By Kyle Williams, RN, CFRN, EMT-P
(DR. BONES SAYS: From time to time, we receive submissions from promising writers in the field of medical preparedness. Today, we have a well-reasoned article from Kyle Williams, a certified flight nurse and paramedic, on CPR and its implementation in survival settings.)
Articles and podcasts on survival medicine generally include advice about obtaining CPR and first aid training as an essential part of our survival skills. Indeed, this training should be a high priority for preppers (as well as everyone), but one question that is rarely addressed is: Are the most modern standards of care applicable to survival situations?
Today, every aspect of healthcare, from basic first aid and CPR up to the most advanced surgical techniques, are based on a fully functional, well integrated, and highly technical healthcare system. The assumption in first aid and CPR training is that for anything more than simple cuts and bruises, our first aid skills are geared at keeping the patient stable until a higher level of care arrives or a patient reaches a hospital. In a survival situation when a higher level of care or transport to a hospital may not be available or may be significantly delayed, it may be necessary to modify the way we provide care. This intent of this article is not to debate current training guidelines; they are based on solid research and evidence.
Over the last decade there have been several changes to the standards of care for CPR. These changes have been based on the best scientific evidence available from large studies and have most certainly led to an increase in survivability.
One of the biggest changes has been to the way non-healthcare providers perform CPR. We have moved from a standard of 15 compressions and 2 ventilations, to compression-only CPR. The theory behind compression-only CPR is that during cardiac arrest, the body’s oxygen consumption is extremely low. The combination of passive oxygenation from the pressure changes in the lungs during compressions and the oxygen that remains in the blood are enough to maintain minimal cerebral oxygenation. Additionally, anytime compressions are stopped, cerebral blood flow stops. It takes a minimum of 15 compressions to build that blood flow back up. In the first few minutes of cardiac arrest, blood flow is what the patient needs most.
In a survival situation, the EMS system is not functioning normally; the single lay-person may be performing CPR for a prolonged period (more than 5-10 minutes). It will be necessary to deliver breaths. With the focus remaining on high-quality compressions, the lone rescuer should perform 30 compressions and 2 ventilations. A second person should assist as soon as possible because with one person performing compressions and the other ventilation, compressions will be interrupted for significantly less time.
WHEN NO HELP WILL BE COMING
What are we to do when the professional rescuers are not able to respond? A discussion of CPR in a survival situation would be remiss without discussion of when CPR should be stopped. Obvious signs of life, such as movement or spontaneous breathing, are signs of return of spontaneous circulation and CPR should be stopped and the patient monitored closely. It is likely that most patients will require continued rescue breathing.
What if the patient does not regain a spontaneous pulse? How long should you perform CPR when help will not be coming? The answer to this question will vary with each situation and here are a few things to think about should you ever be in such a situation.
Are you sure help will not be coming? The likelihood that a patient will regain a spontaneous pulse with CPR alone is extremely small in most cases. The most common non-traumatic cause of cardiac arrest are the lethal arrhythmias ventricular tachycardia and ventricular fibrillation which require defibrillation to convert back to a normal heart rhythm. Without a functioning EMS system to bring a defibrillator to the patient quickly, chances of survival are very low.
The increase in public access defibrillators has increased survival rates dramatically, so know where the closest defibrillator is and learn how to use them. In a witnessed arrest situation in which CPR is started immediately, the rescuer can attempt a precordial thump as a form of manual defibrillation. There are several good Youtube videos on how to perform this procedure.
What is the mechanism of injury? Under the best circumstances, with early CPR, early advanced life support, and rapid transport to a trauma center, a person suffering cardiac arrest caused by traumatic injury has less than 0.1% chance of survival.
(DR. BONES SAYS: As you can imagine, it takes a major degree of trauma to stop a healthy heart; thus, the low survival rate. We will be publishing an article or video on working a portable defibrillator in the near future.)
The most common non-traumatic cause of cardiac arrest in adults over 40 is myocardial infarction, which results in the previously mentioned arrhythmias. With immediate CPR, rapid defibrillation, early advanced life support and transport to a hospital capable of treating the clotted artery, survival is 65% at best. The most common cause of cardiac arrest in children is respiratory arrest. Early CPR and effective ventilation can often reverse the early stages of cardiac arrest in children.
Was this a witnessed cardiac arrest and was CPR started immediately or was there a delay in care? After 5 minutes of cardiac arrest without effective CPR, the chances of survival drop in the single digits even with the best care in a hospital.
What would the patient want? Has the patient ever expressed to you what they would want? Would they want everything done for as long as possible or would they want to die in peace and with dignity? Even if the patient never directly expressed his or her wishes, you may know what their wishes would be based on the life they led or conversations about other similar situations.
(DR. BONES SAYS: Part of your duties as survival medic is to take a history and serve as medical archivist. You should ask every member of your group what their wishes would be in the situation discussed above. Do it BEFORE a disaster occurs.)
Am I prepared to stop? Of all the questions, this is the toughest to answer. Would you be able to stop CPR on a child? On a loved one? On a stranger? As a paramedic and critical care nurse for over 20 years, I have had to make the decision to stop resuscitation many times, but always when the patient was a stranger and I the (somewhat) detached rescuer. Could I make a rational and objective decision to stop CPR on a loved one? Hopefully I will never have to find out, however it is something to take into consideration. Try to be as objective as you can, but if in doubt, go until you cannot go any longer.
WHEN THERE IS NO MORE THAT CAN BE DONE
It has been my experience (and evidence supports these numbers) that patients in cardiac arrest for more than 20 minutes, without return of pulses, have almost no chance of meaningful survival. We will define a meaningful recovery as not just merely regaining a pulse, but more importantly, the ability to live a productive life, to walk, talk, eat, and enjoy life. After all, regaining a pulse only to remain in a vegetative state is not our goal. When it comes to CPR in a survival situation, always remember to pump hard and pump fast, but also continually evaluate whether or not we are helping or harming the patient.
LEGAL ASPECTS OF STOPPING CPR IN A SURVIVAL SITUATION.
In normal times even the most autonomous paramedics must contact a medical control physician and get an order to stop CPR and in the hospital, a physician must be present and make the final decision to stop resuscitation. In first aid and CPR classes, the lay person is taught to keep going until you physically cannot perform compressions any longer. But these are rules for normal times, when two-way radio systems and cell phone services are functioning. What should we do in survival situations? The answer to this question depends on what type of survival situation you are in.
If you are in the backcountry wilderness with no way to communicate with medical authorities, you are in a legitimate survival situation and have to make the decision for yourself using your best judgment.
In most states you are covered by Good Samaritan laws. In a backcountry, SHTF or TEOTWAWKI survival situation, you may or may not have some form of communication with health authorities such as cellular or satellite phone, or a two-way radio. If you do, try to contact the closest 911 center who should be able to patch you through to a local emergency department physician. They should be able to provide you with guidance, as well as assist in the decision that everything reasonable has been done and that it is okay to stop resuscitation. Discussing the decision to stop resuscitation with a physician will provide you with both a level of comfort that you have done everything possible and are making the right decision, as well as provide you with legal backing.
(DR. BONES SAYS: Clearly, this is a difficult decision in a survival scenario. You will be deciding when to stop CPR on a member of your family or mutual assistance group. Understand that the survival rate from any cardiac arrest in a grid-down situation is very low, and so will your resources. CPR will still be a mainstay of training to deal with airway obstructions.)
Today your skills are aimed at supporting an injured person for just a few minutes until help arrives. Being forced into a true survival situation changes the rules of the game in many ways, not the least of which might be turning you into the only care available. If your goal is to learn medical skills for survival situations, is a wise idea to get more in depth training aimed specifically at providing medical care in austere environments. Hopefully this article has given you some food for thought and provided you with a bit of guidance to help you make the right decision should you ever be put in a survival CPR situation.