Sigfreund,
I have an MD behind my name but neither prehospital nor trauma medicine is my gig. That said:

I understand the question to be: if the patient lacks adequate plasma volume to maintain a heartbeat, how can attempting to circulate what remains be helpful? Allow me to attempt some answers.

First, the theoretical. The primary reason we engage in CPR is to prevent or limit damage to vital organs that would otherwise occur without gas exchange. The most vital of these, of course, is the brain. Assuming that the reason the heart has stopped is volume loss, we should keep in mind that the heart and the brain have different metabolic requirements in order to remain viable (not to operate at peak performance, in which case the brain is a hungry beast). We can not assume that the inability to keep the heart going also means that the brain is already dead. Further, if we imagine, say, a lower extremity amputation, we must keep in mind that plasma we circulate through CPR doesn't just go to that opening in the system. Some of that blood will make it to the brain. Some of the blood that goes to the brain will make it back to the heart. And then some of that will make it back to the brain again. Yes, if the hydraulics of the situation don't change then this will fail in (short) time. But that doesn't mean CPR can't be a temporizing measure.

Second, the empirical. Even if they are a scant minority of cases, we know that some GSW victims who receive CPR do survive. Assuming that the perceived need for CPR in at least some of those cases is accurate, and that they didn't ALL receive CPR while their hearts were still beating, this tells us it is at least POSSIBLE that CPR can be effective.

Finally, I see you're also asking, can't we make the situation worse? If we keep pounding on the chest of someone who has bled out, aren't we helping to exsanguinate him? It's true, some of that blood is going to come out those holes. It follows that if we can plug the holes, as the above posters have mentioned, all the better. Intensive care and trauma services emphasize restoring volume before attempting pressure support interventions (and CPR, if we take mean pressure over time, does raise Mean Arterial Pressure above zero). But if no fluids are on the horizon and you're simply counting the seconds until that brain is dead, how much worse could the situation get? I say see if you get a one in a million result.

Mass casualty incidents are a different beast. I think you realize that.

I look forward to other responses, and accept my thinking may need revision.

Daniel

EMT-B.

Worst run of my volunteer career. Pt had a self-inflicted GSW to the head.

This was not an abdominal injury, but we did perform CPR and used a NPA b/c we could not open Pt's jaw.

When we arrived, I could hear my EMT Instructor saying, if they do not have a heart beat, we have to give them one, if they are not breathing, we have to breathe for them.

I won't go into the details here.

The end result was the Pt. survived for a couple of days, long enough for the family to arrive and make arrangements for organ donation. Five people received the gift of life from our Pt.

Thank you, RNshooter, Dan, and the others who made the effort to read and understand my question and give helpful, meaningful answers. The reason I ask questions is not to confirm my biases but to learn, and I have learned from this one.

Strangely enough, I just became a nationally certified EMT and I can tell you the correct answer is to “Stop/Control the bleeding and if there is no pulse start CPR. Remember, Doing CPR can’t hurt you especially if your already dead.

quote:

Originally posted by Southflorida-law:
If the victim has no heart beat and is not breathing, then CPR is a must, regardless of what else is wrong.

Decapitations too?

I hate to be "Captain Obvious", but these "must do" attitudes can be extremely problematic, as they remove any and all sense of discretion out of the equation. Several years ago, a LEO co-worker requested paramedic response to the scene of the "worst case of decomposition" that he'd ever seen, because he always had the paramedics pronounce death rather than take that responsibility himself. That 4:00 AM call to the FD wasn't soon forgotten, as for a couple of weeks we found ourselves responding to a suspiciously abnormal number of cases where our firefighter-paramedic brethren needed our assistance on situations where they "discovered" homeless, intoxicated subjects that might otherwise have been sleeping it off on their own.

It is 0100 here just outside of Mogadishu right now, and after a very long 72 hour day, please forgive me for being rude. I have about 4 hours of sleep before we head to DRC.
As the head medic for our team, what the OP asked seems very straight forward. I even showed our flight surgeon the original question to be sure.

1) there is not such thing under TCCC as SMARCH. If you need the "S" then you should probably stay inside the Starbucks

2)we haven't used ABC since the early 90's. Please get some remedial medical training.

3)the TCCC has been written in blood since before 2001. I did not write it, but many of my brothers have. Please do not dismiss it.

4) under TCCC, the time to plug holes and assess airways is less than 30 secs, so as the care provider, just breathe

When it comes to these types of medical issues, there really is not a whole lot of professional leeway. The modern TCCC is pretty straight forward. And for the love of god, please don't listen to the VietNam era vets who disdain putting on a tourniquet.
With love, a student of 18D

.

Attend a local class on medical training class that specializes in bleeding control:
www.CMS.BleedingControl.org/class/search


There are two Paramedics with YouTube channels that post videos regarding to pre-hospital (field) medical care.

PrepMedic (www.YouTube.com/channel/UCVhScPcuVSTlxwpsq1H_KKw)

Skinny Medic (www.YouTube.com/channel/UCbhaasx1vaOf6jpYQ6FMoKw)

PrepMedic recently posted the full "Stop The Bleed" training course on his channel. If you want to learn about the current standards, I encourage you to watch this video....




SkinnyMedic posted a "Building a Stop the Bleed Kit":


I also encourage you to begin carrying Gloves, QuickClot Gauze, Tourniquet, and the new T3 Israeli Bandage. These items don't take much space.

Wound Packing with Gauze:


Using the T3 Israeli Bandage:

Complicated question, obviously.

In general (civilian) medicine, if it's a traumatic arrest then CPR is not necessary and disturbs a crime scene.

The difficulty comes in a layperson determining if it's a traumatic arrest (specifically finding a pulse when blood pressure may be too low for radial or carotid pulses to be felt).

Starting CPR until professionals arrive is the recommendation of the national CPR programs when a layperson finds an unresponsive person that is not breathing, unless there are obvious injuries incompatible with life, i.e. decapitation or brain matter. It's not even recommended or taught that they check for a pulse, just assess for breathing and unresponsiveness.

However if the person isn't completely dead, and the good samaritnas are doing chest compressions because there was no response/no breathing, and all the blood they are pumping is going into the abdomen from a GSW...you can see the conundrum...

And I've seen people with their brains splattered that didn't know they were dead for several hours (but still had a pulse).

In the civilian world, once the "professionals" arrive, pulse or not, they are still most likely going to hook up a $25,000 cardiac monitor to be sure before they pronounce the person as dead. This can still complicate matters when the heart has electrical activity that doesn't produce a pulse (real thing--it's actually called "Pulse-less Electrical Activity"), and then the "professionals" have to make a judgement call, and can withhold resuscitation efforts.

Another factor to consider, modern EMS systems will not transport active CPR cases, absent extraordinary factors. So if they can't get a pulse back on scene, they aren't going to the hospital.


Specific to your question, if they are bleeding to death, they don't need CPR. They need the bleeding stopped. If they have bled to death, then CPR won't help.

I haven't read all the thread but here is the Tactical Combat Casualty Care Protocols:

https://www.naemt.org/docs/def...pdf?sfvrsn=13fc892_2


Care Under Fire: While under fire but behind cover; stop bleeding.

Tactical Field Care: Out of "hot zone" of danger but in "warm zone" ie behind cover, locked in room, perimeter of armed personnel.

MARCH acronym:
1. Massive hemorrhage is managed through the use of tourniquets, hemostatic dressings, junctional devices, and pressure dressings.
2.Airway is managed by rapid and aggressive opening of the airway to include cricothyroidotomy for difficult airways.
3. Respirations and breathing is managed by the assessment for tension pneumothorax and aggressive use of needle decompression devices to relieve tension and improve breathing.
4. Circulation impairment is assessed and managed through the initiation of intravenous access followed up by administration of tranexamic acid (TXA) if indicated, and a fluid resuscitation challenge using the principles of hypotensive resuscitation. TCCC promotes the early and far forward use of blood and blood products if available over the use colloids and discourages the administration of crystalloids such as normal saline (sodium chloride).
5. Hypothermia prevention is an early and critical intervention to keep a traumatized casualty warm regardless of the operational environment.

The TCCC Protocols are being used in Trauma Centers and are slowly working their way into ambulances, paramedics, and emts.

Sooma and Cody are on target.
Been practicing emergency medicine for close to 20 years now including time in Afghanistan and Iraq. In the case of penetrating trauma stop the bleeding first. As mentioned this is not something that is going to take minutes but rather seconds to accomplish.without enough blood to circulate cpr is pretty pointless.
I always laugh when watching shark week when they will show people doing cpr while blood is pumping out of a severed extremity.
Back in the late 80’s even my ER preceptor said ( back when ACLS protocols were heavily focused on drugs more than they are today) with penetrating trauma “he needs blood not
Lidocaine or cpr”

quote:

Originally posted by chongosuerte:
However if the person isn't completely dead, and the good samaritnas are doing chest compressions because there was no response/no breathing, and all the blood they are pumping is going into the abdomen from a GSW...you can see the conundrum...

To clarify then: Someone might have extremely weak, undetectable pulse that is nevertheless circulating the blood that’s available, but if CPR were performed because it was thought there was no circulation that might make the situation worse by increasing internal bleeding—am I correct in what I understand?

Thanks for that and the comments by the other knowledgeable people.

quote:

Originally posted by sigfreund:

quote:

Originally posted by chongosuerte:
However if the person isn't completely dead, and the good samaritnas are doing chest compressions because there was no response/no breathing, and all the blood they are pumping is going into the abdomen from a GSW...you can see the conundrum...

To clarify then: Someone might have extremely weak, undetectable pulse that is nevertheless circulating the blood that’s available, but if CPR were performed because it was thought there was no circulation that might make the situation worse by increasing internal bleeding—am I correct in what I understand?

Thanks for that and the comments by the other knowledgeable people.

Yes. If they lost a lot of blood, but the bleeding has slowed or stopped due to clotting, it is probable that their blood pressure is too low to produce a palpable pulse. It’s also too low to effectively perfuse the brain. But the problem comes when someone initiates CPR based on unresponsiveness/apnea and the increasing blood pressure (that’s the real goal of CPR) finishes the bleeding out. If it’s external bleeding it could be easily recognized, but internal bleeding would probably finish unnoticed.