drowning - dan diver medical technician
DESCRIPTION
Drowning resuscitation lecture for Divers Alert Network Diver Medical Technician course. Philadelphia, Sep 23, 2013.TRANSCRIPT
22
Disclosure
•Air Travel Paid by DAN
•Honorarium paid to LWB
•Graphic images of fatal and non-fatal drowning patients
Who am I?
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
History of drowning treatment
History of drowning treatment
History of drowning treatment
Dr. Frank Eve
Popular Science July 1946
9999
History of drowning treatment
Objectives
• Understand definition of drowning
• Appreciate epidemiology
• Management
• Disposition of drowning patients
• Don’t blow smoke up pt’s (or colleagues) asses
Definition
•Before 2002– 33 Different Definitions
Definition
•“The process of experiencing respiratory impairment from submersion/immersion in liquid”
•Only 3 outcomes – – Death– No Morbidity – Morbidity
Bangladesh, Lifeguards Without Borders, Aug2009
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
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*
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
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
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
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
•16 y/o ♀– HPI
• Pulled from ocean
• No LOC
• + Submersion
– PEA- Small foam at
mouth/nose
B-Active cough
C- +Radial Pulse
•15 y/o ♂– HPI
• Pulled from ocean
• No LOC
• + Submersion
– PEA- Large foam at
mouth/nose
B-Active cough
C- +Radial Pulse
Maldito!!
•What next?– Sick or Not Sick– Transport or
No Transport
•First, a review of physiology
Lima, 2012
Physiology of Drowning
• Breath holding during struggle
• Attempt to inhale water results in ?laryngospasm–Usually little (<30mL) or NO fluid in lungs
–Reflex Swallowing
Physiology
•Water may enter (1-3mL/kg)– Relaxation after unconsciousness
© 2009 Nucleus Medical Art, Inc.
Mechanism
•Surfactant wash-out
•Direct cellular injury
•Hypoxic Vasoconstriction
•Bronchospasm
• Inflammation
Physiology
• Compliance
• O2 Delivery to brain
Physiology
•Cause of death or morbidity – Anoxic Brain
Injury – Acidosis
•Treatment Oxygen to the
Brain
Physiology
Alive
DeadDose Response Curve
Res
pons
e
Dose
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
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 – HospitalDo not resuscitate if down >1 hour
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
Do we transport?•16 y/o ♀
– HPI• Pulled from ocean• No LOC• + Submersion– PEA- Small foam at mouth/nose B-Active coughC- + Radial Pulse
•15 y/o ♂
– HPI• Pulled from ocean• No LOC• + Submersion– PEA- Large foam at mouth/noseB- Active coughC- +Radial Pulse
• 15 y/o ♂– “Emergency Dept”
“Treatment”– O2 N/C @ 2 LPM
– 4 mg IM Dexamethasone– B12 – 10,000 μg IM– N-Acetylcysteine 20% IV– 30 mL (200mg/mL)
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?
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
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
What about sending them home?
OK to send home after 4-6 hours
•Asymptomatic– GCS ≥14– Normal Respiratory Efforts
– SpO2 ≥ 96% on room air
– No ACLS
Special considerations
In Water Resuscitation
•3X Increased Survival
Special considerations
Special considerations
Special considerations
• Immersion / Swimming Pulmonary Edema– Overhydration– Cold Water– Healthy
•Treatment– Oxygen, Oxygen, Oxygen– ?Antibiotics
4455
C-Spine
•Less than 1% of Drowning patients, all with significant mechanism of injury– Routine C-Spine
immobilization is unnecessary
Special considerations
4466
AED’s in Drowning
•V-Fib/V-Tach?
•Rescuer Safety
•Do not delay Oxygenation / Ventilation
•Minimize interruptions
5858
Special considerations
4477
Heimlich Manuever
• Increased risk of aspiration– Delays
ventilation– Usually <30mL
fluid in lungs– Watch for
vomiting !!!
Special considerations
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
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
•Area of active research
Special considerations
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
5511
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
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
Discussion