Business case for single responder ambulance paramedic to use CPR without stops for ventilating the patient.
Cardiopulmonary resuscitation (CPR) is a procedure that can be administered from a single person in an attempt to keep a person alive that has suffered from cardiac arrest, which causes the heart to stop. Sudden cardiac arrest (SCA) is the leading cause of death in the United States and is usually fatal within minutes unless immediate action is taken such as beginning chest compressions (American Heart Association, 2006). CPR is conducted by using one's hands to compress the chest in an effort to manually keep the heart pumping thus maintaining circulation of oxygenated blood (American Heart Association, 2006). A person administering CPR can combine compressions with artificial respiration via mouth, or an external device thereby forcing air into the lungs. Cardiac arrest is usually the result of an underlying heart condition, or other condition that causes irregular electrical rhythms of the heart (Jackson, 1997). As soon as possible, an electric shock, e.g. An automatic defibrillator (AED), needs to be delivered to the heart to correct the heart arrhythmia that immediately caused the cardiac arrest (American Heart Association, 2006). Unfortunately, many people are not trained in CPR or cannot perform it well enough, choose not help (the "by-stander effect"), or advanced care cannot be given soon enough (Jackson, 1997). This paper examines some of these issues.
Regardless of how many responders conduct CPR, very few patients receiving CPR alone will recover (Cummins, 1985). Statistics vary on how effective CPR is alone, but an approximation of the survival rate is about 5-10% (Jackson, 1997). CPR is not designed to keep people alive per se, rather, CPR is meant to keep oxygenated blood circulating, therefore keeping the brain alive until further, advanced help can be given such as defibrillation. Defibrillation has been shown to improve survival rates in those who collapse from cardiac arrest by as much as 30% but only if administered within 3-5 minutes (American Heart Association, 2006). The brain can only survive for roughly 4-6 minutes before oxygenation if normal, healthy brain function is to be restored (Merchant, 2009).
Other issues that affect the effectiveness of CPR is the capability of the person administering CPR, e.g. identifying when to use CPR, are they in a setting where they can call for help, can they effectively administer chest compressions, and do they even know how to administer CPR (Gallagher, 1995). Based on the American Heart Association guidelines, a rescuer only needs to perform chest compressions when performing CPR. Mouth-to-mouth ventilating is no longer indicated in CPR if a non-healthcare provider is the responder (American Heart Association, 2006). Guidelines also dictate that a layperson responder not check for a pulse worry in a person who suddenly collapses as some pulses are difficult to detect (American Heart Association, 2006). If a person who collapses isn't breathing, is gasping for breath (agonal breathing), or is unresponsive then the rescuer should immediately begin CPR. A single responder must perform CPR continuously, quickly, and with a great deal of weight at a rate of 100 compressions per minute (American Heart Association, 2006). However, compression rate refers to the compression speed rather than the actual number of compressions delivered per minute (American Heart Association, 2006). If the person cannot perform CPR due to injury such that the strength in the arms or hands is compromised, this will also decrease the effectiveness of a single person responding and performing CPR as the quality of CPR greatly counts (Jackson, 1997). With a child, single hand compressions are still appropriate (American Heart Association, 2006). In any case, any CPR regardless if it's imperfect is better than no CPR (American Heart Association, 2006).
How effective compression-only CPR is depends on many factors, which include whether or not the cardiac arrest was caused by a non-cardiac cause amongst many other factors. Beginning CPR as soon as the person collapses is imperative as is the quality of CPR as already stated. One rescuer shouldn't spend more than 5-10 seconds checking the victim's airway and breathing, making sure the scene is safe, and then shouting for help-getting help is critical to the victim's survival (American Heart Association, 2006). Rescuers tire very quickly when giving chest compressions as well, and compressions can't be too slow or shallow. After 1-2 minutes, even if the rescuer doesn't feel tired, the chest compressions they are performing can deteriorate (American Heart Association, 2006).
A 2010 study investigating cardiac arrest (non-cardiac cause) in children aged 1-17 years found that bystanders performing CPR with respiratory ventilations resulted in a better neurological outcome at one month post arrest than compression-only CPR. However, there was no difference between the two methods in children who suffered from cardiac arrest that had a cardiac cause (Hupfl, 2010).
In people less than 20 years of age, CPR with artificial respiration is more effective than compression only CPR (Ogawa et al.).
However, studies show that compression-only CPR is more effective in adults than CPR and respiratory ventilations especially if the bystander is being given instructions by an emergency services (EMS) dispatcher (Hupfl, 2010). This study also showed that there was no difference between survival rates in those that suffered from cardiac arrest receiving CPR from bystanders choosing to administer CPR on their own compared with bystanders receiving instructions from EMS dispatchers while conducting CPR (Hupfl, 2010). This study also showed that compression-only CPR was associated with a 22% increase in survival rate, therefore more effective that compressions along with artificial respiration (Hupfl, 2010). This study also concludes with the fact that gathering enough data on this subject to show any statistical significance regarding which method is more effective is difficult due to issues such as obtaining informed consent, randomizing patients to groups of different CPR techniques, and sticking to study protocol in a very brief window of time (Hupfl, 2010).
Another study showed that in cardiac arrests that occur outside of a healthcare facility respond better to CPR administered from a bystander in addition to using an automatic defibrillator device (AED) than compression-only CPR (Sanna et al.).
There is a an abundance of data that supports, more than can be described in this paper, that in the case of out of healthcare facility cardiac arrests, CPR along with the use of an AED is most effective, but compression-only CPR is better than compressions with mouth-to-mouth respiration.
Cardiac arrest occurs when there is inadequate contraction of the left ventricle usually due to electrical issues of the heart such as irregular arrhythmias with ventricle fibrillation being the most common (American Heart Association, 2006). Irregular arrhythmias cause circulatory failure. Circulation ceases after shallow, irregular breathing, then there's a loss of cardiac output, a rapid loss of blood pressure, and finally, and then loss of consciousness (American Heart Association, 2006). For a brief period following cardiac arrest, there is oxygen consumption, but acidosis soon sets in, even with compressions and the infusion of any oxygen from artificial respirations (Makino, 2005).
CPR is performed in order to restore cardiac output in order to circulate oxygenated blood and must be performed as soon as possible, preferably within 4-6 minutes to prevent brain death (Higashida, 2003). If CPR is administered well, systolic pressure may raise to reasonable levels (American Heart Association, 2006). CPR forces blood, mostly through the arterial part of circulation, from the chest during the actual compression, and when the compressions releases (chest recoil), the chest returns to its normal position, and blood flows through the venous part of circulation (American Heart Association, 2006). When a person isn't performing chest compressions, there isn't any blood flow to the heart and brain (American Heart Association, 2006). This produces a small amount of blood flow, which amounts to roughly 25% of the normal cardiac output (American Heart Association, 2006). When a person administers mouth-to-mouth respirations, they are trying to simulate adequate inspiration, therefore providing adequate ventilation, however, artificial respiration via mouth only produces about 17% of available oxygen, and 4% carbon dioxide (American Heart Association, 2006).
The majority of cardiac arrests occur in the home (Cagle). A study was conducted to investigate the psychological impact of having an AED in the home of people who were at greater risk for cardiac arrest. This group was compared to homes without an AED, but with people in the household who were at risk for cardiac arrest. A survey was used to assess quality of life, which included worries about being left alone. The group with AEDs in the home reported lower, or worse, scores especially in scoring relating to social functioning (Cagle, 2008). The study included a social activities/worry scale, and all groups scored low, but not as low as the AED group (Cagle, 2008). Even still, there were with no significant differences between the groups (Cagle). Clearly, there is a negative psychological impact on responders responding to a cardiac arrest event.
Data continuously shows that within 3-5 minutes after a person has collapsed, if CPR and defibrillation are administered…