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Drowning - DAN Diver Medical Technician
- 1. Drowning Justin Sempsrott, MD Executive Director Lifeguards Without Borders Justin@LifeguardsWithoutBorders.org
- 2. 2 Disclosure • Air Travel Paid by DAN • Honorarium paid to LWB • Graphic images of fatal and non-fatal drowning patients
- 3. Who am I?
- 4. The “Great of Aleppo” held upside down after drowning. 1237 B.C. From the Pylon of the Ramesseum, Thebes. Photographed by Mr. W. M. F. Petrie
- 5. History of drowning treatment
- 6. History of drowning treatment
- 7. History of drowning treatment
- 8. Dr. Frank Eve Popular Science July 1946
- 9. 9999
- 10. History of drowning treatment
- 11. Objectives • Understand definition of drowning • Appreciate epidemiology • Management • Disposition of drowning patients • Don’t blow smoke up pt’s (or colleagues) asses
- 12. Definition • Before 2002 – 33 Different Definitions
- 13. Definition • “The process of experiencing respiratory impairment from submersion/immersion in liquid” • Only 3 outcomes – – Death – No Morbidity – Morbidity Bangladesh, Lifeguards Without Borders, Aug2009
- 14. Definition • Old terms that should NOT be used – Dry – Wet – Active – Passive – Secondary – Near Especially • No difference between salt, chlorine, and freshwater Lima, Peru, 2009
- 15. Who is Drowning? • WHO Global Burden of Disease – 388,000 Drowning Deaths* • 97% in low to middle income countries +1.55 million unreported drowning deaths +6.08 million drowning “incidents” 7.63 million Drowning persons*
- 16. Who is Drowning? • 2nd leading cause of unintentional injury death (1st is MVC’s) • ~10 Deaths/Day in US – 40 Drown and survive – ½ with, ½ w/o morbidity • Male:Female 4:1
- 17. Who is drowning? • Disease of youth – 64% of deaths are<30 yrs – 25% of deaths are < 5 yrs • Alaska, Arizona, California, Florida, Hawaii, Montana, Nevada, Oregon, Utah, & Washington • Drowning surpasses all other causes of death to children age 0-14
- 18. Who is Drowning? • Excludes Floods/Boating/Natural Disasters http://nicedeb.files.wordpress.com/2008/05/sinking-boat.jpg – 2009 USCG Responded to 4,730 incidents • 3,358 injuries • 736 deaths – 72% Drowning 90% without lifejackets 50% (+) EtOH
- 20. Who is Drowning? • Hurricane Katrina – USCG– 33,544 Rescues • 4/6 Rio Flood – 200+ dead • 8/1 Pakistan Flood – 1100+ dead • Indonesia Tsunami – 169,752 dead – 127,294 missing http://www.gearbits.com/images/banda_aceh_tsunami.jpg CDC MMWR March 10, 2006 / 55(09);239-242
- 21. • 16 y/o ♀ – HPI • Pulled from ocean • No LOC • + Submersion – PE A- Small foam at mouth/nose B-Active cough C- +Radial Pulse
- 22. • 15 y/o ♂ – HPI • Pulled from ocean • No LOC • + Submersion – PE A- Large foam at mouth/nose B-Active cough C- +Radial Pulse
- 23. Maldito!! • What next? – Sick or Not Sick – Transport or No Transport • First, a review of physiology Lima, 2012
- 24. Physiology of Drowning • Breath holding during struggle • Attempt to inhale water results in ?laryngospasm –Usually little (<30mL) or NO fluid in lungs –Reflex Swallowing
- 25. Physiology • Water may enter (1-3mL/kg) – Relaxation after unconsciousness © 2009 Nucleus Medical Art, Inc.
- 26. Mechanism • Surfactant wash-out • Direct cellular injury • Hypoxic Vasoconstriction • Bronchospasm • Inflammation
- 27. Physiology • Compliance • O2 Delivery to brain
- 28. Physiology • Cause of death or morbidity – Anoxic Brain Injury – Acidosis • Treatment Oxygen to the Brain
- 30. When to Transport? • 41,729 oceanfront lifeguard rescues in Rio de Janeiro from 1972 – 1991 – 93% Released at scene without further treatment – 2,304 required additional medical care • 89% lived • 11% died
- 31. When to Transport? Grade Signs/Symptoms (s/sx) Mortality Treatment 1 Cough, no foam at mouth/nose -LCTAB 0% Thorough history – Release home with education 2 Small amt foam in mouth or nose, +Rales 0.6% N/C O2 - Hospital 3 Large amt foam, normal BP (+radial pulse) 5.2% ETT/NRB O2 - Hospital 4 Large amt foam, LOW BP (-radial pulse) 19.4% ETT/NRB O2 , IV Fluids - Hospital 5 Respiratory Arrest 44% ETT/NRB O2 , IV Fluids - Hospital 6 Cardiopulmonary Arrest 93% ETT/NRB O2 , IV Fluids, AED – Hospital Do not resuscitate if down >1 hour
- 32. When to Transport? Grade Signs/Symptoms (s/sx) Mortality Treatment 1 Cough, no foam at mouth/nose -LCTAB 0% Thorough history – Release home with education 2 Small amt foam in mouth or nose, +Rales 0.6% N/C O2 – Hospital 3 Large amt foam, normal BP (+radial pulse) 5.2% ETT/NRB O2 - Hospital
- 33. Do we transport? • 16 y/o ♀ – HPI • Pulled from ocean • No LOC • + Submersion – PE A- Small foam at mouth/nose B-Active cough C- + Radial Pulse • 15 y/o ♂ – HPI • Pulled from ocean • No LOC • + Submersion – PE A- Large foam at mouth/nose B- Active cough C- +Radial Pulse
- 34. • 15 y/o ♂ – “Emergency Dept” “Treatmen – O2 N/C @ 2 LPM – 4 mg IM Dexamethasone – B12 – 10,000 μg IM – N-Acetylcysteine 20% IV – 30 mL (200mg/mL)
- 35. You assume care of 16 y/o • A- Patent, copius foam • B- Tachypneic, RR 36, tiring out • C- ST 130 bpm, thready radial pulse • Critical Actions?
- 36. Airway • Intubate / Oxygenate – Pediatric – Laryngospasm • RSI, PPV, Jaw thrust Cricothyrotomy, Lidocaine – Airway obstruction? • Foam, Sand, Mud, Del Taco – Dec Compliance – Vomitus • 86% of Drowning resuscitations http://www.emsresponder.com/article/photos/1130360989690_10.jpg
- 37. Hypoxic Arrest • Cardiac BLS/ACLS – Heart stops, oxygen in blood needs circulating – C,A,B • Drowning, Peds, Traumatic BLS/ACLS – Heart stops because no oxygen in blood – A,B,C
- 38. What about sending them home?
- 39. OK to send home after 4-6 hours • Asymptomatic – GCS ≥14 – Normal Respiratory Efforts – SpO2 ≥ 96% on room air – No ACLS
- 41. In Water Resuscitation • 3X Increased Survival Special considerations
- 44. Special considerations • Immersion / Swimming Pulmonary Edema – Overhydration – Cold Water – Healthy • Treatment – Oxygen, Oxygen, Oxygen – ?Antibiotics
- 45. 4545 C-Spine • Less than 1% of Drowning patients, all with significant mechanism of injury – Routine C-Spine immobilization is unnecessary Special considerations
- 46. 4646 AED’s in Drowning • V-Fib/V-Tach? • Rescuer Safety • Do not delay Oxygenation / Ventilation • Minimize interruptions 5858 Special considerations
- 47. 4747 Heimlich Manuever • Increased risk of aspiration – Delays ventilation – Usually <30mL fluid in lungs – Watch for vomiting !!! Special considerations
- 48. Hypothermia • Hypothermia? – Is it protective? Harmful? What about post-resus? • Water at 91.4°F is thermally neutral • Conductivity is 25-30 x air • All have some degree of hypothermia – Case Reports? • 21 y/o ♀, 45 min 4°C • 5 y/o ♂, 40 min 0°C • 3 y/o ♀, 30 min 8°C • 2.5 y/o ♀, 66 min (19°C) Special considerations
- 49. Hypothermia – Mammalian Diving Reflex • 15%-30% of Humans – Cold and Dead? • Continue resus and rewarm to 94°F – What about post-resus? • Therapeutic Hypothermia has been shown to decrease cerebral oxygen demand and improve neurologic outcomes Special considerations
- 50. Hypothermia • Bottom line – Warm pt to 94°F • If dead, their dead • If not dead, stay there * *Only if hospital protocols are in place Special considerations
- 51. 5151 Antibiotics • No evidence to support routine use – CXR usually abnormal on admission – Febrile response to drowning – Use cultures to guide abx use 6363 Special considerations
- 52. Summary • Understand definition of drowning – Process, not an outcome • Appreciate epidemiology – Highly prevalent worldwide, children <4 • Management – Rapid O2 O2 O2, warm pt to 94°F, vomitus, ignore foam – Hypoxic vs Cardiac cause of arrest • Disposition of drowning patients – Home or ICU • Don’t blow smoke up pt’s (or colleagues) asses – Bring your “A” game, be able to back it up
Notas do Editor
- Utstein template style reporting
- Explain location of these deaths.
- U.S. Coast Guard, Department of Homeland Security (US). Recreational Boating Statistics – 2009 [online]. [cited 2011 Apr 11]. Available from http://www.uscgboating.org/assets/1/workflow_staging/Publications/394.PDF URL: The remaining 30% are trauma, hypothermia, CO poisoning, and other causes. Temporary Insanity II Impaled on Channel Marker Near Bay Bridge Marina on Kent Island: Just before 2 a.m., a 1992, 38-ft. Fountain power boat slammed into a fixed, channel marker, ripping a 17-ft. gash in the forward hull & becoming impaled on the steel piling holding the channel marker. A passenger suffered a broken arm & lacerations; a passing boater rescued the two men. DNR police cited the skipper, who "claimed to have been blinded by the lights of a sailboat", for negligence, traveling at an unsafe speed, & failure to maintain a proper lookout.
- 1831 cases
- 1831 cases