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10/1/2015 Describe the need for a universal drowning definition Name two of the organs that may be impacted from a submersion injury Describe at least three appropriate prehospital care interventions in caring for the submersion injury patient Identify three possible current nursing management strategies for managing the submersion patient Incidence/recent data Males 5 times more than females 2005-2009 mean 3880 deaths/year Estimated 5789 people treated for nonfatal drowning ▪ Difficult to know??? Preventable measures Fence (self closing gate) Unattended children ▪ Lifeguard distracted (socializing, other duties or chores) Poor pool maintenance ▪ Murky waters make it difficult to see 1 10/1/2015 2005 Data Most prevalent from May to August After 1 year of age males account for 75% of drowning deaths (riskier behavior?) Age distribution (peaks) ▪ <5 years: pools, bath tubs, liquid filled containers ▪ 1-4 years 50% die in swimming pools ▪ 15 – 25 years: natural bodies of water ▪ Beaches-rip currents account for 80% Boating drownings: 50% R/T ETOH ▪ >50% adult drownings believed to be R/T ETOH Epilepsy (tub) LQT Syndrome/Heart issues ▪ Cold water and exercise arrhythmias in LQT Syndrome? ▪ Long QT syndrome difficult to prove but mutations have been identified on some drowning victims ▪ Catecholaminergic polymorphic VT? Suicide/homicide Infants < 1 year of age About 50% drownings occurred in bathtub Medical eval, search for other injuries, get social work involved Abuse, neglect? 2 10/1/2015 Various, ambiguous, terminology (at least 20) Near drowning, silent drowning, passive drowning, wet/dry drowning etc. etc. etc. No uniformity has caused confusion Amongst clinicians Amongst data interpreters ▪ Studies inconsistent ▪ Enhance future reporting and enable greater analysis for better treatment options 2002 World Congress of Drowning “Drowning is a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium.” Term drowning used no matter the outcome Outcomes should be classified as death, morbidity, or no morbidity Discourages use of other terms ie wet/dry drowning, near drowning etc. Def accepted by WHO, CDC, ILCOR, AHA Head above water Child struggles 20 seconds Adult struggles 60 seconds Head below water = panic and hold breath H2O in oropharynx/larynx may trigger involuntary laryngospasm (7-10%) 3 10/1/2015 No gas exchange (hypoxia/hypercarbia)=acidosis Water is swallowed Prolonged hypoxia ceases laryngeal spasm/obstruction (if occurred) Victim inhales liquid Victim’s O2 levels quickly dwindle Not enough O2 to the brain Loss of consciousness Apnea Changes in lungs, body fluids, pulm edema, pulm hypertension Death results from prolonged submersion R/T hypoxia Dry drownings happen about 2% Fresh vs. saltwater Floating in Dead Sea Not much difference as earlier thought (canine studies) Aspiration of 22ml/kg for electrolyte change Aspiration of 11 ml/kg for blood vol change Avg. aspiration 2-4 ml/kg Aspiration of fluid content may be clinically relevant ▪ Silt, mud, sewage, bacteria , seaweed, sand, etc. Salt water Impurities and bacteria Pseudomonas putrefactions, Staph. aureus 4 10/1/2015 Cascade of events leading to secondary drowning Lung changes (variable length of submersion) Sig. impairment to gas exchange aspiration (1-3 ml/kg) Surfactant washed out ▪ Alveolar instability ▪ Atelectasis ▪ Dec. lung compliance ▪ V/Q mismatch Damage to alveolar-capillary membrane leads to pulmonary edema Asp. Fluid causes vagal reflexes which causes pulmon. vasoconstriction and pulmon HTN Aspirate vomit further complicate acute lung injury Bronchospasm Fluid in airways ARDS (evidence usually occurs promptly) Noncardiogenic Pulmonary Edema Impaired oxygenation Bilat. Pulm infiltrates 5 10/1/2015 Cardiovascular Effects Hypovolemia R/T increased capillary permeability Rewarming (surface)associated with vasodilatation Pulmonary HTN ▪ Difficult to pump blood to lungs ▪ Less blood returns from lungs ▪ Decreased cardiac output Decreased cardiac output R/T hypoxemia, acidosis Myocardial dysfunction R/T arrythmias CNS effects Initial injury R/T tissue hypoxia and ischemia Secondary injury ▪ Reperfusion, Cerebral edema, Excitory transmitters ▪ Impaired cerebral autoregulation ▪ Hypotension ▪ Sustained acidosis ▪ Hyperglycemia, hypoglycemia ▪ Seizures Hypothermia Hypotension, bradycardia, conduction abnormalities ▪ Hypotension from cold water diuresis Antiarrythmics, insulin may be ineffective and accumulate to toxic levels R/T slowed metabolism and excretion Neuro protective if rapid hypothermia prior to cardiac arrest ▪ Icy water submersion (<10-20 C) ▪ Mammalian diving reflex? ▪ Not happening here? 6 10/1/2015 Drowning Factors (anything that can precipitate syncope) ▪ Seizures, hypoglycemia, hyperventilation (divers 87 vs 146 sec), hypothermia, ETOH, drugs, trauma ▪ Epileptics (15-19 times more likely to drown) ▪ LQTS (exertion, cool water, swimming) ▪ Stroke, heart attack (older pop) What caused the drowning?? Most want to breathe so don’t cry for help Treatment of drowning patients Minimally asymptomatic ▪ Small cough, no foam at mouth or nose ▪ Usually released with instructions to watch for signs All patients with respiratory symptoms ▪ Dyspnea, foam, rales ▪ Transport with O2 BLS at scene (biggest factor influencing survival) ABC not CAB ▪ IF in water pulse check unnecessary ▪ If not in full arrest should respond with few breaths ▪ IF out of water ▪ Credit Wellcome Library Prior to compressions AHA – 2 breaths ERC-5 breaths ▪ Pulse may be hard to feel Bradycardia, hypoxemia, Hypothermia, vasoconstriction 7 10/1/2015 Cervical spine injury Very uncommon 11 out of 2244 victims (0.5%) ▪ All had signs of trauma ▪ Diving, motor vehicle crash Use caution but don’t delay resuscitation Remove from water Maintaining airway Jaw thrust Obstructed with foam or water Rescue breathing in water useful Ventilation and O2 most important initially Chest compressions in water? Heimlich maneuver? 8 10/1/2015 100% oxygen Until pt is able to keep sats >mid 90’s Intubate? ▪ Supraglottic airway (LMA)? PPV use cricoid pressure ▪ Full stomach Suction Vomit ▪ Lateral decubitus ▪ Suction equipment (soft tipped, yankauers, etc) Pulmonary edema (copious secretions)? Remove wet clothing if possible Cover with blankets Monitor VS Monitor for further vomiting Monitor for deterioration Pulmonary edema Shock History Fluid pt was submerged in Temperature of solution Duration of submersion Resuscitative efforts at scene Response to efforts ETOH/drugs suspected (Narcan??) Pre-existing conditions or diseases 9 10/1/2015 Crucial in management (full neurologic recovery) 60 minutes in icy water? 20 minutes in cool water (5-10 mins by other source)? Hot springs or hot tubs much shorter times Submersions (non icy) greater than 25 mins likelihood for poor outcome approaches 100% Inaccurate (rough estimate) Emotional excitement Time of call to rescue arrival Hence, attempt to resuscitate all victims Drowning scope can range from asymptomatic patient (dunked) to pulseless arrest Asymptomatic (observe for approx 4-8 hours then discharge if physician decides with instructions to responsible parent/adult about symptoms) ▪ ▪ ▪ ▪ ▪ Awake, alert No adventitious breath sounds No required rescue breathing or supp O2 Normal pulse ox Normal x ray Resuscitation PALS guidelines but ABC Usually tachycardia then bradycardia then PEA the asystole Hypothermic (<35 C core temp) patient (effects include arrythmias, coagulopathy, impaired immune function, acidosis) ▪ May appear dead d/t profound bradycardia, intense vasoconstriction, marked depression of brain and cardiovascular patient, dilated pupils—begin CPR if unsure 10 10/1/2015 AHA unsure of what temp to start defib Try at least once—may keep trying? (says to follow PALS/ACLS protocols) Medications ▪ “may be reasonable to consider administration of a vasopressor during arrest” AHA 2010 Part 12 Drowning ▪ Ice water drowning rewarm core to minimum of 30 C before stopping CPR—others experts say higher European Resuscitation Council Suggest 3 defibrillations performed Hold Epi until core temp > 30 C, then double time to next dose until temp >35 C Resuscitation Hypothermia (never allow hyperthermia) ▪ Aggressive attempts to restore normal body temp and establish safe steady warming rate while maintaining cardiac stability ▪ Rewarm pt 1-2 C/hour to 33-36 C ▪ Passive rewarming Remove wet cold clothing Warm blankets to insulate patients Resuscitation Hypothermia ▪ Rewarming techniques ▪ Active external rewarming Hot packs Heat lamps Forced air external rewarmers 11 10/1/2015 Resuscitation Hypothermia ▪ Active internal rewarming ▪ ▪ ▪ ▪ Warmed humidified O2 (mask, ETT) Warmed IVF (40-44 C, shortest possible tubing length) Warm saline lavage (gastric, peritoneal, rectal, mediastinal) ECMO (preferred treatment for victim with persistent cardiac instability) Treat shock (tissue perfusion, tachycardia, pulses, cap refill, ALOC, oliguria, etc) Myocardial dysfunction (hypoxia, acidosis) Fluid shift ▪ 20 ml/kg to achieve euvolemia (wary of pulm edema) ▪ Inotropes ▪ Dobutamine Respiratory Intubation (age formula vs Broselow tape) Protects airway ▪ Cuffed vs. uncuffed ▪ Allows administration of higher O2 conc. (protect brain) ▪ Steroids not proven to help and may interfere with healing 12 10/1/2015 Respiratory PEEP (pulmonary edema, decreased lung compliance) ▪ ▪ ▪ ▪ ▪ Recruit atelectic areas of lungs (improve ventilation) Dec degree intrapulmonary shunting Dec. V/Q mismatch Shifts interstitial pulmonary water into capillaries Inc. diameter small and large airways to improve distribution of ventilation ▪ Start usually at 5 and inc from there watching oxygenation and blood pressure Respiratory Bronchodilators for bronchospasm (albuterol) Surfactant administration ▪ Case studies have shown some effectiveness in peds but not adults Wean vent after 24 hours? ▪ Allows time for surfactant regeneration ▪ Pulmonary edema may recur if not resolved sufficiently Methods of ventilation Changes in lung compliance, airway resistance, cardiovascular status Maintain normocarbia and adequate oxygenation Prevent ventilator associated lung injury (low tidal volumes, high PEEP) HFOV 13 10/1/2015 Save the brain (cerebral edema ICP R/T hypoxic neuronal injury) Maintain adequate oxygenation, ventilation (avoid hyperventilating, ETCO2 trends with ABG) Hyperventilate as temporary measure (surgeon on way) Avoid hypotension, hyperthermia (exacerbate neuro damage) Avoid /treat hypo or hyperglycemia ▪ Keep within a range Save the brain Treat seizures ▪ Increases blood flow ▪ Consumes cerebral O2 ▪ May not see (cont EEG?) Save the brain CP monitoring not warranted but may choose to (still treat but no proof of better outcome) Continue to elevate HOB 30 (C-spine cleared) No proof of benefit from barbiturates 14 10/1/2015 Therapeutic hypothermia not working (increased sepsis)? Some experts maintain to consider this option early in course ▪ Neouroprotective ▪ Some say if pt hypothermic with ROSC, then try it ▪ Many variables at play may not reflect on research studies ▪ Vfib cardiac arrest vs asphyxial cardiac arrest NGT/OGT ▪ Removes swallowed water/debris ▪ Warmed gastric saline lavage ▪ Helps ventilation so lungs can expand Pneumonia Pneumonia after submersion showed 60%mortality rate ▪ Aeromonas highest mortality rate Prophylactic ATB not recommended ▪ Unless exposure to grossly contaminated water i.e. sewage Tracheal and blood cultures usually drawn in ED ▪ ATB started at 1st signs infection—many will present with them Patients with signs of pneumonia, bacterial cause should be found and treated…if not coverage should be aimed at prevalent nosocomial flora of hospital 15 10/1/2015 Special considerations Bronchoscopy (removal foreign bodies, debris) ▪ Silt or sand from surfing accident ECMO ▪ Extreme hypothermia ▪ Lung injury (evidence lacking but survival case studies published) ▪ To help remove CO2 (help the brain) ▪ Technologically challenging, practical, logistical issues ARDS ▪ Altered surfactant volume or function, neurogenic pulmonary edema complicates submersion injury ▪ High mortality rate ▪ Permissive hypercapnea to avoid barotrauma may not be an option with hypoxic CNS injury Poor prognosis---No high quality evidence to predict poor neuro outcomes Submersion time > 5 minutes, others say 10 minutes Time to BLS > 10 minutes Resuscitation > 25 minutes Age > 14 years GCS < 5 (comatose, about 75% predictive) ABG pH < 7.1 upon presentation Pupils not reacting after 24 hours (post resuscitation) Poor prognosis No pupil response 24 hours after resuscitation (TH) EEG patterns (burst suppression, loss of reactivity to stimulation) CT scan ▪ First 24 hours may look normal ▪ Loss of gray/white matter differentiation and/or cerebral edema associated with poor prognosis in patients that have arrested 16 10/1/2015 Prognosis Peds more likely to get ROSC than adults from drowning ▪ ▪ ▪ ▪ More witnesses, more people to help (bystander CPR) Comorbidities of adults Protective mechanisms (diving reflex) More aggressive treatment Unfavorable neuro outcome Where do we go? Prevention Questions? Resusci Anne –drowned in the 1880’s France Available upon request 17