Download June 2015 CE Submersion Emergencies

Drowning:
Submersion Emergencies
Presence Regional EMS
June 2015 CE
Objectives
• Define drowning
• Discuss the incidence, risk factors and
prevention of drowning
• List the basic rules of providing water
rescue
• Outline recovery techniques and
resuscitation efforts required for submersion
injuries
Submersion Emergencies
Introduction
• Drowning emergencies are emotionally
traumatic for relatives and loved ones of the
patients and emergency providers.
• Many drownings are preventable tragedies
resulting from poor judgement, alcohol
consumption and inadequate supervision of
children.
Incidence
• There are an estimated 4,500 drowning
related deaths in the United States every
year.
• For every drowning death:
– 2 people drown and survive with no
disability.
– 2 people drown and survive but have
severe neurological impairment
The Numbers May Not Be
Accurate
• Victims of drownings from floods and other
natural disasters are not counted in
drowning deaths.
• Victims of boating accidents are not
counted in drowning deaths.
Who drowns?
• Children under the age of 4 years and
adolescents and young adults aged 15 to 24
years make up the majority of drowning
victims.
• Water sports and the use of alcohol and/or
drugs while swimming increase one’s
chance of suffering a submersion related
injury.
Submersion Emergencies
• Immersion
– An incident in which a patient’s face and/or airway are
covered in water
• Submersion
– An incident in which a patient’s entire body including
the face and airway is submerged in water
• Water Rescue
– An incident in which a person is alert but experiences
some distress while swimming with minimal or
transient symptoms
• Drowning
– An event in which a patient has primary respiratory
impairment from immersion or submersion in a liquid.
The patient may live or die after this event.
Drowning Death
– An event of drowning in which the patient is
pronounced dead within 24 hours of the event.
Pronouncement may occur on scene or at the hospital.
• Drowning-related Death
– Incident in which a submersion patient dies more than
24 hours following the event.
The best treatment
for drowning is
prevention.
Prevention
• Many drowning victims are infants and
small children.
• Prevention can be a matter of following
some common sense practices.
Prevention of Drowning
• Keep only a few inches of water in the
bathtub when bathing young children.
• Never leave young children unsupervised in
bathtubs.
• Never leave children alone in or near a pool
EVEN FOR A MOMENT regardless of
safety precautions such as self locking gate
and pool alarms.
• Be sure that adults and adolescents are
trained in CPR so that they can rescue a
child if necessary.
• Surround pools on all 4 sides with a sturdy
five foot fence. The house should not be
one of the barriers to the pool if there is a
doorway from the home to the pool area.
• Be sure that gates self-close and self-latch at
a height that children cannot reach.
• Keep rescue equipment (shepherd’s hook
and life preserver) and a portable phone
near the pool.
• Avoid inflatable swimming aids such as
“floaties”. They are not a substitute for
approved life vests and can give children a
false sense of security.
• Whenever infants and toddlers are in or
around water, an adult should be within
arm’s length, providing touch supervision.
Where People Drown
Why Do Drownings Occur?
• Swimming/boating issues:
– Exhaustion in the water
– Losing control or being swept into deep water
– Becoming tangled or entrapped while in the
water
– Using poor judgment while in or near water
– Panicking while in water
– Losing a support such as a sinking boat
• Precipitating Factors
– Using alcohol or drugs in or near the water
– Suffering a seizure, heart attack, or other
debilitating condition while in or near water
– Becoming hypothermic while swimming
– Suffering trauma or a diving accident
Pathophysiology of
Drowning
1. Victim’s airway is below the surface of a
liquid
2. Victim involuntarily holds breath
3. Water swallowing begins into posterior
pharynx and into stomach
4. Involuntary laryngospasm (closing of
vocal cords) due to liquids in the
oropharynx.
5. Blood oxygen levels drop and carbon
dioxide levels raise.
6. Due to worsening low oxygen/high carbon
dioxide and unconsciousness
laryngospasm stops and vocal cords open.
7. Gasp reflex – if the victim’s head is out of
the liquid may begin coughing and clearing
airway
8. If the victim’s head is still under the liquid,
liquid enters the lungs.
9. Surfactant “washout” occurs
10. Worsening hypoxia
11. Cardiac arrest
12. DEATH
Drowning Process
Predicting the Outcome of
Drowning
• Duration of submersion
• Severity of hypoxia
• Neurologic impairment due to lack of
oxygen to the brain
• Drowning victims who have spontaneous
respirations and pulses in the field before
arrival in the Emergency Department
usually recover with good neurological
outcomes.
Surviving Drowning/Time
Duration of Submersion
Likely to Survive without Neurological
Damage
0 to up to 5 minutes
90%
5 up to 10 minutes
44%
10 up to 25 minutes
12%
25 minutes or longer
0%
Surviving Drowning/
Clinical Findings
Initial Clinical Findings
Likely to Survive
Without
Neurological
Damage
Some coughing, normal breath sounds
100%
Coughing, with wet rales in one lung
99.4%
Coughing, bilateral wet rales or pulmonary edema, good vital signs
95%
Coughing, bilateral wet rales or pulmonary edema, low BP
80%
No spontaneous respirations, pulse is present
56%
Cardio/pulmonary arrest, no spontaneous breathing, no pulse
7%
Drowning Related Death
• People die in the hospital after a drowning
incident because of
–
–
–
–
Brain death from lack of oxygen
Acute respiratory distress syndrome
Multi-organ system failure
Sepsis (system wide infection)
Management of
Submersion Emergencies
Management
•
•
•
•
Rescue
Airway/Ventilation
Hypothermia
Associated Trauma
Rescue
• Provider Safety
• Don’t Jump in to Help if you Can’t Swim!!!
• Make use of a conveyance device
– Boat
– Raft
– Floatation device
If you are the only rescuer. . .
• If the victim is not breathing provide 2
minutes of rescue breaths before calling
911.
• If the victim is pulseless
and not breathing provide
5 cycles of CPR (2 minutes)
before calling 911.
Airway/Ventilation
• The most dangerous consequence of
submersion emergencies is lack of oxygen.
• Open the victim’s airway as soon as
possible and begin assisted ventilations.
• Rescue breathing should begin as soon as a
submersion victim is removed from the
water.
Let’s practice airway
management
• Practice opening airway and BVM
ventilation
• One rescuer and two rescuer
THERE IS NO NEED
TO DRAIN WATER
FROM THE LUNGS
• Fluids in the airway and lungs of a
submersion victim absorb quickly
• Most water will come from the stomach
No Heimlich Maneuver!!
• Routine use of the Heimlich Maneuver or
chest compressions to remove water only
leads to
– Vomiting
– Aspiration
– Delay in beginning
ventilations
Vomiting
• 67% of submersion victims who require
ventilation assistance vomit.
• 86% of submersion victims who require
ventilation and chest compressions vomit
• If vomiting occurs turn the patient on their
side and suction
•
Body Temperature: Hypothermia
– Body requires core temp of 98.6oF (37oC) for
proper function.
– If core temp significantly rises above or falls
below 98.6oF (37oC), the cells’ ability to function
is impaired, especially those of the brain, heart,
and kidneys.
– Can result in permanent disability and/or death of
the patient.
Submersion and
Hypothermia
• Mammalian Diving Reflex
– The mammalian diving reflex activates when a
person dives into cold water (<70oF).
•
•
•
•
•
Larynx spasms.
Breathing is inhibited.
Heart rate slows.
Blood vessels constrict.
Blood flow to the brain and heart are increased.
• Treat as Hypothermic Cardiac Arrest
How will you manage
hypothermia?
•
•
•
•
•
Check for a pulse for at least 10 seconds
Remove wet clothing
Warm blankets
Turn up heat in unit
Prevent further loss of heat
Associated Trauma
• Routine spinal motion restriction in
submersion emergencies is not
recommended.
• Applying SMR can delay opening the
airway and ventilating the patient.
Spinal Injuries in
Submersion Incidents
Suspect spinal injury if:
• Submersion has resulted from a diving mishap
or long fall.
• Patient is unconscious.
• Patient complains of weakness, paralysis, or
numbness.
• You suspect the possibility of spinal injury.
Immobilization in Water
• Turn the patient into the supine position.
• Restore the airway and begin breaths if
needed.
• Float a spine board under the patient and
secure the patient.
• Remove the patient from the water.
Immobilization in Water
Let’s practice
immobilization
• Practice in the water if you can.
Transport
• Not all submersion victims suffer cardiac or
respiratory arrest.
• Some victims are able to cough and clear their
airway, resuming normal ventilations on their
own.
• All victims of drowning who require care by
EMS, even if they are alert and demonstrate
adequate breathing should be transported to the
hospital for evaluation.
Review
• Consider the following scenario and review
questions as a group.
• If doing this CE individually, please e-mail your
answers to:
• [email protected]
• Use “June 2015 CE” in subject box.
• You will receive an e-mail confirmation. Print this
confirmation for your records, and document the
CE in your PREMSS CE record book.
Submersion Emergencies
Review Questions
1. All of the following are causes of submersion
emergencies except:
A.
B.
C.
D.
E.
F.
Exhaustion
A full stomach
Becoming entangled
Use of alcohol and drugs
Suffering trauma while in the water
Have a medical emergency such as a heart
attack in the water
2. What are the 3 main concerns in submersion
emergencies?
A. Rescue, C-spine injury, airway and heat
exhaustion
B. Rescuer safety, hyperthermia and fractures
C. Airway, breathing and circulation
D. Rescue, airway/ventilation, hypothermia and
associated trauma
3. True or False
Only specially trained rescuers should
attempt to rescue and remove a submersion
victim from deep water.
4. Suspect a C-spine injury in a submersion victim
if they are:
A.
B.
C.
D.
Awake and talking but confused
Unconscious
Moving their arms and legs with no problem
Complaining of chest pain
5. All but which of these happen to the body when
the Mammalian Diving Reflex is activated in
cold water?
A.
B.
C.
D.
The patient becomes hyper-alert
Heart rate slows
Increased blood flow to the brain and heart
Breathing is inhibited
Case Study 1
• You respond with your department to a
drowning at a hotel.
• On arrival you find a young adult male
lying by the pool with 2 adults performing
CPR.
Scene Size Up
• The scene is safe
• The hotel pool does not have a life guard.
• Hotel personnel report that bystanders
found the man at the bottom of the pool.
• Hotel personnel say he could not have been
there for more than 10 minutes.
• The hotel does not have an AED.
Initial Assessment
• Airway: water is in the airway
• Breathing: the man is not breathing
• Circulation: a faint slow pulse is found at a
rate of 30 beats/minute.
• How do you want to proceed?
• Does the patient need an AED at this point?
• If a submersion victim needs an AED what
safety precautions must be taken?
SAMPLE History
• No one knows who the man is so no
SAMPLE history is available.
• A hotel guest tells you that she thinks this
man was diving off the edge of the pool
earlier.
• How will this change your management of
this patient?
• What else could have caused a submersion
emergency in a 20 year-old male?
• Do you need to do any other treatment or
can this man be transported?
Case Study 2
• You are called to a family home for an
unresponsive toddler.
• On arrival you find a frantic young woman
attempting CPR on a small child next to a
child’s wading pool.
Scene Size Up
• It is a warm July day
• The wading pool has 8 inches of water in it
• The young woman is the mother of the
victim Billy who is 3 years old.
• She states “I went to get my cell phone. I
was only gone for a few minutes. He was
face down in the pool.
• Do you need to assume spinal motion
restriction?
Initial Assessment
•
•
•
•
Billy is unresponsive
There is clear water in the airway
Billy is not breathing
Billy has a rapid carotid pulse.
• How do you want to proceed?
• Do you need an AED?
SAMPLE
• Allergies: none
• Medications: none
• Past Medical History: none healthy 3 year-old.
Weighs 32 pounds
• Last meal: Lunch 2 hours ago
• Events: His mother let Billy get in the pool this
afternoon to play. She left him for less than 5
minutes to get her cell phone from the house
• After about 3 minutes of BVM ventilations
Billy begins to cough.
• He vomits a large amount of clear water and
begins to cry lustily.
• He holds out his arms for his mother.
• Pulse is 120, Respirations are 30 and deep.
Head to Toe
• No DCAPP BLS TIC to
–
–
–
–
–
Head
Neck
Chest
Abdomen
Legs, Arms Back
Assessment Cont.
• Billy vomited about 500 cc of clear liquid.
• He has some soft rales in the bases of both
lungs.
• He is able to be comforted by his mother.
• His lips are pale and he is shivering.
• How is Billy doing?
• What additional care does Billy need?
• Does he need to be transported to the
hospital?
Answers
•
•
•
•
•
1.
2.
3.
4.
5.
B
D
True
B
A
• Case Study 1
– Suction airway
– Keep airway open (manual opening, oral
pharyngeal airway)
– Ventilate with BVM with 15 liters 02 at one
breath every 6-8 seconds.
– Begin chest compressions for slow pulse
– Begin passive rewarming (cover with dry
blankets)
• The patient does not need an AED at this
point.
• Dry off his chest before attaching the AED
pads.
• If the patient was diving into the pool he
may have a C-spine injury so Spinal Motion
Restriction must be applied.
• The submersion emergency could have been
caused by:
–
–
–
–
Drug overdose
Alcohol intoxication
Seizures
Cardiac episode
• Continue CPR and transport.
• If ALS treat Bradycardia PEA and transport.
• Case Study 2
– Spinal motion restriction is not indicated
– Suction Billy’s airway and begin BVM
ventilations on 15 liters O2 at 1 breath every 68 seconds.
– No AED is indicated
• Billy is doing better
• He needs:
– passive rewarming with blankets
– Oxygen by Non-rebreather mask or blow by
– Reassurance
He needs transport to the hospital.