Sometimes there are special circumstances in CPR, AED, and Choking. It may be a patient’s size or even an impaled object. Roy helps answer the most …
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.

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