EMT here. CPR rarely works, and sometimes when it does work the result is permanent brain damage so the patient dies the next day anyway.
Nevertheless it's worth doing on people who are having e.g. a sudden cardiac event because you only do CPR on dead people. Which means as long as they died because of some single-point correctable failure, it doesn't hurt to try CPR because it might succeed and that's better than being dead.
OTOH if they died because of multisystem organ failure or distributed catastrophic blunt-force trauma, CPR will never bring them back.
Medical professionals know all this, and as the article points out the moral distress of failed CPR is related not to the fact that it so often fails but that it's inappropriate to even start CPR on an 80 year old patient in a nursing home who has dementia.
Even the CPR class I had to take touched on this. You're unlikely to do much other than break some ribs on an adult, which is not going to be fatal. You just do CPR because what else are you going to do. The same class also did cover that AEDs are basically everywhere and pretty much anyone can use them as long as you remain calm. It also covered that mouth-to-mouth CPR on a 7 year old is a good idea because they tend to do weird stuff like choke on some toy or their food. 47 year olds rarely pass out from choking on food.
The entire purpose of CPR is to get some oxygenated blood through the brain so that there is someone worth saving when help arrives.
CPR is often not performed in time, or well enough, and is likely not a 100% direct replacement for normal breathing; so permanent brain damage is likely even if the person is revived. I don't know if the de-emphasis on rescue breathing makes a difference.
The de-emphasis on rescue breathing was the biggest advance in CPR since it began.
No non-anesthesiologist can do this effectively (even in Advanced Life Support recertification classes, anesthesiologists — including me — struggled to achieve adequate air exchange with rescue breathing on a mannequin, which is far easier than on an unconscious person).
Full energy and attention and effort keeping up deep regular chest compressions at witnessed or just-occurred out of hospital cardiac arrest/loss of consciousness events stands the best chance of a good outcome.
Critical care paramedic. Even when we arrive on scene, airway management and ventilation is a "distant" priority behind defibrillation and effective compressions.
> No non-anesthesiologist can do this effectively (even in Advanced Life Support recertification classes, anesthesiologists — including me — struggled to achieve adequate air exchange with rescue breathing on a mannequin, which is far easier than on an unconscious person).
Hah, and I guarantee your mannequins are far nicer than ours - we do have some Sim-Men for our ALS providers, but BLS providers etc. are practicing on "cheap" mannequins that you either need to artificially hyper-rotate the head back to get air exchange into the 'lungs'.
The citizen CPR classes I teach (well, to providers, too) - the rough rule of thumb is that "for each minute of arrest, the chance of survival goes down 10%", which roughly correlates with my understanding that our blood is generally sufficiently oxygenated for about 7-8 minutes of compressions.
> In-hospital arrests are almost universally fatal.
As are out-of-hospital traumatic arrests.
Other random facts, comments, etc.:
- Start compressions, have someone call 911 (if alone, call and go on speaker, put it down beside you). As soon as you have a defib available, use it, zero delay.
- Contrary to TV and the movies, defibrillation is not like jump starting a car. If the battery is dead, so to speak, that doesn't work. The best analogy for tech people is this: the heart is malfunctioning. If your computer is malfunctioning, you'd ultimately hit Ctrl-Alt-Delete, reboot, and see what happens. That's defibrillation - apply sufficient energy to cause the various nodes of the heart (I'm not being precise here, but trying to explain more easily) to 'failsafe' and reboot, and try to bring about an organized electric current to flow through those nodes to get a coordinated muscle contraction that makes up a pulse.
- You are generally not breaking ribs. You're separating cartilage from the sternum. This is "not a concern".
- Compressions are 1/3 to 1/2 the depth of the chest. If you're not sure, or worried, go deeper (unless it's a little old lady who weighs 80lb, it's pretty difficult to go "too deep").
- If the person is unresponsive, to vigorous stimuli, start CPR. Don't try looking for a pulse. It is difficult to describe to a lay person over the phone where to find the carotids (and do not rely on TV shows to be of any assistance). Contrary to popular belief, doing CPR on someone who actually still has a pulse is -not- a problem. In fact, EMS will continue chest compressions after getting ROSC (return of spontaneous circulation) for a CPR cycle to "support" circulation.
- Once you start CPR, don't stop. Yes, it's hard work. We rotate compressors every two minutes because quality declines. But if you're alone, yeah, it's going to suck, but keep going. It takes about a minute and a half of compressions to build up effective blood pressure for perfusion (because you pushing through the chest wall is obviously less effective than the squeeze of the left ventricle), and only about 8 seconds of no CPR to lose that work. -Even when EMS arrives- they'll tell you to continue CPR until we are literally ready to switch in beside you.
- In adults - realize that we're not "fixing" anything. ROSC is a good "outcome", especially in the field. But we didn't clear the blood vessels of plaque. The fixes for arrest happen in the cath lab or theater. It is entirely possible (and really, the default) that the person will re-arrest while we're packaging or transporting the patient.
- In children, there are two major causes of cardiac arrest: 1) congenital heart defect (known or unknown), or 2) FBAO (foreign body airway obstruction) and similar things, like near-drowning events. For number 2, the merciful aspect is that if the root problem is solved, re-arrest is unlikely. If something is blocking the airway, and is subsequently vomited up, or dislodged by compressions, the problem "goes away".
- Work to the side of your patient. Don't lean over their face or head. That's a good way to get sometimes fairly forceful bloody vomit in your direction. Expect potential incontinence of bladder or even bowel (to quote a gruff instructor I had, "they can't control the function of their heart, what makes you think the muscle tone of the bladder is a higher priority for the body?").
Also, on a personal note, I am very appreciative to the anesthesiologists I know who have been instrumental in my initial and ongoing education for your assistance and teachings as we learn and practiced tube placement in theater.
> doing CPR on someone who actually still has a pulse is -not- a problem
Unless they wake up and say "Ow! Quit doing that." This is very unlikely but it happened to me once when we had a patient who had OD'd on something (we didn't know what) so we gave him Narcan and boom! He's wide awake and complaining that his ribs hurt.
Narcan is extremely potent. While our LE and EMTs carry IN (nasal) Narcan, our Medical Director actually prefers us to gently titrate IV Narcan while providing airway management and ventilation. His perspective is that 1) that makes life a lot easier for everyone involved, because sometimes those patients "come up swinging", and 2) there's a hope that if even a few per cent of those patients are gently roused by the time they get to the ER, they may be more willing to consider addiction help.
But, funny story on what you said: a call for some teens in a park drinking, one is now unconscious. "We think he's had a heart attack!" Dispatcher: "are you sure, not just black out drunk?" (not a good thing, but still). "No, we can't find a pulse...". Dispatcher starts walking them through phone CPR while dispatching us. A few minutes later, some commotion on the phone. "What's happening?" "We're having a really hard time giving him CPR!" "Why?" "He keeps pushing us away and telling us to leave him alone but you said we cannot stop no matter what!"
And on a more serious note, you can have situations where a patient is (mildly) conscious through CPR. We had a patient who had internal bleeding that we were attempting to stabilize to get to theater. He was able to squeeze his wife's hand when she talked to him through our compressions.
Completely agree about the wisdom of Narcan titration when you are able to do it. If you give them too much they can wake up swinging fists because you just ruined the heroin/fentanyl/whatever high they paid $20 for. And in that moment they won't be especially receptive to platitudes like "Dude, you died and I just brought you back to life."
And then 20 minutes later the Narcan will wear off and they can crash again, and you're back to square one.
That's hilarious about the teens. Teens don't have heart attacks. And you can never count on people having common sense.
I love our dispatchers. They work as hard as we do.
> Narcan is extremely potent. While our LE and EMTs carry IN (nasal) Narcan, our Medical Director actually prefers us to gently titrate IV Narcan while providing airway management and ventilation. His perspective is that 1) that makes life a lot easier for everyone involved, because sometimes those patients "come up swinging", and 2) there's a hope that if even a few per cent of those patients are gently roused by the time they get to the ER, they may be more willing to consider addiction help.
Sorry, can you explain this a bit more? Why would a patient who wakes up more gently be more willing to consider addiction help?
Probably not because it's more gentle in itself. More that the experience isn't immediately "antagonistic" with law enforcement presence, the sudden rush of being brought out of the narcotic stupor (well, respiratory depression), in a often less-than-ideal environment.
To be very real, most people that we get to the ER and they take over bringing up the Narcan until that respiratory drive kicks back in (kinda a sleepy morning wakeup feeling), will still AMA and leave. But some may consider or talk about it a bit. And maybe there's a more positive longer term outcome.
I'm not a doctor, but I watch some on YouTube and that practically makes me an expert right? I'd heard that the chest compressions only is preferred now with the exception of potential drowning victims because you're much less certain about the existing oxygen supply in the blood. Is that the case?
> Poor outcomes are not only limited to death. People who survive CPR suffer physical injuries. More than 70 percent of people who receive CPR experience rib fractures, with an average of 7.6 broken ribs.
What happens to the control group of people who don't receive CPR?
Usually fatal within minutes. Broken ribs are survivable (on their own), and are certainly preferable when compared with the outcome of death.
Though I've noticed with the medical profession, speaking as a dumb firie, any outcome less than perfect is considered a 'complication'.
I've been under the knife a few times for various reasons, I've noticed this more and more. Slight bleeding from a closed incision site after surgery, whilst normal, is still "a complication" and a "poor outcome" despite being totally normal.
Perhaps there needs to be more nuanced language when describing these outcomes? What about "probable deviations" for things that are technically complications, but are more or less expected/normal?
Regarding the CPR training we were given: "if you're not breaking ribs, you're not pressing hard enough" (1/3rd chest depth). 'CPR' shown on TV shows and movies, 'rubber bendy arms', is woefully inadequate and I wonder how much of this is contributing to the mortality rate of cardiac events?
Fortunately a lot of AEDs these days will be able to tell you whether you're pressing hard enough with a pressure sensor embedded in some pads.
> Regarding the CPR training we were given: "if you're not breaking ribs, you're not pressing hard enough" (1/3rd chest depth). 'CPR' shown on TV shows and movies, 'rubber bendy arms', is woefully inadequate and I wonder how much of this is contributing to the mortality rate of cardiac events?
Paramedic and ex fire guy, absolutely. I used to tell the guys on my engine, "You're doing push ups on their chest, basically.". 1/3 to 1/2. It's hard to go too deep.
Don't even start me on that asystole tone and paddles being applied...
Treatable, to a point, yes. Essentially, if one of the reasons there's no electrical activity is that it's just "stalled out" due to a lack of fuel for cellular activity, then you can recover. But the window/opportunity is very small (and comes with the accompanying challenge that if the heart is being starved of fuel, the rest of the body is, including the brain).
Current research shows that the administration of epi has little to no effect on survivability, other than within the first six minutes of arrest (which I now want to read more on, because I wonder if there's any correlation with that and the approximately 7-8 minutes of oxygenation in the blood). And then of course there's the complication (for understanding epi in isolation) that if you're in a position to administer epi <6m from arrest, the patient is likely getting holistic CPR.
Epi is believed to help stimulate the return of a shockable rhythm in asystole. But increasingly, it starts to feel like "because we've always done it". (Random fire 'joke': Firefighters hate two things: change, and the way things are.)
I'm in the PNW, where we're not perfect, but generally have some of the highest cardiac arrest survival rates (here, and Rochester MN).
Very early and progressive EMS system, driven by people like Dr Copass (https://www.seattletimes.com/seattle-news/health/dr-michael-...) who helped pioneer a lot of what you'd see in EMS in the early 1970s, and came from a very strong focus in cardiac outcomes. Although that would be unfair to Medic One's cofounder, Dr Cobb (also mentioned in that article) - Copass was the director of emergency medicine at Harborview (Seattle's Level 1 Trauma Center) for 35 years, but had a background in neurology, and Dr Cobb was a cardiologist.
Throughout the PNW (or I'm talking specifically the Puget Sound region - Snohomish, King, Pierce and Thurston counties), that has lived on, with a huge emphasis in bystander CPR as well as heavy participation in research around arrest outcomes and survivability.
So, heavily cultural. Though not perfect (there's certainly areas of EMS in the PNW that can be not as progressive - my own county took far too long to change the scope for long backboard use, i.e. spinal immobilization, finding that there was no real evidence to support its use for that purpose, and often caused patient injury/pain/discomfort or poorer outcomes).
> Broken ribs are survivable (on their own), and are certainly preferable when compared with the outcome of death.
Even if you're 87 and already have a host of health issues? Even if you have a terminal illness (at any age)?
It's a personal choice of course, but I think a substantial number of people would disagree it's "certainly preferable" in a number of scenarios. There's a reason "Do Not Resuscitate" orders are a thing.
> Even if you're 87 and already have a host of health issues? Even if you have a terminal illness (at any age)?
Less so, but suffering a cardiac arrest without treatment (CPR, defibrillation) is almost always a death sentence.
The whole point of CPR is to maintain oxygenated blood flow to the brain long enough for paramedics to arrive and give potentially life-saving treatment.
Because the time frame from cardiac arrest to death is measured in minutes.
One of the reasons why public access AEDs are so prominent now is that the patient's chances of survival are greatly increased with early defibrillation, and that any untrained person can use one now because they're pretty much automatic once applied.
It seems very silly to write an article like this without a single mention of the fact that CPR is only performed on people who are already dead, so any success rates and complications (eg broken ribs) have to be understood in the context of the alternative to providing care, namely that the person stays dead. This is something that’s been emphasized to me in every CPR class I’ve ever taken, which suggests the author’s research process probably has some room for improvement.
> This is something that’s been emphasized to me in every CPR class I’ve ever taken
I have no doubt that's the case, but I don't think that's in conflict with what the article is about? To quote: "A study of surrogate decision makers for ICU patients found that 72 percent of respondents believed that CPR had a success rate greater than 75 percent" Presumably, none of those ICU patients had CPR training.
Also the entire moral distress about "questioning whether the patient even wanted extreme life-saving measures" doesn't really seem in conflict with that. Whether you phrase it as a "life-saving measure" or "the person is already dead" seems a bit semantic. This also ties in with the first point, because as a patient I want to be able to make an informed decision about whether the downsides of a life-saving measure is worth the cost. If you're 25 and fit? It probably is. If you're 89? Well, quite a few people would say it's not.
And merely taking the training will help you deal with other aspects of emergency first aid. The Red Cross's training really pounds in the "check if the scene is safe", etc. sequence that you need to be effective under extreme stress.
CPR is something to do with your hands while you're waiting for the AED to show up.
If you want to improve the odds you or people around you survive a survivable heart related emergency, then find out where your nearest AED is, and if it's too far, get one for yourself.
Also join a notification network that will call you to bring your neighborhood AED to a neighbor in need.
AEDs are magic because they use a feedback loop to choose the right intervention.
Not only that, they're becoming rapidly affordable. In many areas, law enforcement will carry them. They're even becoming affordable for home use ($1,400, although I believe you still need to buy through medical providers, not Costco. You might also pay $100 every year or two for replacing expired pads, and $200 every 2-3 years for a battery).
I had the impression that AEDs and CPR were for different indications. You use an AED if they're fibrillating, and CPR if their heart has stopped entirely. (Though I saw you said above that CPR might help even if they are fibrillating, just to get some blood perfusion.)
Go get trained on modern CPR. The current training is "call for help, get an AED from the environment if you can, the call center might tell you where to get it from, do CPR until the AED arrives, and then follow the AEDs spoken instructions."
If the AED detects it cannot be useful for shocking, it will at least tell you and give you a rhythm to keep doing CPR. So as a casual first aid provider, it doesn't matter to you what the AED can and can't do. Get it, get it hooked up, and let it help you.
AEDs are designed to treat two shockable rhythms: ventricular fibrillation (VF) and ventricular tachycardia (VT). (As a side note, you can have a pulse with VT.)
CPR is designed to provide effective circulation, whether the heart has stopped entirely (asystole), or is not providing effective circulation. You can even have in-betweens, like PEA (pulseless electrical activity) where the heart is providing the electrical signals that should contract the cardiac muscle, but it's just ... not happening, or not happening strongly enough to provide cardiac output.
CPR is really: the heart is not doing what it should, or it's not doing enough of it, or not doing it effectively enough.
In the case of an entirely stopped heart, CPR can provide enough sustenance to get a shockable rhythm that can then be defibrillated.
AEDs are also different from what EMS will use (at the ALS/paramedic level)—we can defibrillate or shock rhythms other than VF/VT, but the rules are different, as are things like pacing, etc.
As a VERY rough guide, a lot of arrests are a devolution, from NSR (normal sinus), i.e. all good, which can become VT, and some time in VT (typically minutes) before degenerating into VF, which is even less effective at cardiac output, and then subsequently into asystole or PEA.
> In reality, people who undergo CPR outside of a hospital setting survive only 10 percent of the time. Within a hospital setting, CPR survival rates are only a bit higher — about 17 percent.
A better title: CPR is successful, just not as successful as people think it is.
Whoever thinks a 1/10 (or nearly 1/5!) shot at not dying otherwise is bad odds clearly doesn’t value their own life. I’ll take all my ribs being broken + being alive for even a week vs being dead and no broken ribs any day of the week. I’d also traumatize myself if I knew I was giving someone a 1/10 (or nearly 1/5!) shot at being alive and not dead. Absolutely none of the “downsides” they cite outweigh fucking dying.
Clicking through to one of the references[0] in the article suggests that a little over 40% of people successfully resuscitated never wake up. So that drops us from 10% out-of-hospital / 17% in-hospital to 6%/10%.
That's still not nothing, but you also need to look at what percentage end up with severe enough brain damage that they're not really the same person anymore, and might have preferred death over that situation.
I value my life quite a lot, but I also value quality of life. I think there are quite a few physical and (especially) mental disabilities that I might not want to live with.
To your point about "ribs broken & alive for a week", I suspect that situation would be helpful for my loved ones to be able to see me and say goodbye, but not so helpful for myself.
As someone who has performed CPR hmm, 500 times (paramedic), I would typically agree. Unwitnessed arrests have very low expectations. If you see me go down, then sure. But beyond that, I (and honestly, many) EMS professionals see themselves as effectively "DNR".
> I’ll take all my ribs being broken + being alive for even a week vs being dead and no broken ribs any day of the week.
If you'd ever spent time around a nursing home, you probably wouldn't say that. Quality of life matters, a lot. Not saying I have a DNR, but these are serious conversations to have before it's too late. I think what's really telling is how doctors and nurses treat themselves. They are almost never seeking maximum days alive no matter the physical and mental cost.
I wonder whether it matters as to how those requiring CPR ended up in hospital in the first place: did they suffer a cardiac event outside of hospital, and arrive at hospital with CPR being continued, as opposed to those who were in hospital to begin with, but suddenly required CPR for whatever reason?
That line in itself seems to suggest that the likelihood of CPR being successful increases slightly when a victim is transported to hospital with CPR continuing throughout from the time of their cardiac event, versus those who never make it to hospital, because the CPR givers stop (exhausted, unable to continue) or because efforts before reaching hospital are considered pointless/time-of-death called (as it was clear to medical professionals that CPR isn't going to bring a clearly dead person back to life).
EMT here. CPR rarely works, and sometimes when it does work the result is permanent brain damage so the patient dies the next day anyway.
Nevertheless it's worth doing on people who are having e.g. a sudden cardiac event because you only do CPR on dead people. Which means as long as they died because of some single-point correctable failure, it doesn't hurt to try CPR because it might succeed and that's better than being dead.
OTOH if they died because of multisystem organ failure or distributed catastrophic blunt-force trauma, CPR will never bring them back.
Medical professionals know all this, and as the article points out the moral distress of failed CPR is related not to the fact that it so often fails but that it's inappropriate to even start CPR on an 80 year old patient in a nursing home who has dementia.
Even the CPR class I had to take touched on this. You're unlikely to do much other than break some ribs on an adult, which is not going to be fatal. You just do CPR because what else are you going to do. The same class also did cover that AEDs are basically everywhere and pretty much anyone can use them as long as you remain calm. It also covered that mouth-to-mouth CPR on a 7 year old is a good idea because they tend to do weird stuff like choke on some toy or their food. 47 year olds rarely pass out from choking on food.
The permanent brain damage is the result of the CPR or the result of oxygen being cut off?
Not the OP, but it's the latter.
The entire purpose of CPR is to get some oxygenated blood through the brain so that there is someone worth saving when help arrives.
CPR is often not performed in time, or well enough, and is likely not a 100% direct replacement for normal breathing; so permanent brain damage is likely even if the person is revived. I don't know if the de-emphasis on rescue breathing makes a difference.
Retired neurosurgical anesthesiologist here.
The de-emphasis on rescue breathing was the biggest advance in CPR since it began.
No non-anesthesiologist can do this effectively (even in Advanced Life Support recertification classes, anesthesiologists — including me — struggled to achieve adequate air exchange with rescue breathing on a mannequin, which is far easier than on an unconscious person).
Full energy and attention and effort keeping up deep regular chest compressions at witnessed or just-occurred out of hospital cardiac arrest/loss of consciousness events stands the best chance of a good outcome.
In-hospital arrests are almost universally fatal.
> Retired neurosurgical anesthesiologist here.
Have things changed over time?
> In-hospital arrests are almost universally fatal.
IHCA stats: "During the pre-surge period, 24.2% survived to discharge in 2020 vs. 24.7% in 2015–2019"
https://pmc.ncbi.nlm.nih.gov/articles/PMC8852282/#:~:text=Du...
"There are more than 356,000 out-of-hospital cardiac arrests (OHCA) annually in the U.S., nearly 90% of them fatal. "
https://www.sca-aware.org/about-sudden-cardiac-arrest/latest...
AEDs have greatly improved this (though this study is the highest I've seen - PAD is public access defibrillator):
"The overall survival to hospital discharge after OHCA treated with PAD showed a median survival of 40.0% (range, 9.1–83.3)."
https://www.ahajournals.org/doi/10.1161/circulationaha.117.0...
Even 90% for OHCA is far from universally fatal.
For IHCA, cath labs have greatly improved things, and we're now living in a world where ECPR is becoming increasingly common.
100%.
Critical care paramedic. Even when we arrive on scene, airway management and ventilation is a "distant" priority behind defibrillation and effective compressions.
> No non-anesthesiologist can do this effectively (even in Advanced Life Support recertification classes, anesthesiologists — including me — struggled to achieve adequate air exchange with rescue breathing on a mannequin, which is far easier than on an unconscious person).
Hah, and I guarantee your mannequins are far nicer than ours - we do have some Sim-Men for our ALS providers, but BLS providers etc. are practicing on "cheap" mannequins that you either need to artificially hyper-rotate the head back to get air exchange into the 'lungs'.
The citizen CPR classes I teach (well, to providers, too) - the rough rule of thumb is that "for each minute of arrest, the chance of survival goes down 10%", which roughly correlates with my understanding that our blood is generally sufficiently oxygenated for about 7-8 minutes of compressions.
> In-hospital arrests are almost universally fatal.
As are out-of-hospital traumatic arrests.
Other random facts, comments, etc.:
- Start compressions, have someone call 911 (if alone, call and go on speaker, put it down beside you). As soon as you have a defib available, use it, zero delay.
- Contrary to TV and the movies, defibrillation is not like jump starting a car. If the battery is dead, so to speak, that doesn't work. The best analogy for tech people is this: the heart is malfunctioning. If your computer is malfunctioning, you'd ultimately hit Ctrl-Alt-Delete, reboot, and see what happens. That's defibrillation - apply sufficient energy to cause the various nodes of the heart (I'm not being precise here, but trying to explain more easily) to 'failsafe' and reboot, and try to bring about an organized electric current to flow through those nodes to get a coordinated muscle contraction that makes up a pulse.
- You are generally not breaking ribs. You're separating cartilage from the sternum. This is "not a concern".
- Compressions are 1/3 to 1/2 the depth of the chest. If you're not sure, or worried, go deeper (unless it's a little old lady who weighs 80lb, it's pretty difficult to go "too deep").
- If the person is unresponsive, to vigorous stimuli, start CPR. Don't try looking for a pulse. It is difficult to describe to a lay person over the phone where to find the carotids (and do not rely on TV shows to be of any assistance). Contrary to popular belief, doing CPR on someone who actually still has a pulse is -not- a problem. In fact, EMS will continue chest compressions after getting ROSC (return of spontaneous circulation) for a CPR cycle to "support" circulation.
- Once you start CPR, don't stop. Yes, it's hard work. We rotate compressors every two minutes because quality declines. But if you're alone, yeah, it's going to suck, but keep going. It takes about a minute and a half of compressions to build up effective blood pressure for perfusion (because you pushing through the chest wall is obviously less effective than the squeeze of the left ventricle), and only about 8 seconds of no CPR to lose that work. -Even when EMS arrives- they'll tell you to continue CPR until we are literally ready to switch in beside you.
- In adults - realize that we're not "fixing" anything. ROSC is a good "outcome", especially in the field. But we didn't clear the blood vessels of plaque. The fixes for arrest happen in the cath lab or theater. It is entirely possible (and really, the default) that the person will re-arrest while we're packaging or transporting the patient.
- In children, there are two major causes of cardiac arrest: 1) congenital heart defect (known or unknown), or 2) FBAO (foreign body airway obstruction) and similar things, like near-drowning events. For number 2, the merciful aspect is that if the root problem is solved, re-arrest is unlikely. If something is blocking the airway, and is subsequently vomited up, or dislodged by compressions, the problem "goes away".
- Work to the side of your patient. Don't lean over their face or head. That's a good way to get sometimes fairly forceful bloody vomit in your direction. Expect potential incontinence of bladder or even bowel (to quote a gruff instructor I had, "they can't control the function of their heart, what makes you think the muscle tone of the bladder is a higher priority for the body?").
Also, on a personal note, I am very appreciative to the anesthesiologists I know who have been instrumental in my initial and ongoing education for your assistance and teachings as we learn and practiced tube placement in theater.
> doing CPR on someone who actually still has a pulse is -not- a problem
Unless they wake up and say "Ow! Quit doing that." This is very unlikely but it happened to me once when we had a patient who had OD'd on something (we didn't know what) so we gave him Narcan and boom! He's wide awake and complaining that his ribs hurt.
Narcan is a true wonder drug.
Narcan is extremely potent. While our LE and EMTs carry IN (nasal) Narcan, our Medical Director actually prefers us to gently titrate IV Narcan while providing airway management and ventilation. His perspective is that 1) that makes life a lot easier for everyone involved, because sometimes those patients "come up swinging", and 2) there's a hope that if even a few per cent of those patients are gently roused by the time they get to the ER, they may be more willing to consider addiction help.
But, funny story on what you said: a call for some teens in a park drinking, one is now unconscious. "We think he's had a heart attack!" Dispatcher: "are you sure, not just black out drunk?" (not a good thing, but still). "No, we can't find a pulse...". Dispatcher starts walking them through phone CPR while dispatching us. A few minutes later, some commotion on the phone. "What's happening?" "We're having a really hard time giving him CPR!" "Why?" "He keeps pushing us away and telling us to leave him alone but you said we cannot stop no matter what!"
And on a more serious note, you can have situations where a patient is (mildly) conscious through CPR. We had a patient who had internal bleeding that we were attempting to stabilize to get to theater. He was able to squeeze his wife's hand when she talked to him through our compressions.
Completely agree about the wisdom of Narcan titration when you are able to do it. If you give them too much they can wake up swinging fists because you just ruined the heroin/fentanyl/whatever high they paid $20 for. And in that moment they won't be especially receptive to platitudes like "Dude, you died and I just brought you back to life."
And then 20 minutes later the Narcan will wear off and they can crash again, and you're back to square one.
That's hilarious about the teens. Teens don't have heart attacks. And you can never count on people having common sense.
I love our dispatchers. They work as hard as we do.
> Narcan is extremely potent. While our LE and EMTs carry IN (nasal) Narcan, our Medical Director actually prefers us to gently titrate IV Narcan while providing airway management and ventilation. His perspective is that 1) that makes life a lot easier for everyone involved, because sometimes those patients "come up swinging", and 2) there's a hope that if even a few per cent of those patients are gently roused by the time they get to the ER, they may be more willing to consider addiction help.
Sorry, can you explain this a bit more? Why would a patient who wakes up more gently be more willing to consider addiction help?
Probably not because it's more gentle in itself. More that the experience isn't immediately "antagonistic" with law enforcement presence, the sudden rush of being brought out of the narcotic stupor (well, respiratory depression), in a often less-than-ideal environment.
To be very real, most people that we get to the ER and they take over bringing up the Narcan until that respiratory drive kicks back in (kinda a sleepy morning wakeup feeling), will still AMA and leave. But some may consider or talk about it a bit. And maybe there's a more positive longer term outcome.
I'm not a doctor, but I watch some on YouTube and that practically makes me an expert right? I'd heard that the chest compressions only is preferred now with the exception of potential drowning victims because you're much less certain about the existing oxygen supply in the blood. Is that the case?
> exception of potential drowning victims
Or children - in children respiratory distress often is the cause of cardiac arrest.
> Poor outcomes are not only limited to death. People who survive CPR suffer physical injuries. More than 70 percent of people who receive CPR experience rib fractures, with an average of 7.6 broken ribs.
What happens to the control group of people who don't receive CPR?
Usually fatal within minutes. Broken ribs are survivable (on their own), and are certainly preferable when compared with the outcome of death.
Though I've noticed with the medical profession, speaking as a dumb firie, any outcome less than perfect is considered a 'complication'.
I've been under the knife a few times for various reasons, I've noticed this more and more. Slight bleeding from a closed incision site after surgery, whilst normal, is still "a complication" and a "poor outcome" despite being totally normal.
Perhaps there needs to be more nuanced language when describing these outcomes? What about "probable deviations" for things that are technically complications, but are more or less expected/normal?
Regarding the CPR training we were given: "if you're not breaking ribs, you're not pressing hard enough" (1/3rd chest depth). 'CPR' shown on TV shows and movies, 'rubber bendy arms', is woefully inadequate and I wonder how much of this is contributing to the mortality rate of cardiac events?
Fortunately a lot of AEDs these days will be able to tell you whether you're pressing hard enough with a pressure sensor embedded in some pads.
> Regarding the CPR training we were given: "if you're not breaking ribs, you're not pressing hard enough" (1/3rd chest depth). 'CPR' shown on TV shows and movies, 'rubber bendy arms', is woefully inadequate and I wonder how much of this is contributing to the mortality rate of cardiac events?
Paramedic and ex fire guy, absolutely. I used to tell the guys on my engine, "You're doing push ups on their chest, basically.". 1/3 to 1/2. It's hard to go too deep.
Don't even start me on that asystole tone and paddles being applied...
> Don't even start me on that asystole tone and paddles being applied...
Dumb firie question...
I understand asystole (flat-lining for those not familiar with the term) isn't a 'shockable rhythm' though it's still treatable, to a point, right?
I haven't been able to find a clear-cut answer that is understandable to my level of training (basic life support).
So where do drugs like epinephrine/adrenaline come into play?
Treatable, to a point, yes. Essentially, if one of the reasons there's no electrical activity is that it's just "stalled out" due to a lack of fuel for cellular activity, then you can recover. But the window/opportunity is very small (and comes with the accompanying challenge that if the heart is being starved of fuel, the rest of the body is, including the brain).
Current research shows that the administration of epi has little to no effect on survivability, other than within the first six minutes of arrest (which I now want to read more on, because I wonder if there's any correlation with that and the approximately 7-8 minutes of oxygenation in the blood). And then of course there's the complication (for understanding epi in isolation) that if you're in a position to administer epi <6m from arrest, the patient is likely getting holistic CPR.
Epi is believed to help stimulate the return of a shockable rhythm in asystole. But increasingly, it starts to feel like "because we've always done it". (Random fire 'joke': Firefighters hate two things: change, and the way things are.)
I'm in the PNW, where we're not perfect, but generally have some of the highest cardiac arrest survival rates (here, and Rochester MN).
Huh. Rochester has Mayo, which I suspect does a bunch of training of people.
Why does PNW have high survival rates?
Very early and progressive EMS system, driven by people like Dr Copass (https://www.seattletimes.com/seattle-news/health/dr-michael-...) who helped pioneer a lot of what you'd see in EMS in the early 1970s, and came from a very strong focus in cardiac outcomes. Although that would be unfair to Medic One's cofounder, Dr Cobb (also mentioned in that article) - Copass was the director of emergency medicine at Harborview (Seattle's Level 1 Trauma Center) for 35 years, but had a background in neurology, and Dr Cobb was a cardiologist.
Throughout the PNW (or I'm talking specifically the Puget Sound region - Snohomish, King, Pierce and Thurston counties), that has lived on, with a huge emphasis in bystander CPR as well as heavy participation in research around arrest outcomes and survivability.
So, heavily cultural. Though not perfect (there's certainly areas of EMS in the PNW that can be not as progressive - my own county took far too long to change the scope for long backboard use, i.e. spinal immobilization, finding that there was no real evidence to support its use for that purpose, and often caused patient injury/pain/discomfort or poorer outcomes).
> Broken ribs are survivable (on their own), and are certainly preferable when compared with the outcome of death.
Even if you're 87 and already have a host of health issues? Even if you have a terminal illness (at any age)?
It's a personal choice of course, but I think a substantial number of people would disagree it's "certainly preferable" in a number of scenarios. There's a reason "Do Not Resuscitate" orders are a thing.
> Even if you're 87 and already have a host of health issues? Even if you have a terminal illness (at any age)?
Less so, but suffering a cardiac arrest without treatment (CPR, defibrillation) is almost always a death sentence.
The whole point of CPR is to maintain oxygenated blood flow to the brain long enough for paramedics to arrive and give potentially life-saving treatment.
Because the time frame from cardiac arrest to death is measured in minutes.
One of the reasons why public access AEDs are so prominent now is that the patient's chances of survival are greatly increased with early defibrillation, and that any untrained person can use one now because they're pretty much automatic once applied.
It seems very silly to write an article like this without a single mention of the fact that CPR is only performed on people who are already dead, so any success rates and complications (eg broken ribs) have to be understood in the context of the alternative to providing care, namely that the person stays dead. This is something that’s been emphasized to me in every CPR class I’ve ever taken, which suggests the author’s research process probably has some room for improvement.
> This is something that’s been emphasized to me in every CPR class I’ve ever taken
I have no doubt that's the case, but I don't think that's in conflict with what the article is about? To quote: "A study of surrogate decision makers for ICU patients found that 72 percent of respondents believed that CPR had a success rate greater than 75 percent" Presumably, none of those ICU patients had CPR training.
Also the entire moral distress about "questioning whether the patient even wanted extreme life-saving measures" doesn't really seem in conflict with that. Whether you phrase it as a "life-saving measure" or "the person is already dead" seems a bit semantic. This also ties in with the first point, because as a patient I want to be able to make an informed decision about whether the downsides of a life-saving measure is worth the cost. If you're 25 and fit? It probably is. If you're 89? Well, quite a few people would say it's not.
And merely taking the training will help you deal with other aspects of emergency first aid. The Red Cross's training really pounds in the "check if the scene is safe", etc. sequence that you need to be effective under extreme stress.
This need some clarification.Not all CRP should be put in one bucket.
Out of hospital/unwitnessed arrests - mortality is bad.
In hospital/witnessed arrests - CRP mortality was better.
Downtime (ie time without perfusion makes a difference) the longer it is - the worse the outcome. The difference between long and short is minutes.
That doesn't mean CRP isn't worth trying. The hard part is making sure families understand when futility begins. Some families never get there.
CPR is something to do with your hands while you're waiting for the AED to show up.
If you want to improve the odds you or people around you survive a survivable heart related emergency, then find out where your nearest AED is, and if it's too far, get one for yourself.
Also join a notification network that will call you to bring your neighborhood AED to a neighbor in need.
AEDs are magic because they use a feedback loop to choose the right intervention.
Not only that, they're becoming rapidly affordable. In many areas, law enforcement will carry them. They're even becoming affordable for home use ($1,400, although I believe you still need to buy through medical providers, not Costco. You might also pay $100 every year or two for replacing expired pads, and $200 every 2-3 years for a battery).
I had the impression that AEDs and CPR were for different indications. You use an AED if they're fibrillating, and CPR if their heart has stopped entirely. (Though I saw you said above that CPR might help even if they are fibrillating, just to get some blood perfusion.)
Go get trained on modern CPR. The current training is "call for help, get an AED from the environment if you can, the call center might tell you where to get it from, do CPR until the AED arrives, and then follow the AEDs spoken instructions."
If the AED detects it cannot be useful for shocking, it will at least tell you and give you a rhythm to keep doing CPR. So as a casual first aid provider, it doesn't matter to you what the AED can and can't do. Get it, get it hooked up, and let it help you.
No, or not entirely:
AEDs are designed to treat two shockable rhythms: ventricular fibrillation (VF) and ventricular tachycardia (VT). (As a side note, you can have a pulse with VT.)
CPR is designed to provide effective circulation, whether the heart has stopped entirely (asystole), or is not providing effective circulation. You can even have in-betweens, like PEA (pulseless electrical activity) where the heart is providing the electrical signals that should contract the cardiac muscle, but it's just ... not happening, or not happening strongly enough to provide cardiac output.
CPR is really: the heart is not doing what it should, or it's not doing enough of it, or not doing it effectively enough.
In the case of an entirely stopped heart, CPR can provide enough sustenance to get a shockable rhythm that can then be defibrillated.
AEDs are also different from what EMS will use (at the ALS/paramedic level)—we can defibrillate or shock rhythms other than VF/VT, but the rules are different, as are things like pacing, etc.
As a VERY rough guide, a lot of arrests are a devolution, from NSR (normal sinus), i.e. all good, which can become VT, and some time in VT (typically minutes) before degenerating into VF, which is even less effective at cardiac output, and then subsequently into asystole or PEA.
Thanks. I appreciate the explanation.
The redundancy in the title is killing me.
Anyway, the core is
> In reality, people who undergo CPR outside of a hospital setting survive only 10 percent of the time. Within a hospital setting, CPR survival rates are only a bit higher — about 17 percent.
And the rest is reasons and consequences.
A better title: CPR is successful, just not as successful as people think it is.
Whoever thinks a 1/10 (or nearly 1/5!) shot at not dying otherwise is bad odds clearly doesn’t value their own life. I’ll take all my ribs being broken + being alive for even a week vs being dead and no broken ribs any day of the week. I’d also traumatize myself if I knew I was giving someone a 1/10 (or nearly 1/5!) shot at being alive and not dead. Absolutely none of the “downsides” they cite outweigh fucking dying.
Clicking through to one of the references[0] in the article suggests that a little over 40% of people successfully resuscitated never wake up. So that drops us from 10% out-of-hospital / 17% in-hospital to 6%/10%.
That's still not nothing, but you also need to look at what percentage end up with severe enough brain damage that they're not really the same person anymore, and might have preferred death over that situation.
I value my life quite a lot, but I also value quality of life. I think there are quite a few physical and (especially) mental disabilities that I might not want to live with.
To your point about "ribs broken & alive for a week", I suspect that situation would be helpful for my loved ones to be able to see me and say goodbye, but not so helpful for myself.
[0] https://pmc.ncbi.nlm.nih.gov/articles/PMC8548866/#Fig3
As someone who has performed CPR hmm, 500 times (paramedic), I would typically agree. Unwitnessed arrests have very low expectations. If you see me go down, then sure. But beyond that, I (and honestly, many) EMS professionals see themselves as effectively "DNR".
> I’ll take all my ribs being broken + being alive for even a week vs being dead and no broken ribs any day of the week.
If you'd ever spent time around a nursing home, you probably wouldn't say that. Quality of life matters, a lot. Not saying I have a DNR, but these are serious conversations to have before it's too late. I think what's really telling is how doctors and nurses treat themselves. They are almost never seeking maximum days alive no matter the physical and mental cost.
I wonder whether it matters as to how those requiring CPR ended up in hospital in the first place: did they suffer a cardiac event outside of hospital, and arrive at hospital with CPR being continued, as opposed to those who were in hospital to begin with, but suddenly required CPR for whatever reason?
That line in itself seems to suggest that the likelihood of CPR being successful increases slightly when a victim is transported to hospital with CPR continuing throughout from the time of their cardiac event, versus those who never make it to hospital, because the CPR givers stop (exhausted, unable to continue) or because efforts before reaching hospital are considered pointless/time-of-death called (as it was clear to medical professionals that CPR isn't going to bring a clearly dead person back to life).