Real life case

[SleepIsGood]

Was at a convention recently..few days ago.

It's cocktail hour. About 30 ppl are around a guy. They yell out is there a doc here? I come to the scene. I see two individuals giving chest compressions. Reportedly they were nurses. What I am told by onlookers is that the guy on the floor was 'having a seizure' . Although he wasnt actively seizing anymore he did have frothing at the mouth. Immediately I ask everyone to help me log roll him to the side. The vomitus comes out. Then I got a napkin cleared out as much secretions and vomitus as possible and then position his neck in the 'sniffing position'. Kept a jaw thrust. I put my ear against his mouth and I can feel air exchange. Pt has spontaneous respirations. Nurses keep giving chest compressions. I tell them to stop. They tell me that he is 'not breathing' even though when I tell them to stop with the compressions I can feel air exchange against my face as well as spontaneous chest rises. I put my ear against the guys chest and can hear b/l breath sounds although decreased. I will concede that the chest rises and breaths were not 'large ones' but definitely were present. Another resident is at the scene with me. She feels a carotid pulse.

What would you do? Continue CPR with giving compressions and breaths as the nurses desire? Stop with CPR.

BTW..towards the middle somewhere I yell out if anyone knows if this guy has a pmhx. Someone yells out he's a diabetic.

Yes, 911 was called. 10 mins into while I was there, EMS still hasnt arrived.

No AED is present at the center. No O2 anywhere. No masks/bags available. I did ask for someone to run into the kitchen to find the sharpest knife they can find, as well as a few straws (just in case a cric was necessary).

What would you do?? And just to let you know...there's about 30-40 ppl surrounding you.

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[UTSouthwestern]

Was at a convention recently..few days ago.

It's cocktail hour. About 30 ppl are around a guy. They yell out is there a doc here? I come to the scene. I see two individuals giving chest compressions. Reportedly they were nurses. What I am told by onlookers is that the guy on the floor was 'having a seizure' . Although he wasnt actively seizing anymore he did have frothing at the mouth. Immediately I ask everyone to help me log roll him to the side. The vomitus comes out. Then I got a napkin cleared out as much secretions and vomitus as possible and then position his neck in the 'sniffing position'. Kept a jaw thrust. I put my ear against his mouth and I can feel air exchange. Pt has spontaneous respirations. Nurses keep giving chest compressions. I tell them to stop. They tell me that he is 'not breathing' even though when I tell them to stop with the compressions I can feel air exchange against my face as well as spontaneous chest rises. I put my ear against the guys chest and can hear b/l breath sounds although decreased. I will concede that the chest rises and breaths were not 'large ones' but definitely were present. Another resident is at the scene with me. She feels a carotid pulse.

What would you do? Continue CPR with giving compressions and breaths as the nurses desire? Stop with CPR.

BTW..towards the middle somewhere I yell out if anyone knows if this guy has a pmhx. Someone yells out he's a diabetic.

Yes, 911 was called. 10 mins into while I was there, EMS still hasnt arrived.

No AED is present at the center. No O2 anywhere. No masks/bags available. I did ask for someone to run into the kitchen to find the sharpest knife they can find, as well as a few straws (just in case a cric was necessary).

What would you do?? And just to let you know...there's about 30-40 ppl surrounding you.

If he's having a seizure, diabetic or otherwise, is breathing, and has a regular pulse, keep the jaw thrust, get an ambulance, and stop the idiots from doing chest compressions.

Even if the patient is hypoglycemic, he is obviously non-responsive and you don't want to shove/shovel juice or something else down his regurgitating throat. Support his airway, keep a finger on the pulse, wait for the ambulance to arrive and tell them to quickly put oxygen on him and obtain IV access. If you want a crude way to check his/her blood sugar level, stick him and look at the color of the blood. If it is intensely dark, the patient is likely hyperglycemic.

Look at the patient's color for a crude estimate of his/her saturation status and support his/her ventilation if you feel he/she needs it.

 

[Noyac]

I would definitely stop the chest compressions if he is in fact breathing and has a pulse. I'd have him on his side as you mentioned and continue with jaw thrust. If his jaw is tight and clenched I'd try to pry something b/w his teeth (molars preferably) sort of like a bite block. As long as this is the case, all you really need to do is wait for the EMS.

I had the same thing happen to me at my sisters rehearsal dinner. My father (a pediatrician) and I did exactly as I described. Generally, seizures don't cause cardiac/respiratory arrest unless something else is going on, like drug use, etc.

 

[Tired Pigeon]

Hard to believe that "nurses" would not be able to recognize the presence of respirations & pulse. Sounds like their nursing education came from watching ER.

 

[SleepIsGood]

Given these 'irregular', inadequate breaths would you all give more 'supportive' breaths?

 

[Noyac]

Given these 'irregular', inadequate breaths would you all give more 'supportive' breaths?

If color was good then probably not. We can tolerate sats in the 60's for a hell of a long time. You ever seen a pulse ox placed on someone at Everest? They are frequently in the 80's, 70's, and even 60's. EMS will be there soon enough.

 

[SleepIsGood]

So here's what I did.

Again, the nurses kept telling me that he wasnt breathing, when I could physically feel air exchange against my ear. I tipped the guy over and used the napkin to take some vomitus out. Put the guy in the sniffing position and maintained jaw thrust. Believe guys these nurses (ICU ones at that) were continuing chest compressions and I then had to 'pull rank' and tell some others to pull these ladies off the guy. I got someone to take a piece of mirror out of some table and then put it against the guys mouth to show 'fog' and prove to them he was 'breathing'.

Again, 10 min into the situation no EMS. I figured he was having a hypoglycemic seizure. I got someone to take some sugar packets (I took some of it and put it under his tongue...figured could get some capillary absorption).

Finally EMS arrives. I tell them to put some O2 on the guy. EMS asks me why these ladies were doing CPR? I told them I have no idea. I then asked them to do an accuchk. His BS was 30 ! We started some D5. Called the hosp later on that day and the following day...guy was doing fine and was going to be d/c'd.

Here's the reason I posted this. Once I cleared the guy's airway, even though his respirations likely had minimal Tidal Vols I figured not giving breaths (despite what the nurses were telling me) was better. 1) The guy was spont breathing 2)The atmospheric O2 is atleast 21% --if someone blew into his mouth I figured the O2 amount would be less and the CO2 would be high.

Was I right to assume this?

Number 2. How important is the pulse in this situation to check? If he's breathing spontaneously and I can see fog on a mirror doesnt that automatically mean his cardiopulm system is intact?

 

[Arch Guillotti]

I did ask for someone to run into the kitchen to find the sharpest knife they can find, as well as a few straws (just in case a cric was necessary).

This has got to be the funniest thing I have read on SDN in a long time.

 

[militarymd]

Agonal breaths....sometimes will give you fog....seen that a few times...even when there is little or no cardiac output.

 

[VolatileAgent]

Agonal breaths....sometimes will give you fog....seen that a few times...even when there is little or no cardiac output.

(dork)

 

[militarymd]

Hey, fat, balding, big eared, doubled chinned guy......yeah, that's right....you know who you are.......

if you don't have anything meaningful to contribute ...and that's like 99% of the time....keep it to yourself.

 

[VentdependenT]

Bleaahhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh!!!!!!!!!!!!!!!!!!!

 

[SleepIsGood]

This has got to be the funniest thing I have read on SDN in a long time.

Tell me about it. Retrospectively, yes I agree.

But hey first thing I heard was someone yelling out, "cant ventilate him". So I'd rather be thinking ahead...

 

[dhb]

The atmospheric O2 is atleast 21% --if someone blew into his mouth I figured the O2 amount would be less and the CO2 would be high.

Expired O2 is 16% so if my math is correct you would need to increase tidal volume by 25% to compensate for the delta O2...
If the guy wasn't blue i wouldn't have blown down his throat

 

[powermd]

Once I cleared the guy's airway, even though his respirations likely had minimal Tidal Vols I figured not giving breaths (despite what the nurses were telling me) was better. 1) The guy was spont breathing 2)The atmospheric O2 is atleast 21% --if someone blew into his mouth I figured the O2 amount would be less and the CO2 would be high.

Was I right to assume this?

Number 2. How important is the pulse in this situation to check? If he's breathing spontaneously and I can see fog on a mirror doesnt that automatically mean his cardiopulm system is intact?

My initial reaction to the situation, thinking it though, was to do exactly as you did. It also occurred to me to reach for sugar packets and put some under the tongue. I was disappointed that it didn't work in practice. Regarding the O2- assisted tidal volumes at 16% FiO2 are probably better than agonal tidal volumes at 21%. I'm not sure I would have gone mouth to mouth on the guy though... I wonder what might be available as a shield/filter to form a seal for breaths while protecting you from vomitus... I couldn't think of anything in a dining room or kitchen that would do that. As a former EMT, I used to keep a CPR mask in my car.

 

[Mman]

if he has vomit in the back of his throat, adding positive pressure to the aspiration risk probably isn't the wisest idea. I mean he's obviously keeping his sats high enough to let his heart maintain perfusion. If he stopped his minimal respirations or lost his pulse or looked blue in the lips, I'd probably resume rescue breathing and/or CPR.

 

[timtye78]

I think you did pretty well for an 'out of hospital' setting. ABCs-you had the basics of life support down much better than the ICU nurses.

Pt had an airway, absolutely unprotected and nonsecured

Pt was breathing-spontaneously even

Circulation-pt had palpable carotid pulse. (Can't remember BP correlation to carotid pulse, femoral pulse roughly correlates to SBP of 70)

Compressions-indicated for lack of pulse or no BP if you have monitor, intended to provide temporary perfusion/circulation. Like others said, PPV with a non-secured airway increases risk of aspiration, and in this situation, the benefits dont outweigh the risks.

Level of consciousness sounds like it was decreased, vomitting, and questionable hypoglycemic seizures. sounds like a good argument for securing the airway if you had supplies and weren't able to increase level of consciousness very soon, eg waiting for D50 and IV. Another good option in this situation would simply be high flow supplemental O2 by mask or nasal cannula plus pulse ox if you could obtain (again if you had it)

If patient is breathing, moving air, not turning blue/cold, palpable pulse-there is no indication for defibrillation. So, AED was not needed either.

(Unless an ekg/aed shows VF/or you have pulseless VT.)

Good job on assessing the patient and standing up to people who may think or even 'appear' more knowledgeable eg older than you. You did the right thing. Great case and fascinating post/discussion!

 

[zippy2u]

Reminds me of back in the day in the hood -- watch for the 2-clown-scam. One clown fakes the seizure and while everyone runs to help, leaving valuables and pocketbooks on the tables, the other clown scarfs the belongings and hightails it out the door. Yeah, Zip has been around the block once or twice... Regards, --Zip

 

[The_Sensei]

Reminds me of back in the day in the hood -- watch for the 2-clown-scam. One clown fakes the seizure and while everyone runs to help, leaving valuables and pocketbooks on the tables, the other clown scarfs the belongings and hightails it out the door. Yeah, Zip has been around the block once or twice... Regards, --Zip

Dude.....much like you're moniker, you zip in here.......make some funny ass comments/observations....then zip on out, sometimes lying dormant for months. I still use the term "piano-handed" that I picked up from you on a semi-regular basis.

Now if only JetPropPilot would show up now and then.....

 

[canjosh]

The latest BLS recommendations emphasize quality chest compressions over rescue breathing. In other words, if it's not your family member's/close friend's vomitus don't expose yourself. The survival rate for out-of-hospital cardiac arrest is 6%, so the benefits are negligible at best. Basically, the patient is screwed if there's no AED available. Even if the guy had been apneic, I wouldn't have done mouth-to-mouth myself. One of the heroic 'nurses' can have at it though!
Inability to partially arouse/depressed gag reflex are generally contraindications for treatment with oral glucose.

 

[SleepIsGood]

The latest BLS recommendations emphasize quality chest compressions over rescue breathing. In other words, if it's not your family member's/close friend's vomitus don't expose yourself. The survival rate for out-of-hospital cardiac arrest is 6%, so the benefits are negligible at best. Basically, the patient is screwed if there's no AED available. Even if the guy had been apneic, I wouldn't have done mouth-to-mouth myself. One of the heroic 'nurses' can have at it though!
Inability to partially arouse/depressed gag reflex are generally contraindications for treatment with oral glucose.

Hey canjosh. totally agree with you on the glcs issue. however, this was just a little sugar under the tongue...figured some sort of capillary absorption may occur....again...urgency of the situation...10min gone by, and no EMS..

 

[TIVA]

Are you sure it was a sugar packet that was handed to you and not "Equal" or "Nutrisweet?"

 

[SleepIsGood]

Are you sure it was a sugar packet that was handed to you and not "Equal" or "Nutrisweet?"

positive...lol

 

[TheSandMan]

So here's what I did.

Again, the nurses kept telling me that he wasnt breathing, when I could physically feel air exchange against my ear. I tipped the guy over and used the napkin to take some vomitus out. Put the guy in the sniffing position and maintained jaw thrust. Believe guys these nurses (ICU ones at that) were continuing chest compressions and I then had to 'pull rank' and tell some others to pull these ladies off the guy. I got someone to take a piece of mirror out of some table and then put it against the guys mouth to show 'fog' and prove to them he was 'breathing'.

Again, 10 min into the situation no EMS. I figured he was having a hypoglycemic seizure. I got someone to take some sugar packets (I took some of it and put it under his tongue...figured could get some capillary absorption).

Finally EMS arrives. I tell them to put some O2 on the guy. EMS asks me why these ladies were doing CPR? I told them I have no idea. I then asked them to do an accuchk. His BS was 30 ! We started some D5. Called the hosp later on that day and the following day...guy was doing fine and was going to be d/c'd.

Here's the reason I posted this. Once I cleared the guy's airway, even though his respirations likely had minimal Tidal Vols I figured not giving breaths (despite what the nurses were telling me) was better. 1) The guy was spont breathing 2)The atmospheric O2 is atleast 21% --if someone blew into his mouth I figured the O2 amount would be less and the CO2 would be high.

Was I right to assume this?

Number 2. How important is the pulse in this situation to check? If he's breathing spontaneously and I can see fog on a mirror doesnt that automatically mean his cardiopulm system is intact?

strong work bro.
as to zippy's comment, if this was a scam and they happened to steal a resident's wallet- they would be sorely disappointed