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Presented by:Presented by:

Katherine June MercadoKatherine June Mercado

AnjelieAnjelie Dawn MendozaDawn Mendoza

TSUNAMI & TSUNAMI &

DROWNINGDROWNING


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DEFINITIONSDEFINITIONS

Drowning:Drowning:AsphyxiaAsphyxiaand death due toand death due tosubmersion in liquidsubmersion in liquid(usually water)(usually water)

Near Drowning:Near Drowning: isissurvival for more thansurvival for more than24 hours from24 hours fromsuffocation bysuffocation bysubmersion.submersion.

Tsunami:Tsunami: TsunamisTsunamisare ocean wavesare ocean wavesproduced byproduced byearthquakes orearthquakes orunderwater landslidesunderwater landslides.


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SOME INTERESTING STATISTICSSOME INTERESTING STATISTICS

99%99% of allof all drowningsdrownings occur inoccur inunsupervised waterunsupervised water ((free flowing)free flowing)

almostalmost halfhalfof allof all drowningsdrownings occuroccur iinnthe company of othersthe company of others (mostly adults)(mostly adults)

almostalmost halfhalfof allof all drowningsdrownings occuroccur lessless

than two metres from safetythan two metres from safety highesthighest risk category arerisk category are males 18males 18--3434

years oldyears old

nearlynearly 40%40%of allof all drowningsdrownings involveinvolvealcoholalcohol

overover halfhalfof victims who drowned whileof victims who drowned whileboating wereboating were not wearing lifejacketsnot wearing lifejackets

most children drown in homemost children drown in homeswimming pools, majority of them beingswimming pools, majority of them beingtoddlerstoddlers


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EPIDEMIOLOGY

Tsunamis:Tsunamis: earthquakeearthquake--inducedinduced

movement of the oceanmovement of the ocean

floor.floor.

LandslidesLandslides

volcanic eruptions, andvolcanic eruptions, and

meteoritesmeteorites

DrowningDrowning Males > FemalesMales > Females

In infants younger than 1 yearIn infants younger than 1 year

Bathtubs and buckets ofBathtubs and buckets ofwaterwater

Child abuseChild abuse

In children aged 1In children aged 1--5 years:5 years: Residential swimming poolsResidential swimming pools

In young adults aged 15In young adults aged 15--1919yearsyears

Submersion injuries usuallySubmersion injuries usuallyin ponds, lakes, rivers,in ponds, lakes, rivers,oceans, and other naturaloceans, and other naturalbodies of water.bodies of water.

Alcohol useAlcohol use

Water sportsWater sports

Cold waterCold water

Peak ages:Peak ages: 11-- 2 years old2 years old

1515--19 years old19 years old


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RISK FACTORSRISK FACTORS Intoxication with drugs/alcohol Venomous stings from aquatic

animals

Head/spinal injuries (Diving

accidents)

Hyperventilation syndrome (BreathHolding) which suppresses the

physiologic response to increased

CO2

Pre-existing medical conditions:

Seizures/DM/ Syncopal episodes

Seizures and cardiac arrhythmiasSeizures and cardiac arrhythmias

Syncope and apneaSyncope and apnea

HypoglycemiaHypoglycemia

MI/ Pre-existing cardiac disease

Hypothermia


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TypesTypes OOff DDrowningrowning Dry:Dry: 15% of cases

Small amount of H20 aspiratedSmall amount of H20 aspirated

It contacts the larynx which has a naturalIt contacts the larynx which has a naturaldefensedefense mechanism, called amechanism, called alaryngospasmlaryngospasm. The larynx expand to block. The larynx expand to blockthe airway, thus often preventing waterthe airway, thus often preventing water

from entering the lungs in.from entering the lungs in.

Wet:Wet:

85% of cases85% of cases

Fluid and electrolyteFluid and electrolyteimbalances occurimbalances occur

TheThe laryngospasmlaryngospasm relaxes asrelaxes as

the person loses consciousness,the person loses consciousness,

and water enters the lungsand water enters the lungs


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WET LUNGFresh Water TypeFresh Water Type

Water moves from alveoliWater moves from alveolito bloodstreamto bloodstream

HemodilutionHemodilution occursoccurs

O2O2 carrying capacitycarrying capacity

decreasesdecreases Water moves into redWater moves into red

cellscells

Red cells swell, ruptureRed cells swell, rupture Increase PotassiumIncrease Potassium

resulting to arrhythmiasresulting to arrhythmias Release ofRelease of hemoglobinhemoglobin intointo

bloodstream result to renalbloodstream result to renalfailurefailure

Loss of surfactant resultLoss of surfactant result

to collapse of alveolito collapse of alveoli


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Salt Water Type:Salt Water Type:

Water moves fromWater moves from

bloodstream to alveolibloodstream to alveoli

HemoconcentrationHemoconcentrationoccurs resulting tooccurs resulting to

shockshock

PulmonaryPulmonary edemaedema

occursoccurs

WET LUNG (CONT..)WET LUNG (CONT..)


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The difference in

pathophysiology of aspiration

of fresh water (hypotonic)

and salt water (hypertonic)

have little clinical

significance.

Fresh water drowning -

hemodilution & intravascular

hemolysis.

Sea water drowning

hemoconcentration and

hypovolemia


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Classifications of DrowningClassifications of Drowning

Active Drowning:Active Drowning: TheThevictim is vertical invictim is vertical inthe water, notthe water, notkicking, stillkicking, still

breathing and usuallybreathing and usuallymoving the arms inmoving the arms inthe effort to bob out ofthe effort to bob out ofthe water. The victimthe water. The victimcant call for help.cant call for help.

Passive Drowning:Passive Drowning: TheThevictim is facevictim is face--down indown inthe water.the water.


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NEAR DROWNING

Do not attemptDo not attemptswimming rescueswimming rescuewithout proper trainingwithout proper training

ThrowThrow -- TowTow RowRow --

GoGo Consider possible neckConsider possible neck

injury:injury: Diving accidentDiving accident

Swimming poolsSwimming pools

Inadequate historyInadequate history

Place patient onPlace patient onspineboardspineboard in waterin water

If possible, beginIf possible, beginpulmonary resuscitationpulmonary resuscitationin waterin water

Resuscitate all coldResuscitate all cold

water drowning (


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Summary of the drowning process:Summary of the drowning process:

1.1. Panic and violent struggle toPanic and violent struggle toreturn to surfacereturn to surface

2.2. Period of CalmnessPeriod of Calmness

3.3. Swallowing of fluid, followed bySwallowing of fluid, followed byvomitingvomiting

4.4. Terminal GaspTerminal Gasp

5.5. UnconsciousnessUnconsciousness

6.6. Possible SeizuresPossible Seizures

7.7. DeathDeath

*The time that this takes is variable, but it could be as*The time that this takes is variable, but it could be as

little aslittle as 12 to 20 seconds12 to 20 seconds from the firstfrom the first panic topanic to

unconsciousness.unconsciousness.


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AAssessment of the Patientssessment of the PatientHistoryHistory

Mechanism and duration ofMechanism and duration ofsubmersionsubmersion

Type and temperature ofType and temperature ofwaterwater

Time to institution of CPRTime to institution of CPR

Time to first spontaneousTime to first spontaneousbreathbreath

Time to return ofTime to return ofspontaneous cardiac outputspontaneous cardiac output

VomitingVomiting

Likelihood of associatedLikelihood of associatedtrauma, other precipitantstrauma, other precipitants(arrhythmia, MI, seizure,(arrhythmia, MI, seizure,

etc).etc).

Signs andSigns and

Symptoms:Symptoms:

Pulmonary edemaPulmonary edema

RespiratoryRespiratoryfailurefailure

ShockShock

AnoxicAnoxic

encelopathyencelopathy

Brain edemaBrain edema Cardiac arrestCardiac arrest

RespiratoryRespiratory

ManifestationsManifestations

CyanosisCyanosis

TrismusTrismus

ApneaApnea TachypneaTachypnea

WheezingWheezing

CardiovascularCardiovascular

ManifestationsManifestations TachycardiaTachycardia

ArrhythmiaArrhythmia

HypotensionHypotension

ShockShock

Cardiac ArrestCardiac Arrest HypotensionHypotension


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Pulmonary/airway:Pulmonary/airway:

Ineffective breathingIneffective breathing

DyspneaDyspnea Respiratory distressRespiratory distress

Crackles,Crackles, ronchironchi

Cough with pinkCough with pink--frothyfrothy

sputumsputum

Foreign body obstructionForeign body obstruction

Other:Other:

PanicPanic

ExhaustionExhaustion ComaComa

InjuriesInjuries

Core temperature slightlyCore temperature slightlybelow or higher thanbelow or higher thannormalnormal

VomitingVomiting


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MANAGEMENT ON SITEMANAGEMENT ON SITE

Get the victim out of theGet the victim out of thewater. CPR may bewater. CPR may bestarted while the victimstarted while the victimis still in the water.is still in the water.

If the victim is breathing,If the victim is breathing,place him on his side. Heplace him on his side. Heshould be able to ejectshould be able to ejectwater himself but mustwater himself but must

be carefully watched.be carefully watched. If not breathing, beginIf not breathing, begin

CPR and shout for help.CPR and shout for help.

Paramedics with ALSParamedics with ALSshouldshould intubateintubate thethe

victim with no heart orvictim with no heart orrespiration rate.respiration rate.

Establish IV line with Ringers

lactate (warmed if available ).

Keep open rate.

Follow the ACLS protocol

regarding drug therapy.

Drowning with severe

hypothermia, if heart rate is so

slow do not intubate since the

victim might develop asystole.

Start rewarming the patient.


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PrehospitalPrehospital ManagementManagement

Assess ABCsAssess ABCs

Clean airway of obstructionClean airway of obstruction

Control airway w/ chin lift orControl airway w/ chin lift orjaw thrust. Protect C spine ifjaw thrust. Protect C spine if

trauma is suspected.trauma is suspected. Begin mouth to mouth orBegin mouth to mouth or

mask ventilation if nomask ventilation if nobreathing present.breathing present.

Begin CPR if no heart rate isBegin CPR if no heart rate is

palpablepalpable Remove wet clothing andRemove wet clothing and

wrap in blanket.wrap in blanket.

For hypothermia, wrap in dryFor hypothermia, wrap in drywarm blanketwarm blanket


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Paramedics with Advance Life SupportParamedics with Advance Life Support

Unit Should:Unit Should:

IntubateIntubate the child if there is no HR orthe child if there is no HR orRRRR

Establish an IV line with warm RingersEstablish an IV line with warm Ringers

lactate. Anlactate. An intraosseousintraosseous infusion may beinfusion may be

used for children.used for children.

Further treatment at site includes:Further treatment at site includes:

Clean the victims mouth with the use ofClean the victims mouth with the use of

finger sweepfinger sweep

Place the victims in the head downPlace the victims in the head downposition to allow fluid drainage from theposition to allow fluid drainage from the

mouth.mouth.

Give oxygen in high concentration byGive oxygen in high concentration by

continuous positive air pressure.continuous positive air pressure.

Perform HeimlichPerform Heimlich manuevermanuever if needed.if needed.


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After initial stabilization,After initial stabilization,

victims who survive canvictims who survive can

be separated into threebe separated into three

groups:groups:

Awake victims who areAwake victims who areneuroligicallyneuroligically responsiveresponsive

and who have signs andand who have signs andsymptoms of respiratorysymptoms of respiratorycompromise.compromise.

Those with spontaneousThose with spontaneous

respirations Glasgowrespirations GlasgowComa scale of over 5.Coma scale of over 5.

Those with GlasgowThose with GlasgowComa scale under 4.Coma scale under 4.


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DROWNED/DEAD VICTIMSDROWNED/DEAD VICTIMS


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Labs andLabs and DDiagnosticsiagnostics


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No difference inelectrolytes and

hematocrit

Average drowningvictim aspirates 3-4ml/kg

No electrolyte orblood volume changes

seen until 22 ml/kgand 11ml/kgrespectively


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Blood gas analysis with coBlood gas analysis with co--

oximetryoximetry to detectto detect

methemoglobinemiamethemoglobinemia andandcarboxyhemoglobinemiacarboxyhemoglobinemia

ToxicologyToxicology to determine alcoholto determine alcohol

or illicit drug useor illicit drug use


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Chest xChest x--rayray to look for fluidto look for fluidin the lungsin the lungs

Neck xNeck x--rayray to look forto look for

fracturesfracturesHead CTHead CT to look forto look for

structural damage to thestructural damage to the

brainbrainECGECG to look for irregularto look for irregular

heart activityheart activity


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PATHOPHYSIOLOGY


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D


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NURSING DIAGNOSES


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Impaired Gas ExchangeImpaired Gas Exchange related factors: surfactantrelated factors: surfactantelimination,elimination, Bronchospasm,Aspiration,pulmonaryBronchospasm,Aspiration,pulmonary edemaedema..

Altered Cerebral PerfusionAltered Cerebral Perfusion related factors: prolongedrelated factors: prolonged

hypoxemia,impairedhypoxemia,impaired gas exchange.gas exchange.

Fluid Volume Excess/DeficitFluid Volume Excess/Deficit Risk for Decreased Cardiac OutputRisk for Decreased Cardiac Output

Risk for infectionRisk for infection

Ineffective breathing patternIneffective breathing pattern related to anxietyrelated to anxiety

AnxietyAnxiety related to hypoxemia, threat to deathrelated to hypoxemia, threat to death

Risk for decreased cardiac outputRisk for decreased cardiac output

Risk for injuryRisk for injury

HypothermiaHypothermia


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LIFE SAVING INTERVENTIONS


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Key Points of Management:Key Points of Management:

DrowningDrowning

Remove from water (effective CPRRemove from water (effective CPR

in water is not possible)in water is not possible)

Start CPRStart CPRHeimlich only for obstructionHeimlich only for obstruction

Move to medical facilityMove to medical facility


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Interventions:Manage and maintain ABCs

Assume cervical spine injury in all drowningvictims and stabilize and/or immobilize cervicalspine

Provide 100% 02 via nonrebreather mask

Anticipate need for intubation if gag reflex is absentEstablish IV access with 2 large bore catheters for

fluid resuscitation and infuse warmed fluids ifappropriate

Assess for other injuries

Remove wet clothing and cover with warm blankets

Obtain temperature and begin rewarming if needed

Obtain cervical spine and chest x-rays

Insert gastric tube.


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KKey points ofey points of MManagementanagement::

TTsunamisunami First aidFirst aid

Prevent hypothermiaPrevent hypothermia

Transfer to safer place in higher groundTransfer to safer place in higher ground

DecontaminationDecontamination


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MEDS

Mannitol (Osmitol) or Furosemide (Lasix)

may be given to decrease free water and

treat cerebral edema.

Antibiotic prophylaxis is not indicated

unless the patient was submerged in

grossly contaminated water or sewage.


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LIFE MAINTAININGLIFE MAINTAINING

INTERVENTIONSINTERVENTIONS


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DROWING

Monitor ABCs, V/S, and LOCMonitor ABCs, V/S, and LOCMonitor OMonitor O22 saturation and cardiac rhythmsaturation and cardiac rhythm

Monitor temperature and maintainMonitor temperature and maintain normothermianormothermia

Monitor for signs of acute respiratory failureMonitor for signs of acute respiratory failure

EndotrachealEndotracheal intubation with mechanicalintubation with mechanicalventilation for respiratory failure, persistentventilation for respiratory failure, persistenthypotension, or impaired airway protective reflexes.hypotension, or impaired airway protective reflexes.

NasogastricNasogastric tube placement for removal oftube placement for removal of

swallowed water and debris (Useswallowed water and debris (Use orogastricorogastric route ifroute ifhead or facial trauma is suggested.)head or facial trauma is suggested.)

Urinary catheter placement for assessment of urineUrinary catheter placement for assessment of urineoutputoutput

(continued)(continued)


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(cont)

Extracorporeal membrane oxygenation (ECMO)Extracorporeal membrane oxygenation (ECMO) --May be considered in the following circumstances:May be considered in the following circumstances:Respiratory compromise resulting from lack of response toRespiratory compromise resulting from lack of response to

conventional mechanical ventilation or highconventional mechanical ventilation or high--frequencyfrequency

ventilationventilationA reasonable probability of the patient recoveringA reasonable probability of the patient recovering

neurologic functionneurologic function

Persistent hypothermia from coldPersistent hypothermia from cold--water drowningwater drowning

BronchoscopyBronchoscopy if needed for removal of foreignif needed for removal of foreign

bodies, such as aspirated debris orbodies, such as aspirated debris or vomitusvomitus Intracranial pressure monitoring in patients withIntracranial pressure monitoring in patients with

traumatic brain injury or mass lesions (traumatic brain injury or mass lesions (egeg,,hematomas)hematomas)


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TSUNAMIS

Help provide save waterHelp provide save water

for drinkingfor drinking

Provide food and shelter

Disease control


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PSYCHOSOCIAL ANDPSYCHOSOCIAL AND

BEHAVIORAL INTERVENTIONSBEHAVIORAL INTERVENTIONS

AND SUPPORTIVE MANAGEMENTAND SUPPORTIVE MANAGEMENT


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DROWNING TSUNAMI

Provide informationProvide information Educating:Educating:

Fence all pools and spasFence all pools and spas

Know the weatherKnow the weather

conditions and locationconditions and locationof underwater hazardsof underwater hazards

before entering thebefore entering the

water.water.

Learn and observe waterLearn and observe water

and boating safety rules.and boating safety rules.

Always wear life jacketsAlways wear life jackets

especially on open water.especially on open water.

Never allow yourself orNever allow yourself or

children to swim alone orchildren to swim alone or

unsupervised.unsupervised.

Active listeningActive listening Provide emotional supportProvide emotional support

Give informationGive information

Discourage victims fromDiscourage victims from

repeated exposure to therepeated exposure to theeventevent

Refer patients toRefer patients totherapists or socialtherapists or socialworkers and mentalworkers and mental

health care serviceshealth care services


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PREVENTION OF COMPLICATIONSPREVENTION OF COMPLICATIONS


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DROWNINGDROWNING

TSUNAMITSUNAMI

ARDSARDS Aspiration pneumoniaAspiration pneumonia

Pulmonary edemaPulmonary edema

HypothermiaHypothermia

Interventions:Interventions: Monitoring of VS, LOC,Monitoring of VS, LOC,

ABCs, O2 saturation,ABCs, O2 saturation,

AuscultateAuscultate for adventitiousfor adventitioussounds in lungs or trachea.sounds in lungs or trachea.

Observe for signs ofObserve for signs ofcyanosis, inadequate chestcyanosis, inadequate chestexpansionexpansion

PositioningPositioning

OxygenationOxygenation

Provide warmed blanketsProvide warmed blankets

Water borneWater borne

transmissions andtransmissions andinfectionsinfections-- waterwater

purification, wastepurification, waste

removal, removal ofremoval, removal of

human and animalhuman and animalremains, and vectorremains, and vector

controlcontrol


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