Immersion Pulmonary Edema in dive accidents

[Duke Dive Medicine]

I was hospitalized for multiple pulmonary emboli last year following minor same day surgery. I complained about being a little short of breath just befor going home, and the MDs seemed extremely worried after the subsequent CAT scan they ordered. They kept me in hospital for two long weeks with IV heparin, and 4 months after discharge on blood thinners. I'm perfectly fine now, but has this experience made me more susceptible to IPE?

If there is any clot remaining in your lungs, it can lead to pulmonary hypertension, which is a precursor to pulmonary edema. If the pulmonary embolus was a one-time occurrence, the clot has resolved, and you don't have a predisposition for deep vein thrombosis or other coagulopathic condition that could cause a repeat incident, your risk of pulmonary edema related to pulmonary embolus is probably no more than that of the general population. Since you're off anticoagulants, it doesn't appear as if your care team believes there's a problem, but if you have questions, it's best to talk to your treating physician.

*edit: BubbleTrubble posted while I was writing this.

 

[agilis]

Thank you Bubbletruble and Duke Dive medicine. I feel confident that I'm at no more risk than the general population (in my age category), since the minor surgery, laser lithotripsy, became complicated by kidney bleeding, resulting in a decision to use curare to totally immobilize me during the procedure, causing clots in one leg which quickly migrated to the lungs. I was amazed to discover, after doing some research, how common these frequently deadly embolisms are, causing a much higher post surgical mortality than most people would ever imagine. I was screened very thoroughly by the pulmonary/nephrological/surgical/internist/hematology team, and assured that I had no underlying issues. It was the surgery and the curare based anesthesia that caused the clots. I'm a long time DAN member, and will consult them for a local dive savvy specialist as an added precaution before my next dive trip in March, which is in part a celebration of my 70th birthday, so I know I have some age related risk factors despite a life-long committment to physical fitness. I'm an extremely conservative diver. Again, my sincere thanks.

 

[raftingtigger]

Deleted, double post.

 

[raftingtigger]

Perhaps you need to look in to the literature surrounding CCR rather than CPR. First a study that address passive ventilation with oral or nasal airways and 02 via non-rebreather using trained rescuers during compression only CCR. It turns out that adding a ventilation via BVM doesn't improve outcomes. More citations favoring compression only CPR follow. If outcomes aren't better why add complexity to the resuscitation process? Pulmonary edema must be one of the few situations where positive pressure ventilation would be beneficial but otherwise Jax isn't crazy discussing CCR without assisted ventilations and I believe she is a resident of Arizona where the first study I cite originated. DDM is correct is stating that in the current AHA Emergency Cardiac Care guidelines drowning is a situation where they recommend traditional CPR with assisted ventilation.

CONCLUSION: Among adult, witnessed, ventricular fibrillation/ventricular tachycardia, out-of-hospital cardiac arrest resuscitated with minimally interrupted cardiac resuscitation, adjusted neurologically intact survival to hospital discharge was higher for individuals receiving initial passive ventilation than those receiving initial bag-valve-mask ventilation.
Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest.
Bobrow BJ, Ewy GA, Clark L, Chikani V, Berg RA, Sanders AB, Vadeboncoeur TF, Hilwig RW, Kern KB.
Ann Emerg Med. 2009 Nov;54(5):656-662.e1. Epub 2009 Aug 6.
PMID: 19660833 [PubMed - indexed for MEDLINE] (full text here)

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CONCLUSION: Instituting the new cardiocerebral resuscitation protocol for managing prehospital cardiac arrest improved survival of adult patients with witnessed cardiac arrest and an initially shockable rhythm.
Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Ewy GA.
Am J Med. 2006 Apr;119(4):335-40.
PMID: 16564776 [PubMed - indexed for MEDLINE]


​

Conclusion
In adult patients with a witnessed cardiac arrest and an initially shockable rhythm, implementation of an out-of-hospital treatment protocol based on the principles of cardiocerebral resuscitation was associated with a dramatic improvement in neurologically intact survival.
Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Barney R, Keilhauer FA, Bellino M, Zuercher M, Ewy GA.
Ann Emerg Med. 2008 Sep;52(3):244-52. Epub 2008 Mar 28.
PMID: 18374452 [PubMed - indexed for MEDLINE]

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Conclusions
Survival-to-hospital discharge of patients with out-of-hospital cardiac
arrest increased after implementation of MICR as an alternate EMS protocol. These
results need to be confirmed in a randomized trial.
Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.
Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB.
JAMA. 2008 Mar 12;299(10):1158-65.
PMID: 18334691 [PubMed - indexed for MEDLINE]
Free Full Text at JAMA

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Conclusions
This report demonstrates that if powerful cardiac compressions are started early, in this case less than two minutes after normothermic arrest, it is possible to maintain circulation and a sort of spontaneous respiratory movements resulting in gas exchange for more than 25 minutes. For this patient, this kind of respiration was sufficient for survival without neurological damage.
Favourable outcome after 26 minutes of “Compression only” resuscitation: a case report.
Steen-Hansen JE.
Scand J Trauma Resusc Emerg Med. 2010 Apr 16;18:19.
PMID: 20398354 [PubMed - indexed for MEDLINE]
Free Full Text from PubMed Central

Citations lifted from Rogue Medic's blog

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The studies cited are talking about WITNESSED, SHOCKABLE RHYTHM, CARDIAC ARRESTS (with the possibility of one of them), while in a diving situation the vast majority are UNwitnessed, RESPIRATORY arrests that lead to a cardiac arrest. Ergo the studies cited have little to no bearing on the type of CPR most effective in a drowning situation. It may turn out that CCR will do just as well, but by the conclusions cited that type of arrest wasn't addressed. To assume that CCR is better in the witnessed, cardiac caused event and therefore it is better in the unwitnessed and/or respiratory caused event is presumptuous.

Until such time as it is shown that CCR is just as good (if not better) than 'conventional' CPR I'll continue to do that in the 'respiratory' arrest situations. I'll use a pocket mask (or like) if, and only if, one is within arms reach. Until then I'll do old fashioned mouth-to-mouth. It can be gross (yes I have done it for real several times), but like Duke Med said - there are no reported cases of disease transmission that way. No regrets or second thought that way.

 

[Bubbletrubble]

Could we please define any ambiguous abbreviations before using them?

For instance, in the posts of renoun and raftingtigger above, "CCR" = cardiocerebral resuscitation.
In a scuba-related Internet forum, readers would be tempted to think that "CCR" stands for closed-circuit rebreather.

 

[DandyDon]

Could we please define any ambiguous abbreviations before using them?

For instance, in the posts of renoun and raftingtigger above, "CCR" = cardiocerebral resuscitation.
In a scuba-related Internet forum, readers would be tempted to think that "CCR" stands for closed-circuit rebreather.

Thanks. I had searched google for "CCR" but found nothing associated. Can we please call it what it is? Compression only (hands-only or cardiocerebral resuscitation) or just Compressions only resuscitation. Some call it "compressions only cpr" but that is misleading since the Pulmonary part is omitted.

 

[Thalassamania]

Closed Chest Compression? CCC?

 

[Bubbletrubble]

Thanks. I had searched google for "CCR" but found nothing associated. Can we please call it what it is? Compression only (hands-only or cardiocerebral resuscitation) or just Compressions only resuscitation. Some call it "compressions only cpr" but that is misleading since the Pulmonary part is omitted.

@DandyDon: My understanding is that cardiocerebral resuscitation (CCR) is not just chest compression-only resuscitation.
(FWIW, in the scientific literature, hands-only resuscitation is often referred to as compression-only CPR.)
CCR is being advocated by some groups specifically for witnessed out-of-hospital cardiac arrest in adults due to ventricular fibrillation.

According to Ewy et al., CCR is comprised of 3 layers of intervention:

• Continuous chest compressions without mouth-to-mouth ventilations for all witnessed cardiac arrests by bystanders and first responders.
• A new ACLS (advanced cardiac life support) algorithm that minimizes chest compression interruptions, delays endotracheal intubation, deemphasizes positive-pressure ventilations, prioritizes defribrillation according to the 3-phase time-sensitive model of ventricular fibrillation, and encourages early administration of epinephrine.
• Establishment of cardiac arrest centers that can provide optimal subsequent treatment (catheterization, controlled hypothermia, other care) for the patient.

CCR is being offered up as alternative for EMS systems to conventional CPR + ACLS procedures.
Layers 2 and 3 of CCR are meant to be carried out only by trained professional responders (EMTs, paramedics, nurses, physicians).

@Thalassamania: "CCC-CPR" is an abbreviation used in the scientific literature to refer to "continuous-chest-compression CPR."

 

[Jax]

So, would it be too much to NOT use acronyms at all, to prevent misunderstanding? Please? raying: