# Wilderness Cardiac Arrest



## EMTBell (Feb 19, 2012)

So I was out snowshoeing with a some guys when a 45 year old male collapsed of a probable MI. I was ahead of him and was not apprised of the situation until 5 minutes later when another guy in the group came up ahead. When I got back to the victim CPR was in progress and I took over. He was pulseless, apneic, and had mild cyanosis on the face. There was gurgling after each rescue breath that I provided. Noting this, and realizing we were in a wilderness situation with no real medical equipment I just placed him in the recovery position and did a finger sweep to clear what I could. However, the victim continued to aspirate and I abandoned the airway completely and went compressions only for about 15 minutes. Then I had the bright idea of using a syringe for suction in conjunction with the recovery position, but the airway was still a mess. Bottom line, rescue didn't get out to my location until 60 minutes into the arrest, and they were only a BLS unit. I just want to know, could my disregard for the airway for such a long period have had a major impact, or was the patient doomed from the start. (Conditions were: snowstorm 20 degrees farenheit, top of mountain, limited medical gear)


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## STXmedic (Feb 19, 2012)

Patient was doomed. Was going to be an obvious long delay in Rescue/EMS response, then working him there, and IF (very big If) they were able to achieve ROSC, it would have been a very long trip to civilization. On the plus side, intra-arrest hypothermia was already initiated...

At least he died doing something enjoyable.


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## KellyBracket (Feb 19, 2012)

Disregard for the airway? Sounds like you went above & beyond.

One could argue for the utility of a precordial thump or two, limited to the first minute or so, but that guy was likely doomed before he hit the snow.


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## jjesusfreak01 (Feb 19, 2012)

KellyBracket said:


> Disregard for the airway? Sounds like you went above & beyond.
> 
> One could argue for the utility of a precordial thump or two, limited to the first minute or so, but that guy was likely doomed before he hit the snow.



Probably what I would have done had I been with him during the arrest. If I knew I was eventually going to get EMS within an hour I might consider doing a CPR rotation.


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## Aidey (Feb 19, 2012)

If I knew the response time was being measured in hours I would have stopped 20 minutes into it. There is statistically no point in keeping it up, even with perfect CPR the defib success rate usually hits zero right around there.


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## Handsome Robb (Feb 19, 2012)

Dude you did everything you could. Like everyone said, the guy was pretty much done before he even arrested. 

Even with ALS support in <10 minutes the survivability is very, very low.


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## systemet (Feb 20, 2012)

Not your fault.  This is the reality of managing an airway BLS for a long period of time.  The first cardiac arrest I ran as an EMT was a lot like this.  No matter how often I log-rolled the guy, or how deep I stuck the Yankauer down his pharynx, I couldn't clear the airway adequately.

I hope this wasn't a friend.

The guy was doomed by circumstance:

* No defibrillator --> right there, pretty much no survival.
* No ability to treat the underlying medical condition --> reduced chance of ROSC, reduced likelihood of keeping them alive in the post-resuscitation period.
* Prolonged time to ALS --> Only important if you have a defibrillator and ROSC
* Prolonged time to definitive care --> which probably isn't ALS in this case, if the CPR goes on for any length of time.

The airway is minor.  I mean, the aspiration pneumonitis will also kill you later in the ICU if you somehow miraculously survive the initial insult, but it's not the issue right now.  

Sorry.  Feel free to pm if you want to talk about it.


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## Melclin (Feb 20, 2012)

Just to echo everybody else, he was done from the start.

You cant kill a person who is already dead. You can always make a resus effort better, but you really can't hurt that person (to be perfectly honest, I think the scenario you described was as best as you could do. I always say nothing perfect, but mate, it sounds like this was pretty close too. Was the syringe affective? And where did it come from? Cool idea. I wouldn't have thought of it). Anyway, as systemet said, baring hypoxic arrests (which this clearly wasn't), a soiled airway might make some trouble for a person later down the track if they get ROSC, but it didn't kill him. 

Aside from that, you can't take responsibility for not being able to stop a person from dying. Its a basic fact of life. You may as well apologise to people every time you couldn't stop them from having an unpleasant bowel movement.


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## mycrofft (Feb 20, 2012)

*As above*

Syringe deal not something to make habit of but it didn't  hurt and showed you were still thinking.


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## systemet (Feb 20, 2012)

mycrofft said:


> Syringe deal not something to make habit of but it didn't  hurt and showed you were still thinking.



As an aside, you can make a reasonable suction device with an ETT and a large syringe.  It will do if you have nothing else.


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## MediMike (Feb 21, 2012)

KellyBracket said:


> Disregard for the airway? Sounds like you went above & beyond.
> 
> One could argue for the utility of a precordial thump or two, limited to the first minute or so, but that guy was likely doomed before he hit the snow.



Seeing as how you've got the fancy initials after your name I'm sure you've got a better idea than me regarding precordial thumps, but I was under the impression that the only efficacy shown with these was with a witnessed VT arrest delivered immediately?  And even then the % was fairly low...


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## systemet (Feb 21, 2012)

MediMike said:


> Seeing as how you've got the fancy initials after your name I'm sure you've got a better idea than me regarding precordial thumps, but I was under the impression that the only efficacy shown with these was with a witnessed VT arrest delivered immediately?  And even then the % was fairly low...



There a case series out there that shows a fairly low rate of conversion to a perfusion rhythm and a fairly high rate of deterioration of VT to VF / asystole.  So it's definitely not recommended when an AED is immediately available.  And you're correct that it's low percentage, but it's the only option for defibrillation here.  I might take a look for one of the studies after I drink a couple more cups of coffee.

In this situation, there's no AED.  So if the patient was in VF / VT (which is a big if), a precordial thump might (and this is low percentage), convert to a perfusing rhythm.  The guy is probably still a long way from PCI or an EMS services that can give thrombolytics.

That would be my reasoning, anyway.


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## Handsome Robb (Feb 21, 2012)

precordial thump is supposed to generate a low amount of joules correct? I wanna say <5J.

Seems like in this situation it's more one of those "well it can't hurt and it _might_ help" type of things. 

systemet brings up a good point as well. If you are lucky enough to get ROSC in a situation like this, with the lack of post resuscitative care, the guy would more than likely code again. 

I'll reiterate what I said before, you did everything in your power bud, there was honestly nothing that could have been done for this guy. 

If it was a friend, I can't imagine what that feels like, and you have my condolence.


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## KellyBracket (Feb 21, 2012)

Like I said, one could argue for *one* properly delivered thump, if you had been there at the *moment* of arrest. Nothing to dwell on, certainly.


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## MediMike (Feb 22, 2012)

KellyBracket said:


> One could argue for the utility of a precordial thump or *two*, limited to the first minute or so



Just wanted to make sure partner haha


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## O 2 (Feb 27, 2012)

Sounds like you did everything right, and everything you could do. 

There are no national standards for wilderness EMS so philosophically you're kinda on your own, while legally you're still bound to the local jurisdictions SOPs or the standard of care if you are out of your area. That being said, local SOPs are rarely written with NO access to an AED or extended transport times in mind. 

FWIW the National Park Service's SOPs for BLS Cardiac Arrest (medical) W/O AED & a transport time of greater than 2 hrs is to do CPR at whatever level you have airway mgmt equipment for - for 30 min. We can then call it if we're unable to get in touch w/ OLMC. 

CPR guidelines don't inculde much in the way of troubleshooting options. As long as you're doing the 'right' thing over the expedient, you should be in the clear. 

The only option not mentioned here was online medical control. Most EMTs groan at the "mother-may-I?" routine, but in gray areas like this, I prefer to lean on the MDs and put the legal burden on them. Your post didn't mentioned how you contacted 911, but perhaps if you had cell or radio contact with 911 a patch or relay could have been established. Our radios can be patched w/ a phone to allow for a 2-way conversation w/ base station.

 Still, the outcome would not have been any different, you would just be a bit more legally protected. 

When people venture into the wilderness, they leave behind the protective blanket of Fire, PD, and EMS. Thats a bad time to go into cardiac arrest. Sound like you did everthing you could have and more.


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## EMTBell (Feb 27, 2012)

Thanks for the responses! I just heard that it was a fully occluded right coronary artery, so I really couldn't have done anything. 

Funny, while I was on with 911 (there was a cell phone tower literally 20 feet away, the only thing on the mountain luckily) some cop tried to tell me to stop CPR 15 minutes into it. Of course that made sense statistically, but I'm pretty sure he can't legally advise me to.


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## Melclin (Feb 27, 2012)

EMTBell said:


> Funny, while I was on with 911 (there was a cell phone tower literally 20 feet away, the only thing on the mountain luckily) some cop tried to tell me to stop CPR 15 minutes into it. Of course that made sense statistically, but I'm pretty sure he can't legally advise me to.



Odd. Any idea why he did that?


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## EMTBell (Feb 27, 2012)

either he watched a lot of House and thought he knew something about medicine :rofl: or he knew how the response time would be so delayed, but I still don't know how he could think of calling off resuscitation efforts, thats  reserved for a physician if I'm not mistaken.


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## Medic535 (Mar 1, 2012)

50-100 cc irrigation syringe, and a small ET tube does work, Rip off the cap of the tube and jam the tube on the syringe and wala! Suction!


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## systemet (Mar 1, 2012)

Medic535 said:


> 50-100 cc irrigation syringe, and a small ET tube does work, Rip off the cap of the tube and jam the tube on the syringe and wala! Suction!



This works really well.  Seconded.


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## EMTBell (Mar 1, 2012)

I just used a 20cc irrigation syringe by itself, effective but slow. I've also heard that sticking a large syringe into an NPA would work?


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