Effectiveness of CPR….

I have spent a number of hours today looking at various videos on YouTube posted by various Rescue and EMS groups in Thailand, and there is a theme that is becoming clear – there is a need for continual training and updates to keep skills in date, and to ensure effectiveness in use of these skills.

Here are two images I captured from some of the videos I was watching today. My comments and thoughts are below.

Image 1: Correct placement of AED pads

In order to ensure an effective shock is delivered, AED pad placement is essential. Refer to the image below and you will see the correct placement position:

Although it may be difficult to see from the screen capture, the pad on the left is incorrectly placed on the abdominal cavity.

they go on the front (anterior) of the chest, one above the right nipple, and the other on the left side of the chest below the left breast area. The only exception is for paediatrics, where one is placed on the back chest wall (posterior) and the other on the front (anterior) left chest wall (ref https://defibshop.com.au/where-to-place-defib-pads/)

Perhaps you will ask why this is either relevant or important?

The purpose of a bi-phasic AED (click to read this article in a new window – it’s really quite informative) is to deliver an electric shock across the heart muscle and in effect stopping all electrical activity in the heart, allowing the heart to (where possible) re-polarise which may allow for a correct rhythm to be re-established. I will publish an article in the training section in the near future which goes into a lot more detail about how an AED works and what happens when you push the shock button. However, correct pad placement is essential otherwise the shock delivered will be ineffective in most cases and the opportunity to establish a viable rhythm will be lost.

The placement in the above picture is incorrect and will most likely have no net benefit to the patient.

Image 2: Correct hand placement for CPR compressions

In this image you will see that the hand position is towards the right anterior wall of the patients chest. This is not the correct placement position. Refer to the picture below:

Correct hand placement is as follows:

Kneel down beside the casualty on the floor level with their chest.
• Place the heel of one hand towards the end of their breastbone, in the centre of their chest.
• Place the heel of your other hand on top of the first hand and interlock your fingers, making sure you keep the fingers off the ribs.
• Lean over the casualty, with your arms straight, pressing down vertically on the breastbone, and press the chest down by 5-6cm (2-2½in).
• Release the pressure without removing your hands from their chest. Allow the chest to come back up fully – this is one compression.
• Repeat 30 times, at a rate of about twice a second .
Give two rescue breaths. (ref:http://www.sja.org.uk/sja/first-aid-advice/loss-of-responsiveness/unresponsive-not-breathing/adult.aspx)

Correct hand placement is essential otherwise the compressions will be of little or no effect.

The other important thing to remember is that you must not compress too fast or too slow! In one video I viewed today, I timed the compressions at over 200 per minute. CPR this fast will be ineffective and will also tire out the person performing it very quickly.

A future article will also focus on effective CPR, looking at the ‘pit stop’ approach to managing a cardiac arrest. Briefly the pit stop method, as described by London Ambulance Service is:

Inspired by Formula One racing, the pit crew concept is designed to bring increased efficiency and structure to the way the London Ambulance Service treats patients in cardiac arrest.

Each member of the team knows exactly what to do, when to do it and how to do it.

Key aspects of the pit crew concept include:

Ensuring there is 360º access to the patient (this may involve physically moving the patient a short distance);
Calm and concise communication at all times;
Use of a cardiac arrest checklist;
Identifying a team leader to manage the cardiac arrest team;
Members of the team adopting predefined positions around the patient in order to deliver different elements of resuscitation efficiently and effectively.

So in summary:

Access to AED at earliest opportunity (where available)
Ensure correct pad placement
Check hand position
Compressions at 100/120 per minute – no faster
Effective ventilation using airway adjuncts (Nasal & Oral airways, iGEL, LMA or ET Tube – all based upon your skill level) with 100% O2
End Tidal CO2 measurement (based upon skill level)
Relevant drugs to correct rhythm (based upon skill level)
Correct the four H’s & T’s

    Hypoxia (low levels of oxygen)
    Hypovolemia (shock)
    Hyperkalemia/hypokalemia/hypoglycemia/hypocalcemia (+ other metabolic disturbances)
    Thrombosis (coronary or pulmonary)
    Tension pneumothorax
    Tamponade (cardiac)

I welcome feedback and comments 🙂


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