# Drowning victim code and ROSC



## seekersofthetruth (Mar 25, 2010)

We had a drowning call last night. A bystander saw a man floating face down in the bay and jumped in and started pulling him to shore by the time we got on scene. We jumped a fence and got a collar and board on him while getting him onto the shore. Pt had a strong radial, along with snoring/gurgling agonal respirations. This guy had the worst mallampati and boots score I have ever seen. He took an OPA airway fairly well but our two intubation tubes were a negative. Even with suction we still couldn't see anything but tounge. Someone else attempted an LMA after the two intubation attempts and that wouldn't even stay in him. So the best airway we had was our OPA. His pressure was originally through the roof at about 240/130. Pulse was about 90, strong, regular. I wanted to put our pt on c-pap to help push all of the fluid out of his airway but 5 paramedics on scene disagreed with me. What are your feelings on this? Anyways he ends up going into pulseleas vtach arrest. With CPR and two rounds of epi and atropine we got ROSC. Anything we could have done differently?


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## seekersofthetruth (Mar 25, 2010)

Oh yah I forgot that they RSI'd him also with versed, succs, and lido. Personally I wouldn't have wasted time trying to RSI him since a field intubation was Practically impossible. Even the doctor at the ER put it in his esophagas. Pt is still alive right now at this moment on a vent in ICU.


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## huey28 (Mar 25, 2010)

atropine in vtach??? you sure


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## Epi-do (Mar 25, 2010)

huey28 said:


> atropine in vtach??? you sure



I caught that too, but figured since the OP is a basic, I would cut him some slack.  Not knowing how long he has been doing EMS, I figure he either got the meds mixed up, or didn't have the rhythm on the monitor right.

What type of airway did they finally get on him in the ER?  How easy was he to ventilate with the OPA?  Granted, it isn't the most secure airway, but if he was ventilating ok, around here a near-drowning most likely wouldn't even have an attempt at intubation made. 

Reason being, it would be a cold water drowning this time of year, thus, the pt would be hypothermic.  We aren't allowed to intubate hypothermic pts due to the possibility that you could stimulate the gag reflex, which in turn could lead to stimulation of the vagus nerve and an already irritated heart, due to the cold could become even more so.  An irritated heart isn't a happy heart, and doing anything to make it worse has the potential to lead to very bad things.

As for CPAP, my understanding is that it is contraindicated in pt's who are unable to control their own airway.  A pt that is unresponsive and/or RSI'ed would qualify as unable to control their own airway, so no CPAP.  Of course, we _still_ don't have it on our trucks, so I could be wrong.


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## el Murpharino (Mar 25, 2010)

seekersofthetruth said:


> Pt had a strong radial, along with snoring/gurgling agonal respirations. This guy had the worst mallampati and boots score I have ever seen. He took an OPA airway fairly well but our two intubation tubes were a negative. Even with suction we still couldn't see anything but tounge. Someone else attempted an LMA after the two intubation attempts and that wouldn't even stay in him. So the best airway we had was our OPA. His pressure was originally through the roof at about 240/130. Pulse was about 90, strong, regular. I wanted to put our pt on c-pap to help push all of the fluid out of his airway but 5 paramedics on scene disagreed with me. What are your feelings on this? Anyways he ends up going into pulseleas vtach arrest. With CPR and two rounds of epi and atropine we got ROSC. Anything we could have done differently?



I wouldn't use CPAP in an unconscious patient with agonal respirations.  A good BLS airway with gentle bagging to avoid gastric inflation is better than nothing.  If you had to crich this patient, then so be it...If your protocols allowed for nasal intubation, that's another option, though we don't use nasal intubations in our area of New York. 

Also, CPAP doesn't "push the fluid out", CPAP improves the ability of the alveoli to get oxygen to the red blood cells by using pressure to drive gas into the alveoli and splint open unused or collapsed alveoli.  It's the same crap as people saying lidocaine "numbs" the heart muscle...


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## triemal04 (Mar 25, 2010)

Forget being unresponsive (which is also a good time to NOT apply CPAP), if he had aganol respirations, what's the point?  While on CPAP the pt will still only be breathing at their own rate; if it's that slow just use a BVM.  And suction in this case...lots of it.

If he accepted an OPA, why the use of RSI?  Did they attempt to intubate him, were unsuccessful, and then tried RSI to overcome any residual gag-flex and muscle tension?  Not always a good idea, and if it was known that he was a difficult intubation based on the mallampati and prior attempts, a horrible idea.

Based on what's been presented, this would have been a good time for an OPA, BVM, suction and, if there was good compliance, that's it.


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## seekersofthetruth (Mar 25, 2010)

yah sorry guys he originally went into asystole. He coded while I was driving so I was just sort of listening to what was going on. I wanted to put cpap on him before he was rsi'd. They said Hr was still fighting the et tube even though I dropped an opa on him fine. Sorry this call was a cluster and it was my first call where someone had to get rsi'd.


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## 18G (Mar 25, 2010)

> We aren't allowed to intubate hypothermic pts due to the possibility that you could stimulate the gag reflex, which in turn could lead to stimulation of the vagus nerve and an already irritated heart



I have heard of this being a theory but have actually been taught it is safe to intubate a hypothermic patient. That is interesting though you guys cant intubate a hypothermic patient. At what temperature do you use to determine severe hypothermia that excludes intubation? Without taking an actual temperature you could be excluding patients that should be intubated. Just curious how that works in your system. 

If the airway was extremely difficult to secure and two ET attempts failed, I would say its pretty risky to RSI at that point. Did they get the tube in the field with RSI? Because you later said that even the ED physician placed the ETT in the esophagus. 

Your crew was right on the CPAP. CPAP was definitely a no-go in this situation. To use CPAP, the patient must be ADEQUATELY BREATHING on their own. A patient as critical as this one needs a secure airway that will enable protection from aspiration and allow ventilations to be managed with appropriate rate and tidal volume. CPAP isn't going to allow you to do this. And also, with this being an arrest patient... you don't know if he is going to go back into arrest or what.   

As someone else touched on, CPAP does NOT push fluid out of the airways. CPAP introduces a positive pressure into the chest that does several things:

1) It allows recruitment of atelectic segments of the lungs. That is, the airways that have collapsed due to fluid, the CPAP allows them to return to function and participate in gas exchange. So CPAP gives you a greater surface area available for gas exchange. 

2) CPAP promotes a reduction of the pulmonary vasculature pressure which allows the fluid in the airways to retreat back across the alveolar-capillary membrane into the space it belongs. The lymphatic system than can get rid of this fluid. CPAP promotes reduction of this pressure by causing a decrease in preload (blood return to the heart) by compressing the inferior vena cava.

Especially in CHF patients who are hypertensive, the increased systemic and pulmonary blood pressure forces fluid across the alveolar-capillary (AC) membrane into lungs spaces it does not belong giving rise to crackles, collapsed airways, and an increased diffusion distance (air has to travel further through the fluid to reach the AC membrane for diffusion to occur). So to reduce these pressures with nitrates (preload reducer), ACE inhibitors (afterload reducers), and CPAP, we enable the fluid to retreat back to where it needs to be outside of the lungs.  

3) CPAP functionally splints open the alveoli by constantly maintaining a positive pressure during the respiratory cycle preventing them from collapsing during expiration.

What may be beneficial in cases of drowning is the use of PEEP. PEEP functions similar to CPAP except the positive pressure is only applied during the exhalation phase. You can use PEEP with a BVM if your service carries PEEP valves.    

CPAP in a sense does "push fluid out of the lungs" by indirect methods, but it is not the best descriptor of how CPAP works.


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## Shishkabob (Mar 25, 2010)

CPAP is contraindicated in patients who are unable to control their airway.  Can't get much more uncontrolled then unconscious... and then subsequently RSI'd.


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## boingo (Mar 26, 2010)

Perhaps a bougie would have been helpful in the intubation.  PEEP, which is essentially cpap would be of benefit once intubate and placed on a vent if oxygenation was still an issue.


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## Veneficus (Mar 26, 2010)

boingo said:


> Perhaps a bougie would have been helpful in the intubation.  PEEP, which is essentially cpap would be of benefit once intubate and placed on a vent if oxygenation was still an issue.



Bougie is a great tool, I don't know why they are not more prevalent in EMS.

After the failed RSI and Failed LMA after the paralytics, perhaps it was time for a scalpel?

knife rhymes with life


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## mycrofft (Mar 26, 2010)

*"Cut" to the chase.*

OPA's are prone to allowing gastric inflation and if the OPA is a little small or the pt just has the snakelike capacity to yawn immensely, the OPA could be last seen slipping back behind the teeth on occasion. Not going to get swallowed, but getting it in before trismus is nice. (Anyone remember jaw screws?).


I was thinking about this case yesterday. Maybe not this time, but such a patient could be a real candidate for having a serious injury such as a small caliber bullet wound, stab, or impaled object missed.


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## usafmedic45 (Mar 27, 2010)

> I wouldn't use CPAP in an unconscious patient with agonal respirations



It's actually contraindicated in any patient that is not adequately spontaneously ventilating.  If they are agonal or have been given a paralytic, they meet this criteria.



> CPAP is contraindicated in patients who are unable to control their airway.



+1. 



> I wanted to put our pt on c-pap to help push all of the fluid out of his airway but 5 paramedics on scene disagreed with me



You'd get more fluid out of his airway much quicker by suctioning.  The paramedics were right.  The CPAP was patently inappropriate in this setting for a few reasons. 



> After the failed RSI and Failed LMA after the paralytics, perhaps it was time for a scalpel?
> 
> knife rhymes with life



Because they were apparently adequately ventilating the patient without resorting to that? Even given my belief in the liberal use of surgical airways (see the "first surgical cric" thread), this case does not need one in any way, shape or form from the description provided.   This is a good reason to keep in mind the rules of airway management I teach in my difficult airway presentations at EMS and RT conferences (the ones highlighted are the ones particularly pertinent here):
*#1:  Oxygenation and ventilation are the goal, not intubation *
*#2:	Your ego: check it at the door*
#3:  Call for help; in fact, call for more help than you think you will need
      Corollary:  The ambulance has wheels, use them. 
*#4:  If it is stupid and it works, it isn’t stupid*
*#5:  Newer/more invasive is not always better*
#6:   Plan ahead (avoid the “coffin corner”)
#7:  Hold your own breath
#8:  If it’s not working, let someone else try or try something else
*     Corollary: If it is working, don’t screw with it.
*#9:  When in doubt, skip to the end of the protocol (surgical airway) *if the patient is crashing*
#10:  If they are still breathing and you are not sure you can take over, don’t stop them from doing so


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## mycrofft (Mar 27, 2010)

*Thanks. 5X*

I'm very glad this didn't devolve into a fresh versus salt water drowning debate...oops.....:mellow:


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## MrBrown (Mar 27, 2010)

Pahleeze, throw your damn board and collar away

CPAP does not "push water" out of the lungs, you have been going to too many Fire Department EMS CCE classes taught by people who don't know WTF they are on about.  

I'd have probably used a bougie or gone for a cricothyrotomy.

Oh, no atropine.


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## usafmedic45 (Mar 27, 2010)

MrBrown said:


> CPAP does not "push water" out of the lungs, you have been going to too many Fire Department EMS CCE classes taught by people who don't know WTF they are on about.



That's a problem beyond just CPAP training.  To explain it to the OP, the "pushing water" effect you are referring to is a minimal effect seen mostly in patients who have pulmonary edema secondary to congestive heart failure.  The increased pressure in the lungs helps to minimize the fluid that is pushed (because of the increased pressure on the vascular side of the alveoli's alveolar-capillary membrane) into the alveoli. The increased airway pressure associated also minimizes the formation of bubbles ("foam") that is sometimes seen in severe pulmonary edema.  There is some reversal of the fluid into the vascular space from the alveoli, but it is believed to be minimal since you have to get the pressure above the level of the pulmonary vasculature and many patients are intolerant of higher pressures.

Simply put, if you have a massive amount of fluid from an outside source (i.e., drowning), CPAP is a piss poor choice because it is going to not only "push the fluid" back into the vascular space, it could theoretically reduce the amount of lung tissue available for ventilation and oxygenation by forcing fluid from the large airways (trachea and bronchi) down into the alveoli, flooding them, washing the surfactant that helps to keep them inflated away possibly leading to atelectasis (collapse of the alveoli) in addition to the direct obstruction effect of the water itself.   Suctioning the patient would remove the airway from the same fluid.  

If one were to insist on continuous positive airway pressure in a ventilated patient who is intubated, a PEEP (positive end expiratory pressure) valve can be placed on the exhalation port of the BVM.  This will give the same effect (a maintained baseline pressure in the lung) as CPAP.  Physiologically, PEEP and CPAP are the same thing.  The difference is that it is called PEEP if the patient is receiving assisted or entirely mechanically delivered ventilations, whereas it is CPAP if the patient is breathing solely on their own.



> gone for a cricothyrotomy



Why?  Please enlighten me as to why a cric would be necessary in this case.


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## Veneficus (Mar 27, 2010)

usafmedic45 said:


> Because they were apparently adequately ventilating the patient without resorting to that? Even given my belief in the liberal use of surgical airways (see the "first surgical cric" thread), this case does not need one in any way, shape or form from the description provided.   This is a good reason to keep in mind the rules of airway management I teach in my difficult airway presentations at EMS and RT conferences (the ones highlighted are the ones particularly pertinent here):
> *#1:  Oxygenation and ventilation are the goal, not intubation *
> *#2:	Your ego: check it at the door*
> #3:  Call for help; in fact, call for more help than you think you will need
> ...




I like to think of it as a logical progression.

If you can ventilate with a bag and OPA, there is no reason to play with a tube unless a provider decides loss of the airway is imminent. 

If a provider is so convinced of the need to control the airway they move to RSI despite noticing that the attempt will be extremely difficult and then even the crash airway fails. Unless there was a mistake in the decision of need, then the treatment should be taken to the next step, not the preceding. 

From the description of this scenario, it sounds like the decision to attempt RSI in the field was erroneous. What I think would push the treatment further was not the initial patient condition, but the subsequent attempts and failures to place a more advanced airway. 

A colleague of mine who works in industrial safety once told me for every incident there are 10 or more unreported near misses. I would definitely call this case a near miss. 

From the description it seems the airway was maintained by chance, not by plan. I don’t like relying on chance.


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## usafmedic45 (Mar 27, 2010)

> From the description it seems the airway was maintained by chance, not by plan. I don’t like relying on chance.



I don't either, but at this point they have stabilized the problem (as best as the OP could tell from the driver's seat).  I can see your point but if you're close to the hospital and the patient is maintaining their sat under BVM ventilation, then perhaps the need to do a surgical airway is minimized.  It's not ideal but it is working for the moment.  Even if it is chance that they got lucky, then the problem is solved at least for the moment and given that they are having problems with the other airway procedures perhaps they should stick with what is working and not try another procedure.


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## MrBrown (Mar 27, 2010)

usafmedic45 said:


> That's a problem beyond just CPAP training.  Why?  Please enlighten me as to why a cric would be necessary in this case.



Its not, my fingers out-gunned my brain


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## LondonMedic (Mar 27, 2010)

mycrofft said:


> I'm very glad this didn't devolve into a fresh versus salt water drowning debate...oops.....:mellow:


Good thing we're not going to talk about how CPAP 'drives the water out of the lungs' in dry drowning.


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## bonedog (Mar 28, 2010)

Wasn't there, seems like the evidence given was missing some patho/licensure...

Hyoid distance, jaw and neck mobility, ability to open mouth,  can all point towards possible adjuncts and pathways.

If the first attempt didn't work hopefully they tried different angle's/alignment, bougie etc.....

Personally my initial training was OR with many different anethestitists and our system is targeted  (or was prior to the dreaded MPDS) so have yet to use a surgical airway(have been taught two)

A buddy of mine was mentoring an ALS from a different system who related she had done three surgical airways on CHF patients? He told her in his career, 30 years, he had never done one......if you get the tube you don't need the knife.


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## usafmedic45 (Mar 29, 2010)

> Hyoid distance, jaw and neck mobility, ability to open mouth, can all point towards possible adjuncts and pathways.



It's more for the "Visualized" vs "Non-visualized" vs "Oh, he's doing OK with us bagging him, so let's not cause any more problems than we already have" decision tree. 



> A buddy of mine was mentoring an ALS from a different system who related she had done three surgical airways on CHF patients?



Come again?  Someone needs to have some remedial training at a minimum.  



> If the first attempt didn't work hopefully they tried different angle's/alignment, bougie etc.....



What concerns me is the failure to get an LMA placed which is more often a result of unfamiliarity with it (read as: lack of practice) than something up with the patient assuming no gag reflex.  Like I said, the goal is to oxygenate and ventilate so the presence or absence of an invasive airway should be considered secondary.


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## bonedog (Mar 29, 2010)

Come again? Someone needs to have some remedial training at a minimum. 


Exactly, different province, different system....


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## FLEMTP (Mar 30, 2010)

If the guy was big enough, and the hands small enough... why not go for a digital intubation? I have large hands, so ive only been able to do it a "hand"ful of times (sorry i had to lol) but if you cant visualize the cords, you can certainly attempt to palpate the epiglottis and pass the tube that way... 

Also, this is a situation maybe the SALT airway could have been used... our agency is using them on a trial basis, but I think they are going to be implemented county wide soon, they've worked out quite well here.


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## bdraft73 (Mar 31, 2010)

*check this out*

to: seekerof the truth


I read your threads on NWFdailynews.com

and now im reading your threads on this website. my understanding after doing my home work is that your a new EMT and a volunteer fire fighter for a dept in my area. You dont know a whole lot about ALS. CPAP isw contraindicated in unconcious pt's. Obviously ever body has already told you this..even emt's that have been on the job for a few months knows this. and know you are saying crap bashing union fire fighters because obviously you cant get a paid job as a firemedic of a fire emt for that matter. Now that we all know who you are you never will. We know how you are and what your name is and what rig you work on so as of now you are black listed. If you dont know what that means please ask your partner im sure she will gladly explain what that entails. So do your homework next time before you start spouting off and making a fool out of yourself and bashing union firefighters. I once too was a volunteer firefighter abut now i am pround to say i am union. Im sure you boss will love to hear all about your bashing of the local fire depts and the local ER doctors you work for. I'll be supprised if you have a job this time next month with that attitude of yours.


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## bdraft73 (Mar 31, 2010)

*cold water what?*

Oh and for i forget, this is florida, the water temp here is now in the 70's and not considered a cold water drowning. RSI or just plaing tubing the pt is the only definative choice of airway control, next to just bagging them that AHA recommends. SO write AHA next time you have a conflict with what you think is right in protocol.h34r:


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## seekersofthetruth (Mar 31, 2010)

Hey bdradt. I didn't make that post on the daily news website. I had already gone and thouroughly apologized to the station for this post getting out and someone posting it on that website. This was my first post on this website and probably my last since someone decided to do that. I have never applied for a fire job here. I actually like the fire departments I work with. The reason behind this whole thread was just to try to learn from. Like I said I already went to the station and apologized to them for the link getting out and that guy "jakeemtp" posting the link. I don't really know what more I can do to make things right. I tried to get this thread deleted several times along with the one on the daily news site.


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## 18G (Mar 31, 2010)

Bdraft73.... what exactly did seekeroftruth do wrong or out of line? All he did was post a call he responded to and asked for feedback. What crime is there in that? Granted, he came off with some wrong suggestions to treatment approach but he is obviously a new EMT. Posting on a message forum and receiving feedback is a awesome way of learning from very experienced people! I think the responses his post generated were very enlightening to seekeroftruth. 

Maybe I'm missing something or there is more to this than seems apparent, but he really didnt do anything wrong. There was no mention of providers names, no reference to departments, unit#'s, etc. It was a very general post. People are allowed to have opinions. So what if he didn't agree with what happened on the call or thought it could have been done differently. You don't ever feel that way on calls?

Perhaps you should use this as a teaching moment so when he encounters a scenerio in the future he will be able to approach it differently and with a different thought process. 

Coming off as an *** and condescending is very counter productive don't ya think. And "black listing"? Really? Over a very generalized post of a call on a message forum? Sounds really overzealous to me. 

Seekeroftruth... don't be intimidated... keep posting and asking questions.


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## usafmedic45 (Apr 1, 2010)

> CPAP isw contraindicated in unconcious pt's.



It is not contraindicated in unconscious patients. It is contraindicated in patients who are not maintaining their own airways and ventilating on their own.  There is a big difference.  If it was contraindicated in all unconscious patients simply because they are unconscious, then it's primary use (amelioration of obstructive sleep apnea) would be impossible.   Before you start bashing someone for not knowing something, make sure you have your facts straight.  



> even emt's that have been on the job for a few months knows this.



Actually a lot of EMTs and medics don't know this.  I've encountered doctors who are just as clueless. 



> So do your homework next time before you start spouting off and making a fool out of yourself and bashing union firefighters. I once too was a volunteer firefighter abut now i am pround to say i am union.



This isn't a debate about union vs. non-union and I'll thank you kindly to keep it that way. 



> RSI or just plaing tubing the pt is the only definative choice of airway control, next to just bagging them that AHA recommends.



Wrong again.  You can establish a definitive airway in several ways (surgical airway, Combitube/King airway, LMA, etc).  All of these methods are used in operating theatres as "definitive airways" on a daily basis. The fact that EMS personnel have it drilled into their heads that either it's ETT or it's not "definitive" is a sign of how poorly educated a lot of us are.   



> next to just bagging them that AHA recommends.



Actually bagging someone is not a definitive airway in the technical sense since it still allows aspiration to occur.   



> Im sure you boss will love to hear all about your bashing of the local fire depts and the local ER doctors you work for. I'll be supprised if you have a job this time next month with that attitude of yours.



As if your attitude is much better?  You've proven you don't know the facts underpinning your job any better, that you have an ego way above what is justified based upon your demonstrated knowledge and you seem to be abusive to your colleagues when you are not certain whether they did something wrong or not.



> Seekeroftruth... don't be intimidated... keep posting and asking questions.



What he said...every forum has their ******s and apparently we gained another one.  Please stick around and learn from those of us who want to teach and not simply bash people and make crap into false divisions (union vs. non-union, paid vs. volunteer, etc).


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## reaper (Apr 1, 2010)

usafmedic45 said:


> It is not contraindicated in unconscious patients. It is contraindicated in patients who are not maintaining their own airways and ventilating on their own.  There is a big difference.  If it was contraindicated in all unconscious patients simply because they are unconscious, then it's primary use (amelioration of obstructive sleep apnea) would be impossible.   Before you start bashing someone for not knowing something, make sure you have your facts straight.
> 
> 
> 
> ...



:beerchug:


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