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.