuck factor." A new study shows it can save more lives.

http://news.yahoo.com/s/ap/20101005/ap_on_he_me/us_med_hands_only_cpr

 

 

Its fall here.  Frost is in the air, the horses are frisky and some of the young horses are nervous about hunting season.  We are already experiencing hearing shots fired in places they should not be so caution while working and riding in the woodlands and prairies is a must.  By the sounds of some shots, it appears some and I use the term losely "hunters" have no clue as to where they are not supposed to be when it comes to pulling out a weapon. 

 

Wildlife are on the move being chased out by farmers combines and getting hit on many highways and by ways giving opportunies to scent test mounts. 

 

Im finding this time of year to be a huge gammette of air qualities ranging in the down right carrion rank to the wonderful smell of fall as various odors prevail carried by the changing air temps and its interesting to watch the live stock  and buzzards as they take in the scents in the winds. Its great to be able to watch animals at their own free will to learn more about how they react when something is in the air.  You can learn a lot about your horse by watching its body language and you can learn a lot about whats in the air by the presence of certain wildlife.

 

Hope everyone is having a safe season.

        Karen

Visit us at STORMS - http://stormyweather1.webs.com/

Genesis 50:9
And there went up with him both chariots and horsemen: and it was a very great company.

 

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