Emergency resuscitation: Part 3 (1963)

[Music] In all asphixia cases where breathing has stopped, the exhaled air method of resuscitation must be started immediately. Nothing must be allowed to interfere with this. However, in many such asphixia cases, it is possible that in addition to respiratory failure, the heart may stop beating as well. It is with such cardiac arrest, should it occur, that we shall now be dealing and we'll use the case of a swimmer drowned in fresh water to study it. But first, let's consider the background to cardiac arrest. In the brain, two of the vital centers controlling the functioning of the body are the respiratory center governing breathing and the cardiac center governing the activity of the heart. In a fixia, when effective respiration is interrupted, the oxygen supply to the brain fails and the respiratory center soon stops functioning. Unless the oxygen supply is quickly restored, the cardiac center will fail a little while later. This means that the heart will stop beating and unless the circulation is restored urgently, death is inevitable. We can think of the sequence of events like this. Normally the rhythm of respiration and heartbeat continue together. If respiration is interrupted for a while, the heartbeat continues but becomes weaker and irregular until it also stops. The time interval between respiratory failure and cardiac arrest is important. In electric shock, the two may happen simultaneously and there is no interval. In freshwater drowning, the interval will be of the order of 2 minutes. While in drowning in seawater, it may be up to 5 minutes. With some poisons, the interval may be as much as 10 minutes. It is during this interval that one would hope to start exhaled air resuscitation as it is unlikely that the heart will stop once E is started. However, if cardiac arrest does occur, the longer the delay in restarting the heart, the more likely is permanent damage to the brain or other vital organs. In this condition where both functions have failed, both ER and closed chest cardiac massage must be carried out together until the heartbeat restarts. Thereafter, E continues alone until natural respiration is restored. And let's now consider the several signs that cardiac arrest has occurred. There will have been no improvement in color after say six inflations by E. No pulse can be detected in the neck. The eyes will have dilated pupils and there will be an overall appearance of impending death. Artificial respiration alone is now quite useless as the oxygen will have no means of getting to the brain. The best method of restarting circulation is closed chest cardiac massage. The method involves intermittent pressure on the lower part of the sternum or breast bone. This compresses the heart against the vertebral column and so squeezes blood from the heart into the circulation. Relaxation of the pressure allows the heart to fill again with blood. Repetition of this cycle of actions maintains a circulation of blood to the vital areas including the brain so that we can examine the method slowly and carefully. We'll first watch a demonstration of cardiac massage alone on a perfectly healthy individual. Although it must be remembered that there is no occasion when CCCM will be used without artificial respiration as well. The first thing to do is to get him onto a hard surface. A bed or other soft surface is no good for closed chest cardiac massage. Then the rescuer feels for the lower half of the sternum on which he places the heel of one hand. The other hand covers it and with his arms straight, the rescuer is now in position to begin. He will show us first in slow time. To start with, he applies a downward force to the chest by bringing his weight to bear vertically over his hands. If this were a truly unconscious person, a movement of the sternum of 1 to 1 and 1/2 in would be achieved, and that would squeeze blood from the heart. When the rescuer takes his weight off his arms, the sternum is allowed to return to its normal position. This causes the heart to fill with blood again. This process of compression and relaxation is sufficient to produce a circulation of blood in the body and when carried out properly at a rate of about 60 pressures a minute, one a second, it will restore the blood pressure and a pulse could be felt. But now, some words of warning. First, with a conscious person, the full movement of 1 to 1 and 1/2 in is not possible and should not be attempted. Secondly, cardiac massage must not be carried out on an unconscious person if the heart is still beating and we must be quite sure that it has stopped. The signs already described are evidence of this, namely no pulse in the neck, no response to e and widely dilated pupils. And now a third word of warning. It should be remembered that pressure here, if greater than that needed to produce adequate depression of the chest, may damage the ribs or cause rupture of the underlying organs. In particular, it may damage the liver or it may damage the heart. If pressure is applied in the wrong direction, it will be inefficient. If pressure is applied too high, it is useless. If too low, it is dangerous to the liver. And if applied to one side, it may again damage the ribs and underlying organs. So the right pressure in the right place in the right direction is essential. Much less force is needed with children. Here one hand is sufficient. But if this was a very young child or a baby, the fingers only should be used to depress the sternum through the smaller distance necessary. So this is closed chest cardiac massage. But cardiac arrest is always accompanied by sessation of breathing. Closed chest cardiac massage alone does not produce effective ventilation of the lungs. So it must be combined with E. With a lone rescuer, this is quite exacting. He should inflate the lungs once and then without wasting time should compress the chest six to eight times. another inflation then six to eight compressions and so on. This double process is very much easier with two rescuers. They time their actions very much as the solitary rescuer did. First an inflation, then six to eight compressions. another inflation and then six to eight compressions and so on. In the real life situation, a pulse is sought periodically, in this case by the qualified first aer present. As soon as it's found to persist, cardiac massage should cease while resuscitation continues. Exhaled air resuscitation is recognized to be a simple untiring method suitable for use in many awkward situations. And now we've seen that coupled with closed chest cardiac massage, it offers an effective means of resuscitation even in extreme cases. There is no doubt it's the best possible method yet discovered. Therefore, make sure you understand the principles of both techniques. Learn the methods, practice and perfect them so that you will have the skill to save a life.