Agonal respirations are an abnormal pattern of breathing characterized by shallow, slow (3-4 per minute), irregular inspirations followed by irregular pauses. They may also be characterized as gasping, labored breathing, perhaps accompanied by strange vocalizations and myoclonus (a brief, involuntary twitching of a muscle ). In some cases, agonal respiirations can mirror normal breathing however become less frequest with time. The cause is due to cerebral ischemia, due to extreme hypoxia or even anoxia which accompanies sudden cardiac arrest.. Agonal breathing is an extremely serious medical sign requiring immediate medical attention, as the condition generally progresses to complete apnea and heralds death .

Agonal respirations are also commonly seen in cases of cardiac arrest , and may persist for several minutes after cessation of heartbeat. The presence of agonal respirations in these cases indicates a more favorable prognosis than in cases of cardiac arrest without agonal respirations.

The following video simulates a patient suffering sudden cardiac arrest followed by a seizure (induced from a sudden lack of oxygen to the brain from the sudden lack of circulation in an arrest). Take note of the timing and characteristics of the agonal respirations.

Video supplied by Ron Straight

One of the most common misconceptions I come across in NLS classes, recerts, etc. is that of victim positioning.  Many people seem to think that lateral, recovery, 3/4 prone, and semi-prone are all the same position - simply on the side.  This is incorrect.  Lateral position is used when ventilating a non-breathing victim.  The airway is manually maintained and hyperextended by the rescuer.  If one were to draw an imaginary line down the body of someone in lateral position it would go directly though their mouth down their throat and into their lungs.  The head usually rests on an extended arm as shown in the picture.  Recovery aka 3/4 Prone aka Drainage are synonyms of the same position.  This is the position in which an unconscious victim should be placed to recover .  In other words, their ABC's are stable and the rescuer is simply waiting for EMS to arrive.  

The example I always use to clarify these positions is vomiting.  Say, for example, you are a rescuer all by yourself and you come across an adult victim.  Once determining they are unconscious the standard is to leave the victim in recovery and call EMS yourself (remember for a child or infant, 2 minutes of immediate care should be done prior to EMS).   If you were to leave the victim in a lateral position, it is very possible that the victim's head could slightly fall back behind the arm and they could vomit.  This would cause aspiration of the vomit possibly killing the patient.  However, if we correctly place this same victim into a 3/4 prone position (see picture) before leaving, even if the victim vomits, they will vomit towards the ground and there will be no chance of creating airway or breathing complications.  It is very important that instructors at every level are familiar with this.  If you teach your Bronze Medallion class to put all victims into a lateral position (or you say "3/4 prone" but really are teaching a lateral position) you create the opportunity to the above described situation.  Students and instructors should be very clear about this point.  

As a side note, in lifeguarding (in some branches anyway) we tend to use a lateral position for all unconscious victims (because of the amount of vomiting and fluid coming from the airway after a drowning episode). This is fine because there is always at least one lifeguard staying with the victim.  Therefore, if vomiting does occur, there is a guard to immediately intervene before any complications can take place.  

LATERAL POSITION

3/4-PRONE aka RECOVERY aka DRAINAGE aka SEMI-PRONE

Besides a lowered LOC, confusion, poor coordination, and trouble speaking, a patient suffering from a TIA or Stroke often displays numbness or weakness on one side of the body (this has to do with one side of the brain being affected). Some simple bilateral symmetry tests can be used to help determine if the patient is suffering from this condition:

• Pupil Reactivity – Check to see if the pupils are equal and whether or not they both react appropriately to light.
• Tongue Test – Ask victim to stick their tongue straight out. The tongue may deviate to one side.
• Smile Test – Have patient smile for you. Check to ensure both sides of the mouth curl up equally.
• Squeeze Test – Have patient squeeze each of your hands as hard as they can. Check for equal strength as they do so.
• Arm Lift – Have patient lift both arms up at the same time. Watch for one side raising an arm faster or higher than the other.

At recerts especially, I find that many lifeguards are confused about oxygen delivery and what constitutes different flow rates.  The bottom line is:

• 10 Lpm for patients BREATHING effectively on their own.
• 15 Lpm for patients who are NOT BREATHING or who require ASSISTED VENTILATIONS.

When you first took your Bronze-level courses and even your CPR course, you were probably taught that part of the Primary Survey was to check ABC's.  When you got to "B" or "breathing" you were to check to see if the victim was breathing or not.  if they were, you could move onto "C", and if they were not, you would give 2 slow ventilations, move onto "C", and continue rescue breathing at a rate of one breath every 5 seconds.  Now this is completely correct, however when we assess Breathing in any patient we should not only be determining if breathing is present or not , but if the breathing is ADEQUATE .  

Many patients may be experiencing what is known as "Inadequate Breathing" as a result of their current condition.  This may also be referred to as "air hunger."  Some common reasons a victim may be experiencing this problem could include: anaphylaxis, chest injuries, drug overdose, poisoning, or severe shock.   Keep in mind, treating the actual condition (with medication, shock treatment, etc.) may help in restoring normal respirations.

So how do we recognize a victim who is not breathing effectively?  We look for signs and symptoms which could indicate this person is not getting enough oxygen.  This could include cyanosis around the lips, fingertips, earlobes, nostrils, etc.  The victim's face and skin may appear to be pale and clammy (shock-like).  The victim themselves may appear anxious, stressed, panicky, and gasping (you have to imagine, being conscious and not being able to get enough air would be a very scary and stressful experience).  They may also be using their neck muscles in an attempt to take in more breath.  The patient's respirations will most likely be very shallow as well.   Another thing to note during your assessment is the rate of breathing.  If the patient is breathing very slowly (hypoventilation) or very quickly (hyperventilation) they may not be getting enough air.  As a VERY GENERAL GUIDELINE, some people say a breath rate under 10bpm or over 30bpm may indicate inadequate breathing.  The bottom line is that it is up to the rescuer to assess the victim and determine if the patient is getting enough air or not.  In a conscious victim this may be as simple as asking, "are getting enough air when you breath?"

If you determine that a patient is breathing inadequately, you should be performing "Assisted Ventilations."  This is essentially a form of rescue breathing for an already breathing patient.  Your goal in doing this is to restore a normal breathing rate and character.  If the patient is breathing very slowly, you may have to ventilate them once every 3 seconds or so to increase their normal respirations.  If the patient is breathing very quickly, you may have to ventilate them once every 5 seconds to decrease their normal respirations.  The actual technique is simple.  Take your pocket mask, inform the patient what you are doing and talk them the entire time if they are conscious, make a seal over the mouth and nose, and ventilate as you would a non-breathing patient.  It is very important you continually monitor this patient to note any signs of improvement or deterioration.

Imagine witnessing someone diving into shallow water. The patron is laying face down, motionless. You immediately signal and respond to the patron. Having made no waves on your approach, you come up beside the person, clamp and turn them over. There is no resistance to your grasp and rollover and just as you bring the patron face up the second guard is there. The patron is wide awake but has not said anything. He is pale, appears scared, and appears to be trying to “gulp” or suck air into his lungs.

This accident happened at a lower mainland pool years ago.

In the real accident, the patron was asked if he wanted to be ventilated after the rescuers realized he was going cyanotic (blue from a lack of oxygen). He attempted to say yes but no sound was heard. Just the patron's lips were seen to move "yes." The rescuers then started to ventilate the patron. The patron had suffered a cervical spinal cord injury and the spinal cord shock had paralyzed his respiratory muscles (diaphragm and intercostal muscles). The patron was unable to breathe. Since he could not breathe the patient could not speak because he could not push air past his vocal cords. After the first few ventilations the patron whispers he needs methylpednisolone.

The initial ventilations filled his lungs and allowed the patron to have air move past his vocal cords and make some noise. This does not mean he is able to breathe. It is simply his natural expiration; he needs to be consistently ventilated to supply him with the oxygen he needs. His request for methylpednisolone is because he is a doctor and is aware of the latest findings that state high doses of methylpednisolone (a type of corticosteroid) help prevent swelling which can (if unabated) impair circulation (blood flow) to the spinal cord. This lack of circulation results in necrosis (death) to part or all the spinal cord that, of course, is irreversible. (Do you need to know this as a lifeguard? Of course not… but it happened, and if you're this far into the explanation you must have some interest of what's happening)

Applying cold to the neck may appear to lesson swelling, but the more significant potential problem is that it will narrow blood vessels feeding the cord and impair circulation and blood flow. Therefore, cold application is not recommended for this or any spinal injured patient.

Palpation (careful touching) of the cervical area is certainly indicated as long as no movement is caused. Remember though, the patient may have no complaints of pain if he has an altered level of consciousness or other injuries that draw his attention away.

Priapism is a definite sign of spinal cord injury in males but its absence does not rule out the possibility of a spinal cord injury.

Assessment of motor and sensory function is very important. So the hospital has a better picture of the acuity of this injury and its potential significance, accurate documentation of your findings is important. Remember, the further up the spinal cord is injured, the more sensory and motor impairment there will be. Incomplete injury to the spinal cord can result in unequal findings. For example the patron may be able to feel your touch but can't move the part you are touching (sensory and motor each leave from opposite sides of the cord).

In this patient, your assessment reveals complete sensory and motor loss below the neck. In other words this patient is quadriplegic. Remember, the (phrenic) nerves leave to innervate the diaphragm (sends the message from the brain to breathe) from cervical vertebrae 3, 4, & 5, so damage to the cord at or above these levels cuts out breathing. To remember this use "C3, C4, C5 - keeps the diaphragm alive." Injury below C5 can still impair breathing because the secondary muscles of respiration, the intercostal (rib elevating muscles), radiate from the bottom of the cervical spinal cord and the top of the thoracic spinal cord.

You are ventilating the patient at a rate of once every three-five seconds or 20 times a minute. This is beneficial to reverse hypoxia caused by the period the patient was apeic. This hyperventilation is useful for head injuries also because it causes vasoconstriction and reduces blood flow to the brain in cases where intra cranial pressure is a concern. This vasoconstruction is important in spinal cord injuries for a similar reason. The tissue swelling in spinal cord injuries can inhibit circulation to the cord. Slowing blood flow down might prevent excessive swelling. The other extreme is equally injurious. If the PCO2 is reduced too much, then circulation is impaired to the point where not enough blood reaches the cord because of the supplying vessels being too narrowed. The rate of 20 breaths per minute is optimal for the first 10-15 minutes, then once every five seconds is optimal.

Since the patient is no longer able to control his body temperature where he is paralyzed, you have covered the patient with a blanket. The patient is starting to take some shallow breaths. You continue to assist his weak ventilations with mouth to mask, being careful to blow in only when the patient is inhaling.

This patron was a man in his early thirties. He badly fractured (compressed) cervical vertebrae 2, 3, 4 & 5. He was in hospital for months. Vertebrae 1-5 were fused together. After much rehabilitation his is walking and practicing medicine again. He has some deficits. He has lost the dexterity in his hands. He has weak upper body strength. He can not blow up a balloon and he cannot turn his head (there are others). Because of the inherent future arthritic problems in his neck his career as a doctor will likely be cut short by 10-15 years. It would appear surprising, from his initial presentation, that he recovered so well. The initial signs and symptoms were those of spinal cord shock, a condition due to trauma to the spinal cord, but as you can see this shock can wear off. This is not to be confused with neurogenic shock.

More compressions aim to increase blood flow to the heart, brain and vital organs. The first few compressions of CPR essentially only “prime” the heart and are not effective at sustaining oxygenation to the body. Therefore, by increasing the total number of compressions, we also increase the overall number of effective compressions.

Under the 2005 guidelines, lay rescuers are not trained to perform artificial respiration; all non-breathing patients are given CPR immediately. If your training agency is performing AR in certain situations (near drownings, assisted ventilations, diaphragm paralysis in a spinal, etc.), the HealthCare Provider standard states ventilations should be given at a rate of one breath every 5-6 seconds.

Ventilating too much air or air too frequently can result in gastric distension (air in the stomach) or increased intra-thoracic pressure which actually diminishes the effectiveness of CPR.

CPR is very physically demanding on the rescuer. An interesting study had candidates performing CPR on mannequins hooked up to machinery measuring optimal rates and depth of the compressions (ie. effectiveness of the procedure). Candidates were told to inform the researchers when they began to tire and felt their CPR was no longer as effective as it was when they started. Most participants made reference to this at 5-7 minutes. However, consistently, after 2-3 minutes, the overall effectiveness as measured by the mannequins was decreased.

Therefore, in a 1-rescuer situation, the rescuer should try to switch off with anothet rescuer every 2 minutes or 5 cycles of 30:2.

In a 2-rescuer situation, the compressor and ventilator should switch positions ever 2 minutes of 5 cycles of 30:2.

It appears that many instructors are teaching the OLD standard for stopping CPR. In the 2000 guidelines, a patient in cardiac arrest was to be reassessed for the return of a pulse after the first minute of CPR and then every few minutes thereafter. In the new standards, once you start CPR, you don't stop unless there is an obvious reason !!!

Reasons to stop CPR:

• Defibrillator is brought out and connected to patient
• EMS arrives and tells you to stop while they take over
• You are too physically exhausted to continue

Reasons to stop CPR to reassess the patient

• The patient show obvious signs of life (active vomiting, patient is withdrawing from your procedure)

DO NOT REASSES THE ABC's OF A PULSELESS PATIENT EVERY FEW MINUTES!!

When performing CPR, especially in an aquatic related incident, it is to be expected that fluid will begin to accumulate in the mouth and upper airway.. This is considered a REGURGITATION (ie. a passive mechanism causing a backward motion of gastric content to travel up the airway). This is caused by a rescuer's actions such as rescue breathing or chest compressions.  There is a common misconception from many lifeguards (and first aiders) that regurgitation and vomiting are the same thing.  VOMITING is an active mechanism caused by the muscular action of the stomach to "throw up" it's contents.  A patient actively vomiting may indicate something about this patient has changed and we need to be aware of this change.

If the victim vomits while performing CPR:

•  Roll the patient, and sweep to clear the airway

•  Reassess ABC's

Currently, many instructors teach that when performing BCLS (basic cardiac life support), if there is a change in victim status, the victim's vital signs should re-assessed. I encourage such a move but the significance of the reactions has been miss-construed. If a victim takes a breath or actively begins vomiting suddenly when CPR or ventilation of a victim is being performed, then the rescuer should stop and re-assess the pulse (and breathing, if breaths are recurrent). THIS IS A CHANGE IN VICTIM STATUS suggesting revival.

If the victim regurgitates while performing CPR:

• Finish the 30 compressions
• Roll the patient, and sweep to clear the airway
• Give 2 breaths
• Position and Resume CPR

Regurgitation is not a change in victim status . Pausing to re-assess vital signs only delays critical circulation which, at best, during CPR provides only one-fourth to one-third of the body's normal circulation. This more acceptable management of regurgitation is confirmed in BCLS literature and has been supported by emergency physicians who have queried why re-assessment was ever taught for regurgitation.

One of the underlying principles of the 2005 CPR Guidelines is to “Minimize interruptions.” Reassessing every time you notice some fluid causes excessive interruptions and simply diminishes the patient's prognosis.