SWORBHP Ask MAC

Answer: The lower the patient’s temperature, the more irritable the myocardium becomes and as such, sensitive to a wide variety of arrhythmias. The most lethal and concerning arrhythmia in hypothermia is actually not atrial fibrillation but rather ventricular fibrillation (VF). Again, as the temperature of the myocardium falls, the closer to the VF threshold the patient becomes. This is why active core re-warming is so essential early in the care of these patients (thus the one shock and go in the directive) since the VF may be refractory to successive countershocks until the patient is re-warmed.

Answer: Excellent question! You are correct, a tracheostomy is an absolute contraindication to the use of CPAP. The obvious concern would be that it would be impossible to maintain a pressure gradient in the lower airways if all of the oxygen is escaping out of the tracheostomy.

If the tube has been recently removed as you suggest, however the stoma (the hole) remains patent, then this contraindication remains. It is imperative for the stoma to be fully healed, closed, and ideally not just within recent weeks of closing over as the concern would be that a “fresh” tracheostomy wound may reopen given the pressure from CPAP. Given the variability of wound closure, it is impossible to list a firm date as to when the wound can be considered “healed”.

Bottom line: If a tracheostomy wound is still patent, or if the paramedic has concern that the tracheostomy wound is freshly closed over from a recent tube removal, it is best to use alternative means at supporting respirations other than CPAP.