PART 2

IMMEDIATE ACTIONS FOR A COLLAPSED PATIENT

PRIMARY ASSESSMENT

Always tap the victim on the shoulders & ask “ Are you OK? ”
If no response then this is an emergency
Do not assume a person who is lying motionless is in trouble
Call for help
Position the victim supine / on his back on a hard surface
Assess ABCDs and begin CPR

AIRWAY
In an unconscious patient the tongue relaxes and falls back closing the airway.

Open airway by either Head Tilt-Chin Lift Technique (easiest) or Jaw Thrust technique.

Look in the mouth and remove any visible obstruction (leave well-fitting dentures in place). Previously a mouth sweep was advocated, using your index finger to sweep across the mouth over the tongue to ensure no foreign body in the way.





BREATHING

Keeping the airway open, look, listen and feel for normal breathing (an occasional gasp, slow, laboured or noisy breathing is not normal). Do not take longer than 10 seconds, time is off essence.

Look – for chest movement.

Listen at the patient’s mouth for breath sounds.

Feel for air on your cheek.



If not breathing normally, give 2 rescue breaths each over 1 second with enough volume to produce visible chest rise. Ensure patent airway when delivering rescue breath. You do no harm by delivering rescue breaths even if the victim is spontaneously breathing.

Rescue breaths can be given via, mouth to mouth ventilation (need to pinch nose),  mouth to mask ventilation or even nose to mouth in certain situations.

Simple airway adjuncts like Oro-pharyngeal airways prevent backward displacement of soft palate & tongue backwards and facilitates rescue breaths.



Bag valve mask, otherwise popularly known as the Ambu bag, made first by the Ambu company but patent right have since expired and now made by many other companies, a self-inflating bag with one way valve connected to mask to provide ventilation. Supplementary oxygen can be used when available, otherwise ventilates the victim’s lungs with room air only. A good seal between mask & patient’s face must be achieved.



CIRCULATION

In the emergency situation it may be difficult to be certain that there is no pulse and it is not surprising that up to 40% responders cannot accurately determine its absence or presence.

NO MATTER if you cannot. If the victim has no signs of life (no movement or normal breathing or coughing), start CPR until help arrives or until victim shows signs of life.

Check for carotid pulse for up to 10 seconds.



Start CPR immediately. Delay in CPR will reduce survival and must be avoided. Conversely, starting CPR even if the victim has a pulse you did not feel does no additional harm.

If the victim has no spontaneous breathing but there is pulse (respiratory arrest), ventilate patient’s lungs and check for circulation every 10 breaths

STARTING CPR

One (or 2) person starts CPR, others should call ACLS team or collect resuscitation equipment such as Ambu, airway, defibrillator, or plan evacuation.

Give 30 chest compressions (rate=100/min) followed by 2 ventilations. Change the person doing chest compressions every 2 minutes due to fatigue on the part of the rescuer. Roughly, the compliance one would feel whilst doing chest compression approximates that of a CPR Mannequin such as "Resusci Anne". If you do not have one, a corner of an extra firm spring mattress has a somewhat similar feel.



Push hard, push fast, allow full chest recoil



Trace the right or left subcostal margin to the xiphoid process, a bump you can fell at the lower portion of the sternum (breast bone).



Place left palm over sternum 2 finger breath away from the xiphoid, this is the site of compression.



Place right palm over left hand and interlock.



This is the ideal position for CPR, elbows extended, locked and pivot from the hips.



Aim to achieve 4-5 cm depth of compression.


CPR CONTINUED

Maintain airway and ventilate lungs with Ambu bag (inspiratory time=1 second).

Add O2 as soon as possible.

Once and if the trachea has been intubated, a process which is not possible in all circumstances and a skill not easy but worthwhile to acquire, continue chest compressions (100/min) uninterrupted (except for defibrillation or pulse checks when indicated) and ventilate lungs (10 breaths/min).

Laryngoscope and endo tracheal tubes of varying sizes.



(End. PART 2)

good stuff xr250dude... 

defibrillation not taught during EFR... 

Good write-up. Thanks for the info.

Anymore pool session?

xr250dude, seems that u have done your research.

But what you need to know is the basic life support and CPR only...i.e the 1st and (part of) 2nd part of your presentation. Remember, most of the time you do not ahve any equipment with you (so no ambu bag, no oropharangeal airway). So only you would make a difference to the survival of the person.

After a few cycles you need to check again if the pulse is back, coz if there is pulse you DO NOT NEED to do CPR i.e chest compression. And if the person has resume breathing of course u do not need to do mouth to mouth (or nose). You need then to put them in a recovery position.

What I suggest if you are really interested is to have a hands on learning. It 's more of a practical thing coz reading about it may not help u when u panic. You can contact Red Cresent or even some of the hospitals who does regular CPR teaching for the public

Lastly, EVERYONE should know CPR and BLS not just divers.

Did anyone notice, the participate suppose to wearing barrier( Gloves) even though during training??? How long that pocket mask been kept.. looks like almost 10 years pocket mask..Discolour already..!!

bump

Reen, the problem with "FAT/Big" person, I presume you mean the obese is not so much finding the spot to apply compression, but that the overall mortality (death rate) is increased by just being obese. If you look at the definition of obesity, it is a Body Mass Index (BMI) > 25 (BMI = wt(kg)/ ht(m)²).


Approximately,

Height      Weight
1.8m         >80kg
1.7m         >71kg
1.6m         >63kg
1.5m         >55kg
1.4m         >48kg

Taken holistically Obesity is just a secondary risk factor.

There are other more important primary or major risk factors, which are arguably more common amongst divers or swimmers.

1. CIGARRETTE SMOKING
2. HYPERTENSION
3. DIABETES
4. HIGH CHOLESTEROL levels.

These factors if present will make restarting the heart that much more difficult, in fact most non-cancer related deaths are attributed to these 4.

Quero, here, I think it is more an issue of availability rather than a sufficiently taught skill with regards to AEDs. It was clearly shown in 2005 AHA CPR guideline review, that early CPR with Defib trumps CPR alone or Defib alone. It is an issue of cost but although expensive, certainly worthwhile when you need one. If you look at local laws, we in Malaysia are not in the forefront. The latest Private Healthcare Facilities act only compels a medical practice to have available an advance airway, and not an AED/Defib. You would have reckoned the AED which is part of BLS would have come first, followed closely by advanced airways and ALS drugs. Thankfully, AEDs are getting cheaper, ~USD1k, but for now the issue as to why a dive operation should have one when the clinic next door doesn't, remains.

Nizaha, the barrier you are referring to, its called skin. From the picture the mask appears old but funnily, from what I am told, seems to be able to pass annual Health Ministry inspections. Your question exemplifies public perception towards CPR which was actually addressed in the news article that is the unwarranted  fear of contracting disease and fear of performing CPR wrongly.

An excerpt from 2005 guidelines with regards to perception of disease transmission from “unprotected” CPR
"Others point out that the public is afraid of transmitted diseases and is reluctant to perform mouth-to-mouth resuscitation. The guidelines emphasize that the data shows that transmission of infection is very low.⁴⁶ The guidelines encourage anyone who is still concerned about infection to use a barrier device to give ventilations, although simple barrier devices (ie, face shields) may not reduce the risk of bacterial transmission.⁴⁷ The guidelines also encourage those who would rather not give mouth-to-mouth ventilations to call for help and start chest compressions only."

46. Mejicano GC, Maki DG. Infections acquired during cardiopulmonary resuscitation: estimating the risk and defining strategies for prevention. Ann Intern Med. 1998; 129: 813–828.
47. Simmons M, Deao D, Moon L, Peters K, Cavanaugh S. Bench evaluation: three face-shield CPR barrier devices. Respir Care. 1995; 40: 618–623.

What’s important is not gloves (never mentioned in guidelines) or equipment aesthetics, its early effective CPR, early Defib.

Syed K. A., BLS is easy to learn, all University Hospitals and some General Hospitals and some Private Hospitals offer BLS courses with certification for a nominal fee. Red Crescent and St John’s Ambulance also offers BLS for their members. The standard course is 2.5 days of theory, practical and test. If you are interested, I can offer for a limited time, FOC, refresher and manual Defib.

Bones, I totally agree with you that in as far as CPR is concerned, there is gross underexposure and that in the ideal world, everyone should be able to give effective CPR. Important point you made about checking for a spontaneous perfusing pulse.

The 2005 guideline differentiate between lay rescuers from healthcare rescuers.

“Lay rescuers should immediately begin cycles of chest compressions and ventilations after delivering 2 rescue breaths for an unresponsive victim. Lay rescuers are not taught to assess for pulse or signs of circulation for an unresponsive victim. Lay rescuers will not be taught to provide rescue breathing without chest compressions.”

The simple reason is that it is difficult even for an experienced rescuer to feel for absence or presence of a pulse in the allowable time of 10 seconds, studies quote only 40% correctly assess pulse, what more then for a Lay rescuer.

kimseng, mike wong, irukanji, jgshuwei, sicko,, others thanks. John, pool sessions any time, can even bring “Anne” the CPR mannequin along ….

xr250dude, example if the person is fat so his/her skin with layers of fat kinda make it a little difficult to find that soft bone like in the picture...so any ezier way to determine the point? 

My EFR instructor say new syllabus teach to look at chest for heart beat.
Then my Rescue Diver's instructor ask me to check heart beat of water surface with wetsuit on.
How to check?

New syllabus in EFR never taught how to check pulse.

And another thing, if victim is a girl how to look for heart beat?

chaiiiiit is this a trick question ??? hahahaha..
both man and girl's heart are at chest maa...so look at chest laaa...kan..kan..?? takkan la want to look some where else..

My EFR instructor say new syllabus teach to look at chest for heart beat.
Then my Rescue Diver's instructor ask me to check heart beat of water surface with wetsuit on.
How to check?

New syllabus in EFR never taught how to check pulse.

And another thing, if victim is a girl how to look for heart beat?

Maybe you should ask, how to check heart beat for a victim like Pamela Anderson?     

Quote from: Mike Wong on October 10, 2008, 07:31:33 AM

My EFR instructor say new syllabus teach to look at chest for heart beat.
Then my Rescue Diver's instructor ask me to check heart beat of water surface with wetsuit on.
How to check?

New syllabus in EFR never taught how to check pulse.

And another thing, if victim is a girl how to look for heart beat?

Maybe you should ask, how to check heart beat for a victim like Pamela Anderson?     

HAHAHAH...

not wanting to sound like sexist.... by laughing but its cute



THE CAROTID PULSE ( HEART BEAT CHECK) is DONE on the neck...

Pam or no Pam..you can.. STOP staring down..concentrate on neck ;P

Firstly, good stuff xr250dude!!

For most divers, I think we got into the EFR stuff when we did the rescue diver course. I think it is critical that anyone who performs CPR has the proper training required.

CONDUCTING CPR ON A BREATHING PERSON CAN RESULT IN SERIOUS INJURY.

During training (on ANNE) or any other dummy, the practical aspects are addressed. You can also clarify all your doubts on pulse, "Pamela Anderson" pulse, etc, etc, too. 

CPR on a child or infant is also covered in most CPR/EFR courses and , as a dad with an 18 month old child, I thought this was really good to know.

I strongly recommend everyone to do this course. (Diver or non diver.)

 

Every diver must and should learn CPR. Thats why i have been bugging my dive gang members to learn..and they keep saying..u know cukuplah.. but what if I pengsan..who' going to help me... 


One more point to stress; getting EFR alone is insufficient..it doesnt end there.. you should get CPR re-certified once a year..
chest compression can be dangerous too if not done correctly- ribs can be cracked...

well... actually, cracked ribs are quite common post CPR, regardless whether you do it correctly or not. it all depends on who is doing the CPR and who's the one receiving the CPR. me done enough CPRs during on call time to verify this  bottom line, if it means bringing some one back, a few cracked ribs are the least of your worries.

The following was just circulated in my company as an alternate to the standard CPR called continues chest compression. (Removes trying to remember ratios, steps, etc.)

http://www.youtube.com/watch?v=E5huVSebZpM

The standard version as below:

Adult Patient:
1st - shake & shout to see if the person is conscience.
2nd - call for help / get an aed if possible.
3rd - open the airway using the head? tilt chin lift method.
4th - check for breathing, look, listen, feel (5-10 secs).
5th - check the carotid artery in the neck for a pulse.
6th - 2 breaths then 30 compressions with two hands interlocked on the sternum for 5 cycles at 30:2 ratio of compressions to breaths.

http://www.youtube.com/watch?v=cPEFskCrdhQ

Hope the info serves as a refresher too!!