Environmental Environmental InjuryInjury

Emergency medicineEmergency medicine

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TopicsTopics

Burns and frostbite Burns and frostbite CCarbonarbon Monoxide Poisoning Monoxide Poisoning HypothermiaHypothermia Heat EmergenciesHeat Emergencies NNeear Drowning and Dysbarismar Drowning and Dysbarism High Altitude Medical ProblemsHigh Altitude Medical Problems Disaster MedicineDisaster Medicine

BurnsBurns

ClassificationClassification EpidemiologEpidemiologyy PPatathhoophysiophysiologlogyy ClinicClinical featuresal features IInhalanhalation injurytion injury TrTreeatment:atment:

– preprehoshospitalpital– Emergency Emergency departmentdepartment– HospHospitalital

- - Admission or transfer to specialized burn centerAdmission or transfer to specialized burn center

BurnsBurns: Clas: Classsificaificationtion, , epidemiologepidemiologyy

BurnsBurns::– tthhermermalal – chcheemicmicalal– electricelectricalal

EpidemiologyEpidemiology: 1,25 mil./: 1,25 mil./yearyear (U (USASA)) AgeAge: 18-35 : 18-35 year-old groupyear-old group,, hot hot li liququididss--

cchhiildrenldren 1-5 1-5 years of age and in the years of age and in the elderlyelderly

MortalitMortality ry rate: 4 % (Uate: 4 % (USSA) A)

Burns:Burns:patpathhoophysiologyphysiology Thermal injury is aThermal injury is a progres progresssiviv injury injury::

– Local:Local: Liberation ofLiberation of vasoactive vasoactive substances substances Disruption of normal Disruption of normal celcell membrane function (Na pump)l membrane function (Na pump) EEdemdema formationa formation

– SSyystemicstemic response response:: neurohormonalneurohormonal ( histamin ( histaminee, kinine, serotonin, arahidonic, kinine, serotonin, arahidonic

acid metabolitesacid metabolites,,free O2free O2 radical radicalss)) Hypovolemic shock,heart-myocardial Hypovolemic shock,heart-myocardial

depression,acidosis,renal failuredepression,acidosis,renal failure)) Factors may influence prognosisFactors may influence prognosis::the severity of the severity of

the burn, presence of inhalation injury, associated the burn, presence of inhalation injury, associated injuries, patient’s age, preexisting diseaseinjuries, patient’s age, preexisting disease

cclinical linical

featuresfeatures

Burn Size: body Burn Size: body surface areasurface area

““99” method” method

- - A. B. WallaceA. B. Wallace

Burn depth:Burn depth: First degreeFirst degree –involve only epidermal layer of skin: the burned –involve only epidermal layer of skin: the burned

skin is red, painful and tender /heal in 7 dayskin is red, painful and tender /heal in 7 daySecond-degree- extend into the dermis, are divided into Second-degree- extend into the dermis, are divided into

superficial partial-thickness and deep partialsuperficial partial-thickness and deep partial –thickness –thickness burns- there is blisteringburns- there is blistering the skin, the derm is red and very the skin, the derm is red and very painful to touch- heal withpainful to touch- heal with’’ ’’ restitutio ad integrum” in 14-21 drestitutio ad integrum” in 14-21 dThird degree involve the entire thickness of the skinThird degree involve the entire thickness of the skin,,all all

epidermal and dermal structures are destroyed, the skin is epidermal and dermal structures are destroyed, the skin is charred, pale, pailess and leathery, heal “per secundam charred, pale, pailess and leathery, heal “per secundam intentionintentioneem”, needs surgical repair and skin grafting.m”, needs surgical repair and skin grafting.

Fourth-degree burns Fourth-degree burns extend through the skin to the extend through the skin to the subcutaneous fat, muscle, and even bone-amputation or subcutaneous fat, muscle, and even bone-amputation or extensive reconstructionextensive reconstruction..

Burns-clinicalBurns-clinical

AAmerican merican BBurn urn AAssociation ssociation CriteriaCriteria

Major burnsMajor burns I-III-II, > 25 %, 10-50 year, > 25 %, 10-50 year I-III-II, > 20 %, < 10 sau , > 20 %, < 10 sau > >

50 ani50 ani IIIII-II-IV, > 10 %V, > 10 % HandsHands,,face,feet,face,feet, perineu perineumm Burns crossing major jointsBurns crossing major joints CCircumferenircumferenttialial burns of an burns of an

extremityextremity IInhalanhalation injurytion injury Burns complicated by Burns complicated by

fractures and otherfractures and other trauma trauma EElectriclectrical burnsal burns Burns in infants and the Burns in infants and the

elderlyelderly Poor-risk patientsPoor-risk patients

MModeratoderatee I-III-II, , 15-15-25 %, 10-50 ani25 %, 10-50 ani I-III-II, , 10-10-20 %, < 10 sau > 20 %, < 10 sau >

50 year50 year IIIII-II-IV, < 10 %V, < 10 %

MinorMinor I-III-II, < , < 1515 %, 10-50 year %, 10-50 year I-III-II, < , < 1010 %, < 10 sau > %, < 10 sau >

50 year50 year IIIII-II-IV, < 2 %V, < 2 %

Inhalation injuryInhalation injury SmokeSmoke- - small particles, reach the terminal small particles, reach the terminal

bronchioles- bronchospasm, edema,decreases bronchioles- bronchospasm, edema,decreases alveolaralveolar surfactant activity,airflow surfactant activity,airflow obstrucobstructiontion,, atelectasisatelectasis

COCO poisoning poisoning:: produces brain hypoxia and coma produces brain hypoxia and coma DiagnosDiagnosisis::history,physical signs: facial burns, history,physical signs: facial burns,

singed nasal hair,soot in the mouth or nose, singed nasal hair,soot in the mouth or nose, hoarseness,carbonaceous sputum, expiratory hoarseness,carbonaceous sputum, expiratory wheezing wheezing

Endotracheal intubation: Endotracheal intubation: – Full-thickness burns of the face or perioral region,Full-thickness burns of the face or perioral region, – CircumferCircumfereential neck burns, ntial neck burns, – Acute respiratory distress, Acute respiratory distress, – ProgresProgresssiveive hoarseness or air hunger , hoarseness or air hunger , – Respiratory depression or altered mental status, Respiratory depression or altered mental status, – Supraglottic edema or inflammation on bronhoscopySupraglottic edema or inflammation on bronhoscopy

Prehospital treatment Prehospital treatment

Stop the burning processStop the burning process Establish airwayEstablish airway Oxigenoterapy Oxigenoterapy Fluid resuscitationFluid resuscitation Relive painRelive pain Protect the burn woundProtect the burn wound Transport Transport

Burns:treatmentBurns:treatment ABC ABC Fluids (cristaloids): Fluids (cristaloids): Lactated Ringer’s 4 ml x weight(kg) x BSA (%)Lactated Ringer’s 4 ml x weight(kg) x BSA (%),,

over initial 24 h ( ½ over the first 8 h, ½ over over initial 24 h ( ½ over the first 8 h, ½ over the subsequent 16 h)the subsequent 16 h)

Monitoring BP, HR, capillary refill time,mental Monitoring BP, HR, capillary refill time,mental status , urinary outputstatus , urinary output(0,5-1ml/kg/h)(0,5-1ml/kg/h)

CBC, electrolytes, BUN, creatinine, glucose, CBC, electrolytes, BUN, creatinine, glucose, Arterial blood gases,chest radiograph, Arterial blood gases,chest radiograph,

carboxiHb, ecg, bronhoscopycarboxiHb, ecg, bronhoscopy Tetanus immunizationTetanus immunization Pain: narcotic analgesis, anxiolyticPain: narcotic analgesis, anxiolytic

Burns: local treatment Burns: local treatment

Initially: clean, dry sheetInitially: clean, dry sheetSmall burns: moist saline-Small burns: moist saline-

soaked dressing, local soaked dressing, local cooling (reduces histamine cooling (reduces histamine release, release, kkinin formation, Tx inin formation, Tx B2 production)B2 production)

Large burns: Large burns: sterilesterile drapes, transfer drapes, transfer

Circumferential deep burns: Circumferential deep burns: escharotomyescharotomy

AntibioticsAntibiotics

ChemChemicical burnsal burns

Home, Home, agriculturagriculturee, industri, industrialal,, research research laboratorlaboratoriesies, militar, militaryy, ,

AciAcidsds (organic (organics ands and anorganic anorganicss)- )- coagulation coagulation necronecrosissis

AlAlkkalialiss- li- liququefefaction necrosisaction necrosis othersothers- local- local and and general general injury injury Thermal injury Thermal injury (erit(erithhememaa, , blistering,full-blistering,full-

thickness ,thickness ,necronecrosissis))is determined is determined byby::strength/strength/concentraconcentration of the tion of the agentagent , ,quantityquantity,,duration of conduration of contact, tact, mecmechhanism anism ofof ac acttiioon, n, extent of penetrationextent of penetration..

CheChemicmical burnsal burns- - trtreeatmentatment

DiluDilution,irrigation to avoid the agenttion,irrigation to avoid the agent Irrigation-continued for hours in the case Irrigation-continued for hours in the case

of alkali burnsof alkali burns Topical antimicrobial agentsTopical antimicrobial agents Dilution of phenol andDilution of phenol and oxid de Ca oxid de Ca with with

water may enhance penetrationwater may enhance penetration GGeneraleneral treatment if burns treatment if burns >> 2020 %% Local Local

treatment:autografts,heterografts,homogrtreatment:autografts,heterografts,homograftsafts

EElectriclectrical burnsal burns Factors associated with severity of electrical Factors associated with severity of electrical

injuriesinjuries::– Current Current IntensitIntensityy (A) (A)– Electrical potentialElectrical potential ( (VV))– TTyyppe ofe of cur currrent (ent (AC AC sau sau DCDC))– Tissue resistanceTissue resistance– Duration ofDuration of contact contact– CCururrrentent pathway( vertical, horizontal) pathway( vertical, horizontal)– EnvEnviiromental circumstancesromental circumstances

ClinicClinical featuresal features: : – Local:Local:cutaneous burns at the point of entry and exitcutaneous burns at the point of entry and exit– General: General: Cardiac arrest (Cardiac arrest (FV, asistolFV, asistola)a),, neurologic neurologicalal, ,

vascularvascular injury injury, muscular, muscular injury injury, mioglobinur, mioglobinuryy

EElectriclectrical burnsal burns- - trtreeatmentatment

ABC with spinal immobilizationABC with spinal immobilization CCardiacardiac arrhythmias-ACLS protocol arrhythmias-ACLS protocol Fluids rFluids resuscitaesuscitationtion: Ringer: Ringer’s lactate or ’s lactate or

normal salinenormal saline 20-40 ml/kg 20-40 ml/kg over the first hourover the first hour rhrhabdomabdomyyololysisysis: 50 mEq bicarbonat/l: 50 mEq bicarbonat/l of fluid of fluid Wound careWound care: exci: excisionsion,,etcetc TTetanetanus immunizationus immunization Prophylactic administration of parenteral Prophylactic administration of parenteral

antibioticsantibiotics

Frostbite and cold Frostbite and cold related injuryrelated injury

Def: tisDef: tissue injurysue injury after cold exposureafter cold exposure HyHystorstoryy: Hannibal: Hannibal(losing half his 46000 man (losing half his 46000 man

crosing the Pyrenean Alps)crosing the Pyrenean Alps), Napoleon, Napoleon’s ’s surgeon -surgeon -Larrey,Larrey,World War World War ll-trench foot-trench foot

FactorFactorss::duration of contact, humidity,wind, duration of contact, humidity,wind, altitude,clothing,medical condition,behavior altitude,clothing,medical condition,behavior

PPatoatophysiolphysiologogyy CCliniclinical featuresal features TrTreeatment: preatment: prehohospital, spital, emergency emergency

departmentdepartment

Frosbite Frosbite patophysiologypatophysiology

Prefreeze StatePrefreeze State: tissue cooling, increased : tissue cooling, increased viscosity,capilary constriction-dilatation cycleviscosity,capilary constriction-dilatation cycle

Frozen state:extracellular ice crystal Frozen state:extracellular ice crystal formation, intracellular dehydration and formation, intracellular dehydration and hyperosmolarity,fluid crossing cell membranehyperosmolarity,fluid crossing cell membrane

Ischemic and vascular complicationsIschemic and vascular complications: : reperfusion injury,endothelium leaky , cogulation reperfusion injury,endothelium leaky , cogulation from stasis, leakage of destructive prostaglandins from stasis, leakage of destructive prostaglandins and oxigen free radicalsand oxigen free radicals,, vasoconstriction and vasoconstriction and arteriovenoarteriovenouuss shunting, necrosis demarcation and shunting, necrosis demarcation and gangrenegangrene

Frostbite severityFrostbite severity I degreeI degree: partial skin : partial skin

freezingfreezing,erythema,edema,hyperemia,no blisters or ,erythema,edema,hyperemia,no blisters or necrosis, occasional skin desquamation( 5-10 d later)necrosis, occasional skin desquamation( 5-10 d later)

II degreeII degree:full-thickness injury:full-thickness injury, erythema, substantial , erythema, substantial edema, vesicles with clear fluid,blisters that desquamate edema, vesicles with clear fluid,blisters that desquamate and form blackened escharand form blackened eschar

III degreeIII degree:full-thickness skin and subcutaneous freezing , :full-thickness skin and subcutaneous freezing , violaceous or hemorrhagic blisters, skin necrosis, blue-violaceous or hemorrhagic blisters, skin necrosis, blue-gray discolorationgray discoloration

IV degreeIV degree: full-thickness skin: full-thickness skin,subcutaneous tissue, ,subcutaneous tissue, muscle, tendon,and bone freezing,little edema,initially muscle, tendon,and bone freezing,little edema,initially mottled,deep red or cyanotic, eventually dry, black, mottled,deep red or cyanotic, eventually dry, black, mummifiedmummified

TreatmentTreatment

prehospital: wet and constrictive clothing should prehospital: wet and constrictive clothing should be removed,the involved extremities should be be removed,the involved extremities should be elevated and wrapped in dry sterile gauzeelevated and wrapped in dry sterile gauze

Hospital: Hospital: bath at 40-42 C for 10-30 min with active bath at 40-42 C for 10-30 min with active motion, parenteral analgesicsmotion, parenteral analgesics(mor(morphphin 0,1 mg/kg, in 0,1 mg/kg, meperidină 1-1,5 mg/kg)meperidină 1-1,5 mg/kg)

Local: Local: – debride clear blisters,debride clear blisters,– leaveleave hemor hemorrhrhagicagic vesicles intact vesicles intact,,dress with aloe veradress with aloe vera– Tetanus prophylaxis, penicilina G Tetanus prophylaxis, penicilina G (500.000/6 h)(500.000/6 h), ,

ibuprophen 400mg,begin daily hydrotherapyibuprophen 400mg,begin daily hydrotherapy SurgerySurgery

CCarbonarbon monoxide monoxide poisoningpoisoning

EpidemiologEpidemiologyy: mediu industrial, casnic, : mediu industrial, casnic, incendiuincendiu

patopatophysiophysiologlogyy clinicclinicalal DiagnosiDiagnosiss TrTreeatment atment

PPatathhoophysiophysiologlogyy

CO forms a ligand withCO forms a ligand with respirator respiratory pigmentsy pigments andand enz enzyymemess::– HbHb

ReduceReduces thes the O2 O2 carriage carriage Transform the oxyhemoglobinTransform the oxyhemoglobin dis disssociociation curveation curve FormaFormation oftion of HbCO – HbCO – ““chcheemicmical anemia”al anemia”

– MMyyoglobin (miocardică)oglobin (miocardică)– CCyytoctochhromromee P P--450450– CCyytoctochhromromee aaa3a3

Direct tDirect toxicoxic efects efects

CarbonCarbon monoxid poisoning monoxid poisoning: : diagnosidiagnosiss

HysHystortoryy PhysiPhysiccal examal exam: : neurological examinationneurological examination, , skin skin

colorcolor Paraclinic: co-oximetrParaclinic: co-oximetryy, HbCO, HbCO level level Lab:Lab:CBCCBC,, metabolic metabolic acido acidosissis, , serum bicarbonate serum bicarbonate

level, serum lactate level, serum electrolyteslevel, serum lactate level, serum electrolytes Ecg: mEcg: myyocardiocardial ischemiaal ischemia Serum CK and CK-MBSerum CK and CK-MB,m,myyoglobinoglobin, urine , urine

toxicologytoxicology Chest -rayChest -ray CT / IRM: CT / IRM: cerebral cerebral ischemicischemic injury injury

CO poisoningCO poisoning: tr: treeatment atment

ABC , ABC , CPR in cardiac arrestCPR in cardiac arrest Mild CO toxicityMild CO toxicity: :

– Normobaric oNormobaric oxxyygen 100 % gen 100 % by mask forby mask for 4 4 h/h/ventilatory assistance: bag-valve-mask ventilatory assistance: bag-valve-mask ventilation or endotracheal intubationventilation or endotracheal intubation

SSererious CO toxicityious CO toxicity: : – HyHyperbaricperbaric oxigen oxigen 100 % 100 % atat 2,4 – 2,8 AT 2,4 – 2,8 AT

90 min90 min

HHyypotpothhermiaermia

DefiniDefinitiontion ClasClasssificificationation EtiologEtiologyy DiagnosisDiagnosis EEcg changescg changes TrTreeatmentatment

HypothermiaHypothermia-- definidefinitiontion

Core (Core (CentralCentral) temperature) temperature < 35 < 35 C( esofagian/ rectalC( esofagian/ rectal

clasificationclasification: : – mild mild 35-32 C35-32 C– medimediumum 32-28 C32-28 C– severesevere < 28 C< 28 C

HypothermiaHypothermia-- causescauses ““Accidental”Accidental” ((enviromentalenviromental)) Metabolic:Metabolic: hhyypotpothyhyroidiroidismsm, h, hyypoadrenalism,poadrenalism,

hhyypopituitarism, hpopituitarism, hyypoglicemipoglicemiaa HyHypotpothhalamic aalamic andnd CCNNS dysfunction S dysfunction (trauma, (trauma,

tumori,tumori, AVC,AVC, B. Wernicke)B. Wernicke) SepsisSepsis DDermaermal diseasel disease Iatrogenic (fluid rIatrogenic (fluid resuscitaesuscitation)tion) Acute incapaciting illnessAcute incapaciting illness Toxics Toxics ((ddrogrogss,, etanol, fenotiazin,etanol, fenotiazin, sedativsedativss, ,

hhypypnoticnotics)s)

HypothermiaHypothermia-- efectefectss

Cardiovascular:Cardiovascular: inotrop inotrop and and cronotrop negativ, cronotrop negativ, hhyypovolemipovolemiaa, , life-threatening dysrhymiaslife-threatening dysrhymias;;

Respirator: Respirator: tatachychypnepneaa, , decrease in respiratory decrease in respiratory rate and tidal volrate and tidal volum, dum, depression of cough and gagepression of cough and gag reflexereflexess ( (aspiration aspiration pneumonipneumoniaa););

SSNC:NC: depresdepresssiionon, confu, confussiionon, let, lethhargargyy, com, comaa;; Renal: Renal: “cold “cold diudiurreesissis ”, ”, ssignificant volume lossesignificant volume losses, ,

rrhhabdomabdomyyololysisysis,, acute tubular acute tubular necro necrosissis, renal, renal failurefailure (m (myyoglobinurioglobinuriaa, , renal renalhhyypoperfupoperfusionsion););

CID CID (hemoconcentra(hemoconcentrationtion,, increase in blood increase in blood viscosityviscosity, coagul, coagulopathyopathy););

acid-baacid-bassee disturbances disturbances: : acidoacidosis(CO2 sis(CO2 retention),retention),alcaloalcalosis(diminished CO2 production)sis(diminished CO2 production)..

ECG: JECG: J wave wave Osborn Osborn PR, QRS, QT prolongationPR, QRS, QT prolongation, T, T-wave inversions-wave inversions Sinus bSinus bradradyycardicardiaa , , nodal rhythms nodal rhythms PVCs, AV blockPVCs, AV block Atrial fAtrial fibriibrilllalattiionon oror flutter flutter VFVF, as, asyystolstolaa

CPRCPR Passive rewarming: removal cold environmentPassive rewarming: removal cold environment Active external rewarming:warm water Active external rewarming:warm water

immersion,heating blankets, radiant heat, immersion,heating blankets, radiant heat, forced airforced air

Active internal rewarming: Active internal rewarming: – Ventilation with warm O2,Ventilation with warm O2,– Heated i.v. fluids, Heated i.v. fluids, – Gastrointestinal tract lavage,bladder lavage, Gastrointestinal tract lavage,bladder lavage,

pleural lavage,pleural lavage, extracorporeal pleural lavage,pleural lavage, extracorporeal rewarming, mediastinal lavage via thoracotomyrewarming, mediastinal lavage via thoracotomy

HypothermiaHypothermia-- treatment treatment

Heat emergenciesHeat emergencies

DefiniDefinitiontion, epidemiolog, epidemiologyy RRisisk factorsk factors PPatathhoophysiophysiologielogie ClinicClinical formsal forms Clinical and paraclinical dClinical and paraclinical diagnosiiagnosiss ComplicaComplicationstions TrTreeatmentatment PrognosPrognosisis

Heat emergency: dHeat emergency: defef.., , epidemiologepidemiologyy

USA:390 deaths/year caused by the effects of USA:390 deaths/year caused by the effects of heat and excessive heat exposureheat and excessive heat exposure;;

The second leading cause of death among young The second leading cause of death among young athletesathletes;;

Risk groupRisk group::elderly withelderly with cardiopulmonar cardiopulmonary illnessesy illnesses Environmental faEnvironmental fatotorsrs: :

– TemperaturTemperaturee;;– HuHumiditmidityy;;– Sun exposureSun exposure– The windThe wind;;

RiskRisk FactorFactors for s for serious heat injuryserious heat injury

DehydratioDehydratio ObesityObesity Heavy or impermeable clothingHeavy or impermeable clothing Lack of aclimatizationLack of aclimatization

HHeatstrokeeatstroke

Central temperature> Central temperature> 40,5 C;40,5 C; MentalMental status status;; MortalitaMortalitalitylity 10 %; 10 %; EEndotoxinndotoxin and and citokin citokin action action

CCliniclinicss

Temperatură centrală (esofagiană, Temperatură centrală (esofagiană, rectală, vezicală) rectală, vezicală) > > 40,5 C;40,5 C;

Tahicardie, tahipnee, hipotensiune;Tahicardie, tahipnee, hipotensiune; Iritabilitate, confuzie, obnubilare;Iritabilitate, confuzie, obnubilare; Convulsii, stare de comă,hemiplegie;Convulsii, stare de comă,hemiplegie; Echimoze, epistaxis, hematemeză, Echimoze, epistaxis, hematemeză,

hematurie (CID).hematurie (CID).

PParaclinicaraclinicss

Chest x-ray Pulmonary edema, pulmonary congestion, adult respiratory distress syndrome

EKG Conduction abnormalities, nonspecific ST-T wave changes, arrhythmias, myocardial infarctionABG Respiratory alkalosis, oxygenation status

Cardiac isoenzymes Myocardial injury

CBC Leukocytosis, elevated hematocrit

Fibrinogin, fibrin split products Coagulopathy, disseminated intravascular coagulation

LDH, AST, ALT, CK, potassium, BUN

Elevated in renal or hepatic injury

Lactate Commonly elevated in exertional heat stroke, predicts poor prognosis in classic heat stroke

Calcium, phosphorus, glucose Decreased

Urinalysis Myoglobin casts, red blood cells

Near DrowningNear Drowning

Drowning- death from suffocation Drowning- death from suffocation after submersionafter submersion

Near drowning- survive, at least Near drowning- survive, at least temporarily after suffocation by temporarily after suffocation by submersionsubmersion

Epidemiology- children <4 years, Epidemiology- children <4 years, teenagersteenagers

Associatead risk Associatead risk factorsfactors Alcohol or drug useAlcohol or drug use Traumatic injury – spinal injuryTraumatic injury – spinal injury HypothermiaHypothermia

PathophysiologyPathophysiology

Water – airway- flooding of Water – airway- flooding of alveoli- impairment of gas alveoli- impairment of gas exchangeexchange

Initial hypoxemiaInitial hypoxemia Respiratory failureRespiratory failure Ischemic neurologic injuryIschemic neurologic injury

PathophysiologyPathophysiology

•Noncardiogenic pulmonary edema•Poor perfusion and hypoxemia•Metabolic acidosis•Electrolyte abnormalities•Disseminated intravascular coagulation•Acute tubular necrosis

Prehospital carePrehospital care

Rapid , cautious removal of theRapid , cautious removal of the

victim from the watervictim from the water Spinal precautionsSpinal precautions Cardiopulmonary resuscitationCardiopulmonary resuscitation Supplemental oxygen on all patientsSupplemental oxygen on all patients ETT and assisted ventilation ETT and assisted ventilation No postural drainageNo postural drainage No Heimlich maneuverNo Heimlich maneuver

Hospital careHospital care

Clear spineClear spine Pulmonary support: O2 or Pulmonary support: O2 or

supplemental oxygensupplemental oxygen MonitorMonitor Laboratory studies: CBC, electolytes, Laboratory studies: CBC, electolytes,

glucose, pulse oximetry, arterial glucose, pulse oximetry, arterial blood gases, chest x-ray, ecgblood gases, chest x-ray, ecg

Nasogastric tube, Foley catheterNasogastric tube, Foley catheter

ComplicaComplicationstions PrognosiPrognosiss ArrhythmiasArrhythmias;; Aspiration Aspiration

pneumonia , pneumonia , irreversible lung irreversible lung injuryinjury;;

Sepsis;Sepsis; NNeurologiceurologic deficits deficits;;

Vary with the time of Vary with the time of hipoxi hipoxiaa;;

Cardiac arrest Cardiac arrest –– mortality ratemortality rate

35 - 60 %;35 - 60 %; Neurologic deficitNeurologic deficit

60 – 100 60 – 100 %;%;

DispositionsDispositions• I-Patients with no evidence of significant I-Patients with no evidence of significant

submersion may be discharged submersion may be discharged

• II- asymptomatic or mild symptoms – II- asymptomatic or mild symptoms – observed in ED, chest x ray, arterial observed in ED, chest x ray, arterial blood gases, pulse-oximetry blood gases, pulse-oximetry ;;

• III- mild and moderate hypoxemia- III- mild and moderate hypoxemia- oxygen therapy- admitted or oxygen therapy- admitted or dischargeddischarged;;

• IV-intubation and mechanical IV-intubation and mechanical ventilation – neurologic status and ventilation – neurologic status and pulmonary injurypulmonary injury