2003 OPEN FORUM Abstracts
Pre-hospital Use of Continuous Positive Airway Pressure for Saltwater Near-Drowning.
David Pavlakovich RRT, Russell K. Miller MD FACEP.
Mr. Pavlakovich is the Senior Respiratory Therapist for Emergency
Services at the University of Texas Medical Branch, Galveston, Texas.
Dr. Miller is Clinical Assistant Professor of Surgery and Emergency
Medicine at UTMB and is the Medical Director for the Galveston County
Beach Patrol and Galveston EMS.
Background: Acute respiratory failure (ARF) secondary to saltwater near-drowning is a life-threatening emergency that accounts for a significant number of pre-hospital intubations by EMS personnel. Each year, primarily during the summer months, the Galveston County Beach Patrol (GCBP) responds to about 10-15 near-drownings that require them to call Galveston EMS (GEMS) for further assistance. Of these calls the vast majority requires endotracheal intubation secondary to ARF and the inability to manage the hypoxemia and tachypnea associated with near-drowning. Such intubations, in turn, lead to a significant number of intensive care admissions and often lengthen hospital stays. Full face mask and nasal CPAP have been used with great success in the hospital setting for many years to avoid intubation of patients suffering from ARF secondary to near-drowning and EMS providers in Galveston have had this option for some time now. Our research questions were simple. By providing nasal CPAP as an option to GCBP Lifeguards, can we reduce 1) the intubation rate (in the field) of patients suffering from ARF secondary to near-drowning and 2) the intensive care admission rate and length of stay for patients suffering from ARF secondary to near-drowning?
Method: We conducted a study of CPAP, using a prospective treatment design, from June 1, 1998 through September 31, 1998, during the period of time that the GCBP Lifeguards were on duty. We enrolled adult patients suffering from ARF secondary to saltwater near-drowning. The nasal CPAP system used was kept in a kit that is easily carried to the patient. It consisted of a Downs flow generator (Vital Signs), CPAP/BiPAP tubing, Briggs adaptor ("T" piece), corrugated tubing, adjustable PEEP valve (Bird/LDS PEEP Flow), and a nasal CPAP/BiPAP mask (Healthdyne). The DFG was connected to the 50 PSI outlet of the oxygen tank used by GCBP. Upon rescue from the Gulf of Mexico, the GCBP personnel gauged the level of respiratory distress. If it was sufficient to warrant calling GEMS for further assistance and possible endotracheal intubation, then nasal CPAP was applied at 10 cm H2O pressure. Care of the patient would then be transferred to GEMS, upon their arrival to the scene. GEMS then transported the patients via ambulance to the University of Texas Medical Branch Emergency Department, where supportive care was continued.
RESULTS: GCBP responded to 10 patients suffering from ARF secondary to near-drowning who met criteria for intubation. All 10 received CPAP. Of those 10, CPAP was discontinued on 1 who required immediate intubation secondary to sand in the airway. This patient subsequently expired. Nine were placed on CPAP successfully and avoided intubation. All of the patients were admitted to the ICU for close observation and continuation of CPAP. All were subsequently discharged from the ICU the following day.
Conclusions: In the hospital setting, CPAP has previously proven to be an effective alternative to endotracheal intubation for patients suffering from ARF secondary to near-drowning. Study results showed similar effectiveness in the pre-hospital setting. Use of CPAP by GCBP personnel can significantly reduce rates of endotracheal intubation. Given our policy of ICU admission for all patients receiving NIPPV, the ICU admission rate was not reduced although the lengths of stay were reduced to one day.