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.
