CPR While Moving

[Echoburger]

Hi, I've been wondering, what is the proper/best way to perform CPR on a cardiac/full arrest patient while on a stretcher that is moving?

Is it a wise idea to put both feet on the stretcher's bottom rails? Could you potentially distribute the weight unequally and cause the stretcher to fall?

Also, one more thing. I understand that quality CPR is performed best when the person is directly over the person they are doing CPR on with their arms locked. In an ambulance situation, is it appropriate to sit on the bench and perform CPR or would it be necessary to stand so you could be directly over your arms when compressing?

Thanks.

[spenac]

Hey Echo first missed seeing around here lately you young troublemaker.

As to rolling CPR it is against AHA guidelines to do rolling codes anymore. No matter what position you attempt to take you will be getting bounced around and compressions will get interrupted. I'm sure some will give you their methods but really services need to start working codes on scene then pronounce them if no ROSC. Sorry not much help.

[WolfmanHarris]

You shouldn't be performing CPR moving anywhere as per AHA guidelines.

Unfortunately, that's not always the case. For instance in my service PCP's are not currently part of the BLS medical termination of resuscitation study. So if for some reason a PCP crew were to respond to a VSA and not receive ACP back-up we would have to transport. This is frustrating, but remains a hypothetical as I'm yet to see a VSA not get an ACP on scene before we finish our directive.

There is no way I can imagine to perform CPR effectively on a moving stretcher, nor can it be done effectively or safely in a moving vehicle. Essentially it's a crap sandwich and everyone has to take a bite. The patient will get crappy CPR, not perfuse and stay dead. The provider will have to place themselves in a potentially hazardous situation for minimal gain.

So what I would suggest is:

- lower the stretcher to keep centre of gravity low before considering riding the rail

- place more then the usual two providers to move the stretcher

- any interruptions in compressions (i.e. loading the stretcher) should be planned ahead and communicated to limit interuptions as much as possible

- during transport, for ****'s sake, DRIVE SLOW!

[MS Medic]

I agree with spenac, but there are occaisions such as one I had last month.

I had a code at a nursing home that was in PEA when we arrived on scene. Worked it for 20 minutes, pushed algorithm drugs and treated H&T. In the process, the pt converted to asystole. I called med control to pronounce. The doctor told me to work it for 10 more min and if I did not get any change, I could call it. (This was a staff doc who is usually pretty good on med control, so I don't know why he told me to do that.) The problem was that the nursing home is directly across the street from the hospital, so I could not justify not transporting. In that case, I did CPR from the room to the truck and from the truck to the ER. About a year before that, I had a trauma pt that coded en route to the hospital and had to work it into the ER.

But to answer the question, I am a small guy and I have 2 people rolling the stretcher while I stand on the undercarriage and do compressions from the side. I find this to be the "most effective" method as it allows me to focus on compressions and not have to worry about the stretcher's movements.

Edited October 2, 2009 by MS Medic

[HERBIE1]

Sorry folks, but I disagree here. Is optimal CPR being performed while in motion- of course not. Is it a reason NOT to do CPR enroute- no way, especially if you have a short transport time. WHat if the person does not meet your system's criteria for termination? Different scenarios.

With multiple people to help, we do CPR with someone doing proper 2 handed CPR while someone holds the belt of the person standing. On my own, I will stand, hold the overhead bar with one hand and do compressions with the other. Effective? Apparently good enough, since I've had ROSC's and even saves using this technique.

Again, we do the best we can with the circumstances we encounter. Guidelines- whether they are AHA, PHTLS, or CPR are just that- guidelines. Doing something is better than nothing.

[mobey]

Ya could just sit on thier pelvis and bang on thier chest that way.

Kidding, kidding.

"Riding the rail" as much as I hate to admit it, is about the most efficient way for those of us who do not have field termination orders.

Just make sure there is something hard benieth your patient.

[JakeEMTP]

Yeah, we have field termination orders. Spenac has it right yet again! If you absolutely have to do CPR enroute for some reason, the only thing I can think of is your patient codes enroute to the hospital, please make sure you have a backboard under you patient. The Attending Physicians at the hospital we go to HATE when crews bring dead people in. There is nothing more the hospital can do that cannot be done in the field.

Herbie, while I agree with a lot you have to say, I feel you missed this one. When you feel you're doing something, essentially you're doing nothing.

Edited October 2, 2009 by JakeEMTP

[Mateo_1387]

The doctor told me to work it for 10 more min and if I did not get any change, I could call it. (This was a staff doc who is usually pretty good on med control, so I don't know why he told me to do that.) The problem was that the nursing home is directly across the street from the hospital, so I could not justify not transporting.

Why couldn't you justify it? You even had an order to terminate in ten minutes provided there is no ROSC.

[Echoburger]

Thanks for all the replies, everyone.

Yes, I've seen a couple instances of people riding the bottom rails of the stretcher. However, I just have a gut feeling that the stretcher could tip over or something like that...

The city that I ride out in happens to transport every (as in, a lot) of the codes due to fact that the medical control system is...well...crappy to say the least.

I have never thought of holding the top metal rails in the ambulance and compressing with one hand. That sounds like an option, since it's so bumpy in the back. I guess you'd just have to push harder since you only have one hand compressing.

:-)

[HERBIE1]

Yeah, we have field termination orders. Spenac has it right yet again! If you absolutely have to do CPR enroute for some reason, the only thing I can think of is your patient codes enroute to the hospital, please make sure you have a backboard under you patient. The Attending Physicians at the hospital we go to HATE when crews bring dead people in. There is nothing more the hospital can do that cannot be done in the field.

Herbie, while I agree with a lot you have to say, I feel you missed this one. When you feel you're doing something, essentially you're doing nothing.

That comment was in regards to the inference that it's a waste of time to continue to do CPR if we have no ROSC. I was trying to say that in the absence of a termination protocol, although the odds are essentially nil, any efforts would be better than doing nothing. Before we had in field termination capabilities, it was frustrating to work a patient, even knowing our efforts were probably in vain, and as soon as we hit the ER the, MD would review our treatment, confirm asystole or even a PEA, confirm ET placement, and call the code without every doing a thing for the patient.

We used to get the occasional- "This person is dead, why are they here?' from a new or moonlighting doc unfamiliar with local protocols. I would have to explain that we do cannot terminate a resuscitation without a doctor present. Now ER's know the person is at least still viable, they do not meet termination criteria, or we would not be transporting.

Certainly field termination is a better use of resources- both of EMS and ER's but not everyone has this luxury- especially BLS providers.