Question: How many analyses would you perform on a patient who is VSA following a drowning. Is it considered special circumstances, should the patient be transported after one analysis? Or should we transport after the first rhythm that doesn't result in a defibrillation? How many shocks total if patient stays in a shockable rhythm (4 max or more)?
The question of cardiac arrest in a drowning population has been asked several times previously on the Ask MAC website. In short, patients who have arrested after drowning fall under the Medical Cardiac Arrest Directive. Nonetheless there is still a lot of controversy surrounding drowning and cardiac arrest. As such, please see the following answer:
The debate has centered upon whether the medical TOR has to be an arrest of suspected cardiac etiology in nature (as it says on the directive) or can it also include arrests felt to be asphyxial in etiology (such as drowning, hanging and electrocution- not an exhaustive list).
The concern of the Medical Council was how does the paramedic decide what arrest was caused by asphyxia vs. one of cardiac etiology when often details even on scene are difficult to obtain? You can imagine how many FAQ we would get as to what constitutes a cardiac arrest from a cardiac cause vs. an asphyxial!
The consensus from the SWORBHP Medical Council was for the paramedic to not attempt to break it down asphyxial vs. cardiac on scene€¦ it gets too confusing.
We feel it is reasonable if all other criteria for TOR are met, patch to the BHP and let them be involved in the decision making. We did not want to have to place the paramedic in the difficult position of having to decide on scene- you have enough to do! If the BHP decides that a TOR is reasonable, then follow that protocol, and if not, transport the patient and continue resuscitation as directed.
As an aside, the support for this decision came from the previous ROC trial across North America which studied CPR rates. It was felt by ROC investigators that it was too difficult and unfair to make a paramedic decide on scene what caused the arrest, so arrests caused by asphyxia are treated the same as arrests caused by a presumed cardiac etiology. The Medical Council from SWORBHP thought this would be easier for all paramedics to adopt this same strategy for TOR.
As for a patient who remains in a shockable rhythm, as per the ALS PCS 4.0.1 plan for extrication and transport for patients with refractory ventricular fibrillation and pediatric cardiac arrest (after 3 analyses), ensure quality CPR can be continued. ACPs will patch for further direction (and prepare for transport as unlikely to receive pronouncement for patients in refractory VF) while PCPs will transport after 4th analysis or ROSC.