Recent discussions
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Tony Bennison
Agreed. It is flawed to expect anyone to differentiate the underlying cause of the arrest in this scenario - it could be cardiac in origin, even in a fit, young individual. -
Tony Bennison
I am very pleased that this issue is now the subject of a review - long overdue, in my opinion, and I believe the debate should be widened beyond the standard 'drowning = respiratory' model.. For a start, it is flawed to assume that the apnoeic patient pulled from water has 'drowned'.. The underlying cause could very well be cardiac in origin - even in an apparently healthy, young individual. The UK charity Cardiac Risk in the Young advise that the incidence of cardiac pathology is probably under-reported at post-mortem due to assumptions made that drowning is the primary cause, when there could have in fact been an underlying arrhythmia. Especially difficult to detect post-mortem if this was an electrical/metabolic disorder such as Brugadas, as opposed to a structural disorder such as HCM. This was graphically shown in the episode of 'Bondi Rescue' of the young Japanese student dragged from the sea in arrest. He was treated by the lifeguards in accordance with drowning protocols. On admittance to hospital it became apparent he had an underlying dysrhythmia. Second flawed assumption is that blowing expired air (or even via BVM) into the patients mouth results in improved oxygen saturations. This is too simplistic a justification for this approach, on which the science and evidence is - at best - inconclusive. Finally, the debate needs to get away from the respiratory vs cardiac argument and stop extrapolating what we assume from hospital or lab based studies. None of these include the mental and physical stress of extricating this patient in the first place, the practical challenge of trying to quickly and accurately identify normal vs agonal efforts and a pulse, all in difficult circumstances and usually a public place. Opening and maintaining a patent airway in these patients is sometimes impossible, as is trying to deliver effective ventilation without causing reflux.. Chest compressions are simple and straightforward in this situation - airway and breathing are often not - particularly for the non-health care professional. And above all we have to keep in mind that if we want to make these guidelines accessible to everyone, so that any bystander is willing to step forward, they have to be simple and reassuring - complexity is the enemy here and it is ridiculous to expect anyone to differentiate cardiac vs respiratory in this highly stressful, often panicky environment - the rescuer here will mostly be lay people who train infrequently and rarely experience the reality of pre hospital arrest - they need clear, unambiguous instructions. I believe the approach should be good quality chest compressions first and foremost, reassuring the rescuer that if the patient is in cardiac arrest, the compressions will help promote a perfusion pressure until the defib arrives, but if the patient has 'drowned' and is in respiratory arrest with an output, the compressions by themselves will often stimulate the patient to cough, gag, vomit/reflux - actions which in themselves may well restore normal breathing.. Yes of course - the longer the problem continues - oxygen will become more imperative - but it is only EMS with an airway adjunct/BVM/high flow 100% who can influence this - if the patient doesnt survive this event - whether cardiac or respiratory in origin, it could never be shown to be because a bystander had failed to do the 'Kiss of Life'.. Thank you for allowing me to comment and apologies for my long response, done on my phone! Best wishes to all. -
Carl Gwinnutt
As someone who lives by the coast and trains local lifeboat personnel they have recognised that those who suffer a cardiac arrest 'out at sea' can be divided into 2 main groups which I find quite interesting. The first is the 'youngsters' who are most likely to have drowned and have a hypoxic arrest. I have taught the crew that ventilation in this group with additional oxygen (they have facemark with the ability to add oxygen) is important and may in some cases be all that is required. Furthermore, trying to do quality CPR in a RIB is very difficult (see below). The second group are the older generation who frequently have co-morbidities and are more likely to have a primary cardiac cause of their arrest. In this group, the key thing is for them to start chest compressions as a primary procedure and get the person to the nearest AED. The crew have a map of all the AEDs along the coastline they cover and normally this only takes a few minutes, but is weather dependant. If this is delayed by more than a few minutes, they may then decide to add rescue breaths with supplementary oxygen. Doing CPR is very difficult but I decided to let them work out what they feel is the best position for the victim to make this as easy as possible, and they decided that they would lift the victim's legs up and place them on the side of the RIB! This of course may actually be beneficial and help with venous return. Food for thought.......... -
Haldun Akoglu
I think ventilation first approach is well known and accepted in public and repeatedly reinforced in movies and series. Moving towards CAB would actually mean a change from common knowledge for lay person education. For professionals, CAB should be thought as the only approach. -
Gerard Meijer
Is there a pre-ventilation action to clear the airway of any oropharyngeal 'foreign body' eg water, in the case of drowning by putting the casualty briefly on their side to allow whatever is there to 'drain' out? To ventilate extraneous water, bile or any liquid down into the bronchial system sound counterproductive. -
Gerard Meijer
Dear Leonard May I beg to differ on being too late to increase competence. It would seem that the incentive to become more efficient/effective is heightened by the pandemic. As a first aid trainer with SES I have noted a more intense interest in the CPR component. My wish-list includes having the compression measuring device available. -
Gerard Meijer
Is there any organisation which is examining the 'retention' aspects of CPR abilities? It would be easy to do in house within organisations I would venture to propose. Training retention of any knowledge is good but how good is it and what makes it better? It is not possible to be quite as regulatory as the national paramedic training which mandates regular reviews - which is why their personnel are so good at it. -
Gerard Meijer
I have a 5 year old granddaughter who attends a private school and very interested in the resuscitation information she has been taught. Full marks to the school swimming trainers who have included the processes in their swimming safety briefs. I shall be seeking to take her training in the safety domain by involving her in the Royal Life Saving programme. her mother has board her joining Little Nippers at the Southbank pool facility. These little minds are so curious and take up skills like sponges. -
Shinichiro Ohshimo
Congratulations on the completion of the Systematic Review! I appreciate your excellent work. I think this SR is a new recommendation on the order of resuscitation in drowning. One concern is that the cause of drowning may be a mixture of airway obstruction and non-respiratory causes such as fatal arrhythmia. Is it possible to make the same recommendation for drowning and cardiopulmonary arrest due to fatal arrhythmia? -
Shinichiro Ohshimo
Congratulations on the completion of the Scoping Review! I highly appreciate your Scoping Review. I think this Scoping Review includes an important finding for the training of CPR instructors. One question I have is whether the teaching skills of instructors differ depending on their job title. If there are certain professions that are better suited for teaching, this may provide hints for other professions to improve their skills.