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Special Considerations for CPR, AED, & Choking
So over the years of doing trainings, I've had many questions come in via email and telephone support in regards to special considerations related to CPR, automated external defibrillators and choking skills and the different patients a rescuer may encounter. So I thought we would do our own training episode that talks specifically about these special considerations so as to not confuse or elongate the training when it gets to the specific skill. However, I thought it was important because these special considerations can sometimes throw in an anomaly to how we treat the different types of patients with those special considerations. So, let's talk about CPR first. The three different topics that I thought were the most popular were the size of the patient, the crepitice or crunching feeling that one might feel either because they have rib fractures or simply because we had a separation of cartilage from the sternum when we did the compressions and thirdly impaled objects when we do CPR compressions. So when we talk about the patient's size, it doesn't mean that the person is necessarily obese or overly large. It could be that a small child is trying to rescue a large normal adult. In this difference in size can create its own problems. I always encourage my students to remember that if they for whatever reason cannot do an adequate chest compression because it takes an extra amount of pressure, or more weight than the rescuer has to do, the 2 to 2.4 effective depth for the chest compression, it's always good to call 911, get help on the way, but also maybe recruit another rescuer as a bystander. Get help from other people. Maybe there's another larger person that you could teach how to do those chest compressions to. They're very simple, but they could actually become your liaison and be able to do that effective chest compression when you may not be large enough to do it yourself. Secondly, a lot of people get concerned that they're hurting the cardiac arrest patient when they do the chest compression and they hear a pop. Or they feel this snapping and crackling or crunching feeling. This could be especially related to a traumatic injury now followed up with cardiac arrest. Or the normal problem that we encounter, which is really no problem at all, and that's just when the sternum pops from the rib cage because it's connected by cartilage. Much like when you crack your neck or when you crack your knuckles, it's releasing that air trapped in that cartilage. It isn't as scary as it may feel or sound, and in reality the patient is already dead or we wouldn't be doing cardiac compressions. So it's important to understand that we cannot hurt the victim worse. We can only help them through CPR compressions. So don't let that snapping, cracking or popping deter you from doing deep, good compressions at a good rate. And lastly, impaled objects in the chest. The only time that would stop us from doing CPR compressions is if the impaled object was actually in the exact location where we would do chest compressions. If that's the case, call 911, keep the scene safe, and do whatever else you can do to stop bleeding or other issues. But obviously we're not going to be able to do CPR compressions if a knife or some kind of bar is sticking right out of the middle of the sternum. This is a bad situation and unfortunately bad things happen to good people and there isn't always going to be a good ending to a sad story. But if the impaled object is somewhere else and not in the way of chest compressions, work around that impaled object and do the CPR compressions to the best of your ability. This also applies to rescue breathing where something might actually be impaled in the mouth, the face, or in the airway. Do what you can the best you can, activate EMS and that's the way you're going to encourage the best outcome no matter what the problem. Now lets talk about the special considerations as it relates to automated external defibrillators, otherwise known as AED's. There's about 4 main topics that I hear the questions come in most often. And they're related to jewelry that might be in the way of the electrical shock. Two, medication patches that might be applied to the skin in the way of the pad. Three, is it okay to have an under-wire bra in place and use the defibrillator and four, what is the problem if there's breast tissue in the way. So we want to talk about those four as they probably are the big ones and I want to make sure we empower you to know what to do if you encounter any of these situations. Let's go through them. Number one, do I have to worry about jewelry? Well, that's really a good question actually. Because we've seen an evolution of the types of jewelry that we might see. And that includes not only necklaces but it may include piercings. And the thing of it is is that piercings normally don't cause a problem unless the piercing is directly where we need to apply the pad or they're directly in the pathway where the electricity might travel. Chains or necklaces are easy to move. They can just be put to the side. They don't even have to be taken off. Now piercings can be left in place unless like I said, they're right where you need to place the pad or directly involved in the pathway of the electricity. Secondly, we're going to talk about patches that are medicated. This includes nitro patches, pain relief patches or other medications. If you encounter a patch that might actually be located on the upper right side, that could be something that would cause problems. And if the AED actually is used and that patch is in place it has been known to cause burns. So if you find that just simply take the patch off, wipe the medication off and apply your pads as normal. Thirdly, lets talk about under-wire bras. There's been a lot of questions about whether or not you can leave that in place. And I think just to keep it safe, if the under-wire bra looks like it might be interfering with the pathway of the electricity, remove the bra and move it to the side. That way we won't actually running a risk of causing electricity to follow the surface of the chest wall and be redirected around the heart through the under-wire bra. And lastly, when we talk about the gender difference between male and female the consideration of breast tissue might be a question. All you would have to do if it applies, is simply move the breast tissue out of the way so that you can apply the pad to the left mid axillary rib cage. And then you should be fine. These special considerations are important to understand and when we understand how to get around them, we can use the AED extremely well. And lastly, the special considerations as they apply to choking patients. The three that I really want to talk about that seem to be the most popular that I hear from you the students and other people is what do I do if the patient is too large for me and I can't reach around them. Number two, what if they're pregnant, and number three, what if it's an obstruction that won't come out. So let's break those out. The first one is again the disparation between a smaller rescuer and a large patient. I can't reach my arms around them. I can't reach them because they're too big. Maybe they have a big belly. Maybe it's just the fact that they're overly large and I'm overly small and it's not working. Two things--look for a bystander that you can get to help you. That's maybe larger and can actually reach around or you might be able to actually go up to the sternum and do those inward thrusts on their sternum instead of doing them on their abdomen. We simply would reach around, tuck our thumb in, go under the breast, on the sternum and do inwards thrusts. Worst case scenario, the patient is going to pass out in about a minute and a half and they're going to be on the ground. I say that because it's going to be extremely difficult to encourage a choking person to lay down on the floor for you. So we're going to do the best we can with what we've got, but eventually they will go unconscious if they don't clear the obstruction themselves or they don't get air in and actually circulate oxygen. Once they're on the ground, we're going to do CPR compressions. And there isn't really a problem with that unless they're an extremely large person, and in that case we're going to need help. But again, we've called 911. EMS will be there soon and they'll be able to help us as well. And in most cases, even by accident we can sometimes get that object out. It's very effective. But number two, we want to talk about pregnant females. Now when women are pregnant, there's two patients involved. The person themselves, the patient primary, and secondary, the baby in the womb. So when we have this situation, if we think that they could even possibly be pregnant or they have a distended abdomen, I say we think of it as a possible pregnant female and we avoid doing any abdominal thrust. That kind of abdominal thrust can injure the uterus and injure the baby. So let's devoid the area all together. It's just as effective to go under the breasts and on the sternum and do inward thrusts on the sternum while they're still conscious. If they go unconscious, we lay them down and we're going to be doing compressions like we do in CPR anyway. We don't do abdominal thrusts from the unconscious unresponsive anymore. We only do CPR type compressions to get the obstruction clear and it's extremely effective. Lastly, what do I do if it a hard to get out object. This is a really scary part, and I say prevention is the best cure. No doing the how many marshmallows can I fit in my mouth before I can't even breathe. That stuff becomes slimy. It gets gooey, it melts. And if that's inhaled, it is so difficult to get out with normal abdominal or chest thrusts. The reason because that type of stuff forms like a gluey substance and even though we do do an effective abdominal or chest thrust, and we move a little bit of trapped air up the airway and through that goo, the air pops through like a bubble. And then when we go to give them a breath or they go to take a breath, it seals back over. We not only see this with gooey types of food, but we see it with mylar and with laytex. We see it with coins. Coins get stuck in the larynx and it works like a one way valve. It popped open when we actually do the abdominal thrust. But then it pops closed when we try and take a breath or we try to give a breath. So in my opinion as not only a professional rescuer, but even as a dad, I say prevent, because it's going to be better than the cure. Keep in mind that EMS has special tools to try to help. We have suction equipment. We have different forceps to reach down there. We have intubation equipment to be able to see deeper. We have deep suctioning catheters. But, in the best case scenario, you're going to keep trying to do the same procedures we taught you in this course. Chest compressions or abdominal thrusts until it comes out, they can breathe, or until help arrives.
Many questions come in related to special considerations for performing CPR, using AEDs, and applying choking skills, so we decided to take the most common of the bunch and share them with you. Along with our recommendations of how to treat different types of patients in light of these considerations.
Special Considerations for CPR
The three most common concerns we hear when it comes to performing CPR are:
- The size of the patient.
- The crunching sound and feeling when performing chest compressions.
- Impaled objects in the chest.
The Size of the Patient
This has more to do with the size discrepancy between rescuer and patient than the size of the patient alone. Sometimes, when performing chest compressions, a patient will require more weight than a rescuer can muster. If this happens, try to recruit a bystander to assist you while you guide them along.
Performing chest compressions isn't difficult, particularly if there's someone next to you telling you how to do them.
Crunching and Popping Sounds
These sound worse than they usually are. These sounds and crunching feelings could be related to a traumatic injury. But more likely, it's just due to the separation of cartilage from the sternum, which also sounds worse than it is. Think of it how you would cracking your knuckles. You're simply releasing air trapped inside cartilage.
Also keep in mind that you're not going to hurt the victim any more, as they are already dead.
Impaled Chest Objects
The only way an impaled object would keep you from performing chest compressions is if the object were in the exact location. If that's the case, all you can do is call 911, keep the scene safe, and do whatever you can do to control bleeding or other issues.
However, if you can, just work around the impaled object and perform compressions to the best of your ability.
This situation could also arise when it comes to giving rescue breaths, should the patient have an impaled object in the mouth, face, or airway.
Special Considerations for AEDs
It's important to understand that to get better use from an AED, you may have to understand and use a few workarounds. And when it comes to using AEDs, these are the four most common concerns we hear.
- How to handle jewelry.
- How to handle patches.
- How to handle underwire bras.
- How to handle breast tissue that's in the way.
Jewelry
As the types of jewelry changes over the years, questions concerning jewelry also change. When it comes to necklaces, these are easy to move out of the way; no need to take them off.
However, with piercings, location matters. If the piercing is directly where a pad would go, or if it appears like it would interfere with the pathway of the electricity, remove the piercing first. Otherwise, piercings shouldn't pose any problems.
Patches
Nitro patches, pain relief patches, and other types of medication patches come off easily. So, if a patch is resting where an AED patch should go, remove it, wipe the area so it's dry, and apply the pad as normal.
Underwire Bras
Unless you think the bra's wires will interfere with the pathway of electricity, like sending it any where other than where it should go, then remove the bra. Otherwise, you're probably OK using an AED with it in place.
Breast Tissue
If you encounter breast tissue where an AED pad should go – likely the mid auxiliary rib cage – simply move it and apply the pad.
Special Considerations for Choking
The three most common concerns we hear with choking incidents are:
- What if the choking victim is too large?
- What if the choking victim is pregnant?
- What if the obstruction won't come out?
The Patient is Too Large
Again, we see where a discrepancy in size between rescuer and victim matters. If the victim you're trying to help is too large for you to get your arms around, enlist the help of a bystander, and like before, you can guide the bystander through the abdominal thrust technique.
Otherwise, if there are no bystanders and it's just you, consider using the inward thrusts directly on the sternum instead, just as you would a pregnant woman. Tuck in your thumb, go under the breast, and onto the sternum. Thrust inward, rather than up and inward like you would with abdominal thrusts.
Worst case scenario: The victim will pass out in 90 seconds or so and wind up on the ground, safely if you help them down. And then you begin doing chest compressions, which are extremely effective at clearing obstructions.
The Patient is Pregnant
A pregnant patient is really two patients – one primary patient (mother) and one secondary patient (baby). If you suspect a conscious choking female adult to be pregnant, avoid performing abdominal thrusts, as these can injure the uterus or baby.
Instead, perform inward thrusts on the sternum as is described above.
The Obstruction Won't Come Out
This isn't common, but it's scary when it happens. And most of the time, it could have easily been avoided.
Certain gooey foods, like marshmallows, can act almost like glue if inhaled. Other items that pose unusual risks include mylar and latex. Coins are also particularly hazardous. If they are swallowed just right, they can act like a one-way valve in the larynx – one that opens with a compression and closes with a rescue breath.
In the event of emergencies like this, where difficult obstructions won't come out, EMS personnel also have special tools to assist them, such as suction equipment and forceps that can reach down the throat.