If a firefighter is unresponsive and not breathing or not breathing normally, assume they are in cardiac arrest and begin resuscitation starting with chest compressions.
Our advice, based on the best available evidence and the AHA guidelines, is that the FD-CPR technique is a special means of extrication and as such will necessitate some deviation from the standard algorithms. Thankfully this is only for a short duration, perhaps 30-45 seconds. Once the firefighter is successfully doffed, the usual resuscitation bundle can begin with a pulse check if that is common in your area, and continue with 30:2 C.A.B. ordering, or 10:1 with upstroke ventilation, or continuous compressions manually, or even via mechanical devices.
The FD-CPR process is the missing link in the rescue of a downed firefighter. It serves as a bridge from hot zone extrication by a rapid intervention team to medical attention without further compromising no-flow time in a potential cardiac arrest.
The initial assessment of a downed firefighter will be by the firefighters that find and perform the extrication from the hot zone. The RIT or FAST members will establish if the FF is responsive in any form. Breathing can be assessed through the regulator; however, pulse checks are usually not performed in extreme environments. Not only will it be difficult to palpate a pulse point in a firefighter with full PPE, the rescuer would have to remove their gloves to perform this task. Something that we would not recommend in a hazardous environment.
In the case of an unresponsive firefighter, we feel the likelihood of cardiac arrest is high if any of the following are true:
- Rescuers witnessed a sudden collapse of a firefighter
- No audible breathing through the SCBA can be heard
- The air alarm is ringing
- The air gauge is empty
- The facemask was removed in a toxic environment
The evidence available shows that CPR is unlikely to cause harm to a victim who happens to be only deeply unresponsive. In support of this guideance are a few studies of healthcare providers of all levels (EMT through MD) that found pulse checks only a bit more accurate than a coin toss; thus, if there is any doubt it is best to begin CPR.
In these situation, we believe that delaying chest compressions is of greater consequence than performing CPR on someone with a pulse.
Similar practices are performed nationwide with dispatch-directed CPR for laypersons. Two of the most common Emergency Medical Dispatch questions upon receiving a 911 call are:
- Is the patient conscious?
- Is he/she breathing normally?
If the caller advises that they are unresponsive and not breathing, not breathing normally or gasping, the pre-arrival instructions are to perform chest compressions until trained providers arrives.
If the firefighter is not thought to be in cardiac arrest, instead of compressions the second rescuer will work to remove the firefighter quickly with rescuers 3 and 4. In our conversation with other departments, many have adopted this technique to help them remove any unresponsive / semi-conscious firefighters from their gear (such as during rehab or other areas).