You are working a morning shift as a Paramedic/ECA crew on an ambulance when a call comes through for a person reportedly seen floating down a river. The location is 10 minutes drive away.
You are travelling to the scene when an update comes through from control saying that the Fire service has managed to rescue the patient from the river. They seem to be unresponsive and Fire are asking for Ambulance support. Police on scene detail that this patient was reported missing last night with family concerns over mental health and suicidal threats.
You arrive on scene where Fire have dragged the patient from the riverside to the road next to it. They are frantically using a BVM on the patient and calling you over to help.
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You approach the Firefighter with what kit you can carry. The patient is soaking wet, unconscious, and a very pale colour. The Firefighter explains that they have made some respiratory effort but it is very poor with a lot or gurgling and airway noise. The patient is a young male in his early twenties. There is a bridge further upstream where they think he may have jumped from.
There is no obvious catastrophic haemorrhage, what is your next priority?
Alongside airway, what further considerations should be aware of
You have a look in the airway and see a lot of fluid. Your colleague passes you the suction device and you suction the airway. A lot of fluid is removed and the airway is now clear. What is your next action?
You note the patient has a respiratory rate of 6 breaths per minute. You take over the BVM and assist with ventilation. You feel a lot of resistance, and are struggling to get good rise and fall of the chest. As you look again, you can see that a lot of fluid has collected in the airway again. You return to suctioning but fluid continues to collect. What advanced airway adjunct could you consider early on to help secure the airway and reduce the risk of further aspiration
You secure an ETT airway and now have much better rise and fall of the chest. You instruct one of the firefighters to inflate the BVM every 6 seconds. Your colleague at this point has removed some of the wet clothing and replaced with dry blankets. They have started to do some observations; BVM resp rate of 10 – 12, carotid heart rate of 42, oxygen sats unreadable on the cold extremities, temperature of 29.8°C, blood pressure 78/44, capnography 40 mmHg, FLAPS TWELVE ok apart from some aspiration.
What is your next action?
You look for IV sites but it is impossible to see any point of access, so you find the head of humerus and IO the patient. The patient remains unconscious throughout the procedure. Your colleague provides you with warm fluids and you start to run them. While you were gaining IO access, your colleague was removing further clothing and replacing with dry blankets.
What is the next action?
Your colleague has set up the stretcher and scoop, and has the back of the ambulance ready to accept the patient with heaters on. You move the patient into the back of the ambulance with assistance of the Firefighters and start a reassessment of the patient. As you start, capnography on the ECG significantly drops and the patient goes into cardiac arrest. In general, if attending a drowning cardiac arrest patient, are 5 inflation breaths recommended at the start of the resuscitation?
You look at the defib screen and see the patient is in VF. The patient’s temperature is still under 30°C, what is your next action?
You come to your second rhythm assessment and again see VF on the screen. Do you shock a second time?
When a patients’ temperature is below 30°C, what is the maximum number of shocks you can give?
You have completed another cycle and the rhythm check shows VF again. You give your third and last shock. The patients’ temp is still 29.8°C. Your colleague passes you adrenaline 1:10000 and amiodarone. How much adrenaline do you give?
You advise your colleague that you can’t give any drugs due to the patients’ temperature being below 30°C, and so you continue your efforts resuscitating and trying to warm the patient. A second crew arrives to assist in your resus efforts.
Given the context of the scenario, after 20 minutes of ALS, are you able to cease resuscitation of the patient?