To:              All OEC Instructors, OEC Instructor Trainers & OEC Supervisors

From:          Larry Bost, Education Committee Chair

There have been some major changes in CPR this year and as always some major confusion.  The chart below provides an “at-a-glance” look at the current CPR guidelines for healthcare providers (as presented by the American Heart Association) as well as the NSP policy regarding NSP-approved CPR providers. I asked NSP medical advisor Michael Millin, MD and OEC program director, Ed McNamara to look at these changes and to prepare a informational report on how these changes will affect Patrollers.  Dr. Millin's response is below.  I would like to thank Dr. Millin and Ed McNamara for their quick response to this question.

Dr. Millin’s Analysis

This is actually an interesting question that is filled with controversy and quite a bit of active research.

The short answer to your question is that the current recommendation is that CPR preformed by a trained healthcare provider (including OEC technicians) should include both chest compressions and rescue breaths in a ratio of 30 compressions to 2 breaths. The long answer is a bit more complex, so please bear with me. For many years it has been believed that the keys to survival from sudden cardiac arrest are chest compressions and defibrillation. The primary initial rhythm in sudden cardiac arrest is typically ventricular fibrillation, which is best treated with electrical defibrillation. The purpose of chest compressions is to circulate blood to the cardiac muscle.

Despite years of community programs to get bystanders to perform chest compressions, there are still low percentages of sudden cardiac arrest patients that get bystander CPR. It is believed that one reason for low bystander CPR is fear of doing mouth-to-mouth rescue breathing. Therefore, researchers have examined the question of survivability if CPR is performed by the lay public with only chest compressions. These studies have clearly shown that when performed by the lay public compression only CPR is just as effective as standard CPR with compressions and rescue breathing. It is this research that has evolved to the most recent recommendation by the American Heart Association (AHA). It is important to understand that the above mentioned research has all been examining CPR in the hands of the lay public. At this point in time, the medical literature is not able to answer the question of standard CPR vs. compression only CPR when performed by a skilled healthcare worker. This is why the recommendation for trained healthcare providers is to continue with standard CPR.

If you are ever truly faced with doing CPR in your capacity as an OEC technician you will notice that CPR is hard work. You will break ribs on your patient, and after 2 minutes of pushing hard, pushing fast you will be exhausted. While I have seen the value of chest compressions in my own clinical practice, this is supported in the literature as well. The most notable recent study was published by Wik, et al. that demonstrated for those patients with a down time greater than 5 minutes, chest compressions before defibrillation were more successful that just defibrillation. The bottom line is that the current literature supports compression only CPR when performed by the lay public and standard CPR when performed by a skilled healthcare worker. When performing CPR, Push hard and push fast for 30 compressions then perform 2 rescue breaths. Do five cycles and then using an AED, defibrillate if indicated. After defibrillation immediately Push hard, push fast. Do not check for a pulse. Frequently rotate the rescuer doing the chest compressions to minimize fatigue and degradation of the quality of the compressions. Finally, the coordination of doing CPR and getting the patient out of the environment can be quite complex. Exactly how you do this is up to your area. You should look to your local medical advisors, patrol leadership, and area management for direction. The fact is that you may have to stop chest compressions in order to get the patient off the side of a mountain. This is not ideal, but it is reality. If you do have to stop chest compressions, your area should develop a protocol that utilizes resources to as much as possible minimize the time that the patient is without CPR. The reason that this should be an issue of local direction is that the best way to minimize time without CPR will be dependent on the local resources and the topography of the area. I will say that at my local hill we have developed a protocol whereby two patrollers take the patient down in a toboggan. Other patrollers are then strategically placed at about 30 second intervals to perform CPR along the route to the base of the mountain.

While we have not had an actual case yet with this new protocol, we have practiced it many times and it seems to work well. Regardless, every area is different so every area should develop a system before the event that works for the local area. The key is to have a protocol in place that works before the actual event. In addition, I can’t stress enough that regardless of the details of your area’s protocol, it should not put OEC technicians at harm. Your plan should not put OEC technicians (or the public for that matter) at harm for the purpose of trying to save the life of a dead person that has a low chance of survival. Just so that we are clear one more time: 30 compressions with 2 breaths – Push Hard, Push Fast.

- Michael G Millin, MD, MPH, FACEP NSP National Medical Advisor

Current CPR Guidelines (for healthcare providers)

Maneuver	Adult: 8 years and older	Child: 1 to 8 years	Infant: Under 1 year
Activate	Activate / call for AED when victim found unresponsive If asphyxial arrest likely, call after 5 cycles (2 minutes) of CPR	Activate after performing 5 cycles of CPR For sudden, witnessed collapse, activate after verifying that victim unresponsive
Airway	Head tilt-chin lift (suspected trauma; use jaw thrust)
Breaths Breath check < 10 secs)	2 breaths at 1 second/breath	2 effective breaths at 1 second/breath
Rescue breathing without chest compressions	10-12 breaths/min (approximately 1 breath every 5-6 seconds)	12-20 breaths/min (approximately 1 breath every 3-5 seconds)
Rescue breaths for CPR with advanced airway	8-10 breaths/min (approximately 1 breath every 6-8 seconds)
Foreign-body airway obstruction	Abdominal thrusts		Back slaps and chest thrusts
Circulation Pulse check (< 10 secs)	Carotid (can use femoral in child)		Brachial or femoral
Compression landmarks	Center of chest, between nipples		Just below nipple line
Compression method: Push hard and fast Allow complete recoil	2 Hands: Heel of 1 hand, other hand on top	2 Hands: Heel of 1 hand, with second on top, or, 1 Hand: Heel of 1hand only	1 rescuer: 2 fingers 2 rescuers: 2 thumb-encircling hands
Compression depth	1 ½ - 2 inches	About 1/3 – ½ the Depth of the chest
Compression rate	About 100/min.
Compression- ventilation ratio	30:2	30:2 (single rescuer) 15:2 2 rescuers

NSP-Approved CPR Providers

All active NSP members must demonstrate their CPR skills each season, regardless of the certifying agency’s requirements or the expiration date of the card. (All active NSP members must hold a current professional-rescuer CPR certification from the American Heart Association, the American Red Cross, the National Safety Council, or American Safety and Health Institute, or Medic First Aid. This training must include breathing and cardiac emergencies, and adult, infant, child, and two-rescuer CPR techniques.)

- 2007-2008 Polices & Procedures, 14.3.4.1