Friday, January 18, 2013

ST-segment elevation myocardial infarction after drowning

ST-segment elevation myocardial infarction after drowning

Authors: Hesham Rashad Omar, Madhu Shree Gundavaram, Ehab El-Khabiry, Yaseen Ali, and Enrico Mario Camporesi
Journal: Internal and Emergency Medicine (Italian Society of Internal Medicine)

Very interesting case study.  The morbidity and mortality from drowning stems from the primary hypoxic injury and can been seen in the end organ damage of patients, the most worrisome and devastating of which is usually encephalopathy.  This case highlights the cardiovascular effects of hypoxia in a patient who we would otherwise not expect to see it in.  The paper tells of a 16 year old patient who was brought in after a drowning injury in which the initial ECG showed ST segment elevations consistent with inferior MI.  The patient was then taken to the cath lab, but cath was cancelled due to resolving elevations in a repeat ECG;  eventual troponins were positive.  Unfortunately the patient continued to decompensate from there on out until he was diagnosed as brain dead.  

As we all know, MI can be the inciting event for drowning injury, but in a patient this age we can assume that it was an indicator of end organ injury.  I would have like to have seen a post-mortem report to determine if there was any cardiac abnormalities, but all in all an interesting case.


Monday, January 7, 2013

Lifeguard Fatigue and CPR

Effect of physical fatigue on the quality cardiopulmonary resuscitation: a water rescue study of lifeguards
Authors: Roberto Barcala-Furelos, et al.

This study, out of Spain, provided some evidence to support the idea that fatigue from an in-water rescue leads to sub-optimal CPR.  A study of this nature has been done before, but this one was performed after the updated 2010 CPR protocols.  As you can imagine, it doesn't provide any mind-blowing information, and pretty much serves to tell us what we already know, but this type of evidence may come in handy when designing training programs or lobbying for increased resources.

The basic design of the study:

  • Had lifeguards perform CPR on mannequins both during a resting phase and after enacting a simulated/standardized rescue
  • Used feedback mannequins to monitor quality of CPR
  • Compared CPR quality between genders and between resting and post-rescue 
Important results:
  • Gender did not effect quality of CPR
  • Overall, CPR quality was poor compared to standard
    • Low number of correct ventilations (very important in drowning)
    • Although in increase in compressions after rescue, there were less correct compressions performed
    • Fatigue worsened overall CPR
With high quality CPR, especially ventilations, playing such an important role in survival after drowning, this study should be taken into consideration when designing lifeguard training programs and drafting standard operating procedures.  Steps should be taken to maximize "real-world" scenarios with an emphasis on maintaing high quality skills despite the adrenaline rush and to account for this rescuer fatigue when establishing on-scene protocols and the roles of auxillary responders.