Is CPR Performed on a Moving Ambulance Stretcher Effective?

[Ridryder 911]

Is CPR Performed on a Moving Ambulance Stretcher Effective?

http://www.merginet.com/index.cfm?pg=cardi...fn=CPRstretcher

By Bryan E. Bledsoe, DO, FACEP

March 2006, MERGINET—We are learning a great deal more about cardiac arrest. We know now that victims of blunt trauma who are in cardiac arrest when EMS arrives are dead and resuscitation efforts will be futile. Likewise, we are learning that if CPR and defibrillation are not applied soon after the onset of cardiac arrest, the chances of survival decrease by about 10 percent per minute.

By the time the patient is 10 minutes out from cardiac arrest, without emergency care their chances of survival are dismal. In many countries, CPR and ACLS measures are provided in the field. If unsuccessful, efforts are terminated and the patient pronounced dead and left for the mortuary. This is a good practice. There is little an emergency physician can do for a medical cardiac arrest in a hospital that a paramedic cannot do in the prehospital setting. Now, this may change when we start inducing hypothermia in cardiac arrest patients. But, until then, we really ought to stop transporting dead people.

I have always questioned the quality of CPR provided in a moving ambulance or on a moving stretcher. Many times in my paramedic career I “rode” the rails of an ambulance stretcher while attempting CPR. But, how effective was that practice? Now, researchers at the University of Pittsburgh have studied the technique.

Using a prospective, randomized crossover design, volunteers (EMT students, paramedic students, EM residents) were assigned to two-person teams. Each team performed two 6-minute bouts of CPR on a recording Resusci-Anne either placed on the ground or placed on a moving ambulance stretcher. One team member provided bag-valve-mask (BVM) ventilations and the other provided chest compressions. After three minutes into each bout, the roles were reversed.

There were 62 subjects and thus 31 teams. They found that the difference between the rate of compressions on the floor and on the moving ambulance stretcher were not statistically different. The tidal volumes delivered by BVM were not statistically different between the positions. However, compression depth and percentage of correct compressions were better when performed on the floor than on the moving ambulance stretcher. In addition, the percentage of correct ventilations was better for the floor position.

They concluded that chest compressions and ventilation quality of CPR on the ground was superior to CPR performed on the moving ambulance stretcher. One point that was clear from the recent 2005 American Heart Association CPR guidelines is that uninterrupted chest compressions are very important in terms of patient survival.

This study showed that the practice of attempting CPR on a moving ambulance stretcher resulted in compromised CPR. I think every EMS system needs to revisit their protocols and positions on field termination of CPR in medical cardiac arrests so as to minimize transport of patients needing CPR.

Reference

Kim JA. Vogel D. Guimond G. Hostler D. Wang HE. Menegazi JJ. “A Randomized Controlled Comparison of Cardiopulmonary Resuscitation Performed on the Floor and on a Moving Ambulance Stretcher.” Prehospital Emergency Care. 2006; 10:38-70.

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So does this mean I can call more codes, because I have to move them ?... sounds like it. Definitely less work in ER.

R/r 911

[bandaidpatrol]

I suppose it's better than nothing.

I liked the old cots, you're six inches off the ground, just straddle the guy and continue with CPR. No chance the cot will hit a "doorway bump" and flip, and no hitting your head on hanging signs. I had four stitches after hitting my head on metal sign hanging off the ceiling. Needless to say, that "Ambulance Entrance" sign disappeared that night... I think I still have it in the garage.

[kevkei]

So this confirms what we all already suspected. So what? I think it is unrealistic to summise that we discontinue on the basis that during transit, compression quality deteriorates. There are more influential and supportive arguments than this for this practice.

There are also certain patients that we can't call on scene and therefore have to transport. Don't get me wrong, my preference is to work a code to it's fullest and if appropriate, discontinue on scene.

[TechMedic05]

Yeah. It would then make it rather difficult to explain some situations. What if you intercept a service for a patient in an asystolic arrest, and work the patient on scene? Happens. Now, after working for a few minutes, heaven forbid you actually get a return of spontaneous circulation. Is there anything there to protect providers from a potential liability for not transporting in a timely manner? It would seem rather...silly...to work a patient on scene for 10, 15 minutes, and then be all hurried to transport a serious patient.

Just my $0.02

[Kenny]

Have a look at this automatic CPR machine

[cosgrojo]

Yeah. It would then make it rather difficult to explain some situations. What if you intercept a service for a patient in an asystolic arrest, and work the patient on scene? Happens. Now, after working for a few minutes, heaven forbid you actually get a return of spontaneous circulation. Is there anything there to protect providers from a potential liability for not transporting in a timely manner? It would seem rather...silly...to work a patient on scene for 10, 15 minutes, and then be all hurried to transport a serious patient.

Just my $0.02

I would have to agree with you on this one. I think it would be irresponsible of us to not transport in a timely manner when reasonable. This idea that enroute CPR is less effective is not exactly mind-blowing. Maybe we should practice in the same manner as the study indicated. In our Basic courses actually have a module of en-route CPR. Ride that stretcher... stradle that mannikin... Instead of throwing the practice out the window and staying on scene until you make the call, how 'bout get better at that particular skill. I'm sure that better techniques could be developed. If not... just buy everyone one of those thumpers pictured above. 8)

[Ridryder 911]

As an instructor, I used to place recording mannequins on back of moving ambulances, and have students continue compressions with ventilation's going hallways.. carrying down stairs... etc. It is impressive how much error can occur in compression strength and interruptions.

Only a few of you might remember the non-interrupted technique of CPR. There used to be at one time the compression technique to switch With the chest rescuer would change on 3 and the second rescuer would immediately get prepared with the hand intercepting on 4 & 5. Marathons used to be held to raise money for AHA and P.R. Demonstrating CPR was never interrupted for 24 hrs or so.. etc.

Wonder why AHA did not resuscitate that method since it was studied and approved successful... this would decrease the interruption period as well....

With more research we do .. the more it appears we should lesscare & treatment for the patient and declare death more often ?

Food for thought.

R/R 911

[cosgrojo]

Wonder why AHA did not resuscitate that method since it was studied and approved successful... this would decrease the interruption period as well.... R/R 911

Pun intended?

[bandaidpatrol]

Have a look at this automatic CPR machine

We've had those for over twenty years, good on a chopper, waste of O2 on an ambulance.

[TechMedic05]

The Autopulse looks to be a bit better of an option than the pumper. unfortunately, they're [i believe] still investigating a thoracic spinal fracture that was possibly caused by the Autopulse.

Realistically, with new research coming around, it should be neat to see the new toys people make.