Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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A hint of puritanism
- Nicolas Simon (26 June 1998)
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HIV transmission and mouth-to-mouth ventilation: a rational approach
- Carlos Frederico Arend (10 August 1998)
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Response to Immediate Back-slapping
- Rosanna Hessels (12 October 1998)
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A critical typographical error!
- Tom Davison (13 January 1999)
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Re: A critical typographical error!
- Marcus Müllner (23 January 1999)
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Re: A hint of puritanism
- Aubrey Harris (4 May 1999)
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Nicolas Simon, MD Poissy France
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Sirs, The illustrations to the paper are clear and relevant. There is only one flaw : you should never start chest comressions on a fully dressed person. the chest should always be bared for at leat three reasons: airway freedom, better chack of Mouth to Mouth breathing efficiency (expiratory retraction of chest wall) and easier location and check of chest compressions. The victims in the drawings should be bare above the waist with their belts unhooked. Maybe there is a hint of puritan correctness in your otherwise excellent illustrations. yours truthfully, |
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Carlos Frederico Arend, Medical student Federal University of Rio Grande do Sul - Brazil
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EDITOR - Instruction in cardiopulmonary resuscitation (CPR) has become a standard part of training for medical personnel and is widely recommended for the lay public. However, concerns regarding mouth-to-mouth ventilation appears to create substantial barriers to performance of CPR in and out of hospital setting. This is especially true if there is visible blood around the mouth of the victim. Transmission of HIV during mouth-to-mouth ventilation requires that three conditions be fulfilled: (1) an HIV positive victim, (2) blood-blood contact, and (3) seroconversion of the rescuer. Knowing the prevalence of each one of these independent risk factors, it is possible to calculate the chance of contamination. The HIV prevalence in United Kingdom is about 0,0004%. Considering that the victim has visible blood around the mouth, blood-blood contact will be possible if the rescuer possesses a microlesion in his/her oral mucosa. Such microlesion may be present in up to 50% of healthy persons . Seroconversion happens in 0,3% of the cases of blood-blood contact. Therefore, the chance of contamination is approximately one in a hundred milion (0,0004x50x0,3). This is a hundred thousand times lower than the risk of anaphylactic shock after the use of penicilins. Also, not a single case of transmission of HIV by mouth-to-mouth ventilation was reported, while there are two cases of persons probably infected by kiss route. The very low frequency with wich HIV has been transmitted trough oral-to-oral route is impressive. This is probably due to the risk of infection may depend on the size of the innoculum, wich is frequently small by oral-to-oral route. The finding of inhibitory substances in saliva may further reduce the probability of infection and cannot be considered in our numerical estimatives. Educating about the percent of patients that survive cardiac arrest, the actual risks of contracting HIV, and preventative measures, should result in an increased willingness of laypersons and physicians to perform mouth-to-mouth ventilation on victims of cardiac arrest. |
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Rosanna Hessels, pre-med student (Head lifeguard during the summer months) Redeemer College, ON, Canada (lifeguarded at Silver Lake United Church Camp, Kinloss, ON)
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As a lifeguard instructed under the Canadian system of resuscitation, I have been taught to use only abdominal thrusts to assist a casualty who is choking. The back-slaps described in the article are prefaced by a warning about the hazard of an obstruction becoming further lodged in the airway. The abdominal thrusts all but elimate the need for the casualty to be bent over. The sole use of abdominal thrusts reduces the amount of time that the object is in the airway. The diaphram is compressed by a series of abdominal thrusts. The pressure of the air in the lungs increases until the obstruction is expelled with a great deal of force (the obstruction will fly!) The procedure for the abdominal thrusts are as follows: (for conscious adult) -Determine if the person is choking (Are you choking?) -If person is choking encourage coughing and shout for help Then... -Stand behind the casualty -Plant your feet (brace yourself), place one of them between the casualty's feet -Wrap your arms around the peron's waist -Make a fist -Place the thumb side of fist against middle of casualty's abdomen just above navel and well below the xiphoid process (the lower tip of the breatbone) -Grasp fist with your other hand -Press fist into perons abdomen with a quick upward thrust -Each thrust should be a separate and distinct attempt to dislodge object Repeat abdominal thrusts until... -object is coughed up -person starts to breathe or cough forcefully -person becomes unconscious If person becomes unconscious...you are behind him/her already and are able to lower him/her gently down to the ground while supporting the head. Call for help if you haven't done so already. From there, continue with a cycle of 5 abdominal thrusts, a fingersweep and two attempts to ventilate. Do this until Emergengy Medical Services (EMS) takes over or the object is cleared, (if cleared place casualty in recovery position). Note: After being treated with abdominal thrusts, the casualty should be advised to see his/her physician, to ensure that the internal organs have not been damaged. Source: "First Aid: The Vital Link", The Canadian Red Cross Society, 1994 |
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Tom Davison, BRCS Resuscitation Support Trainer BRCS Bedford Centre
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At the end of the description of the recovery procedure in this article, the following statement is made. "...there is no doubt that placing an unconscious non-breathing victim into the recovery position can be life-saving" Surely this is a typographical error, and should refer to an unconscious breathing victim. A non breathing victim is unlikely to begin spontaneous breathing by simply being placed into the recovery position, and the emphasis should be placed firmly on the initiation of rescue breathing in such cases. |
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Marcus Müllner, Editorial Registrar, acting Letters Editor BMJ
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Correction Mr Davison is right, it should read "...there is no doubt that placing an unconscious , breathing [not: non-breathing] victim into the recovery position can be life saving". The correction was published on August 28, 1998 (BMJ 1998;317:501). |
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Aubrey Harris, BCLS Instructor
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With regard to the need to bare a chest prior to giving chest compressions: I have noticed this standard in several very old publications (although I cannot vouch for the French or European current standards). As an instructor in CPR not only to civilians, but also to the Department of National Defence for the past eight years, I have never taught to bare the chest (although it is mentioned to loosen constrictive clothing). There are advantages to leaving the patient clothed during resuscitation, including: maintaining some casualty's warmth to lessen shock, avoiding trouble with bystanders who misinterpret what is seen, and (for females) quick landmarking based on the cross-over point on the bra. For a first responder, it may also be less difficult to ask them to perform this action without asking them to strip the casualty. While some landmarking may be easier to do by baring the chest, it seems unecessary in the long-run. |
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