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Dissecting the Medical Issues in Pediatric Drowning
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Dissecting the Medical Issues in Pediatric Drowning

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  • 1. Pediatric Submersion Peter Antevy MD Davie Fire Rescue, Medical Director American Ambulance, Medical Director Miramar Fire Rescue, Asst. Medical Director Broward College EMS, Medical Director JDCH, Pediatric Emergency Medicine
  • 2. Pediatric Submersion Disclosure• Pediatric Emergency Standards, Inc. – Founder and CEO – Consulting – Pediatric Resuscitation System
  • 3. Pediatric Submersion
  • 4. Pool Danger 4
  • 5. Pediatric Drowning Objectives• Allan’s Story• Broselow Demo• Where are kids resuscitated• Epinephrine administration• Hypothermia?• Oxygen (too much vs. too little)• ABC vs. CAB
  • 6. A Day at the Beach
  • 7. Pediatric Submersion Prevention Rescue Medical
  • 8. A Similar StoryPregnancy Delivery Life
  • 9. Pediatric Drowning Allan’s Story
  • 10. Pediatric Drowning Allan is down• Recognize - Understand - React• Will you step in?• Can you control your adrenaline surge?• Will you do something wrong? Do you know the physiology?
  • 11. Pediatric Drowning Allan is down• Rescue arrives in 4 minutes• Child found blue and without a pulse• CPR ensues• Child transported rapidly to Joe DiMaggio Children’s Hospital He is unconscious
  • 12. Pediatric Drowning Allan is down• ED Arrival – Copious amounts of emesis – Moderate respiratory distress – O2 Sat of 92% on 100% non-rebreather – Minutes later he vomits a frothy pink fluid What is happening?
  • 13. Pediatric Drowning ED Management• Placed on a ventilator• Labs suggest significant illness – Oxygen starvation – Elevated Acid levels• IV medications & fluid• Transferred to PICU
  • 14. Pediatric Drowning PICU Course• Severe lung swelling at 12 hours• Significant brain swelling over 24 hours• Tracheostomy and Gastrostomy tubes• Multiple specialists involved• 3 month hospitalization
  • 15. Pediatric Drowning A Mothers Reflection• Initial explanation did not sink in• I was told he didn’t drown, so I thought he’d be OK• They asked if I want to disconnect the ventilator at 48 hours• Things sunk in at 3 weeks
  • 16. Pediatric Drowning Allan’s Story
  • 17. Pediatric Drowning Allan
  • 18. “Pool’s Gold” • 3 year old male • Submerged in pool
  • 19. Pediatric DrowningLet’s Start from the Beginning You are the Paramedic
  • 20. Pediatric Drowning Timeline ChildChild falls poolside EMS EDinto pool No Pulse Arrival Arrival The Variables - CPR on Scene - Resus location - Epinephrine 911 Call - when & where 0 5 min 13 min 22 min Why is Epinephrine Important?
  • 21. PALS UPDATE Epinephrine10 mL
  • 22. PALS UPDATE Epinephrine • CPR • Epinephrine10 mL
  • 23. Epi in Cardiac Arrest
  • 24. Epi in Cardiac Arrest 11.3 6 1.3 0.6 Epi No Epi Epi No Epi
  • 25. Pediatric Drowning Critical Minutes Early • CPR • Epinephrine10 mL
  • 26. Pediatric Drowning Submersion Time
  • 27. Pediatric Drowning CPR Duration
  • 28. Pediatric Drowning ER Resuscitation• Prolonged resuscitation (ACLS >25 min) of warm water pediatric drowning victims is NOT indicated• The longest ED CPR with a good neurologic outcome was 12 minutes
  • 29. Pediatric Drowning Bystander CPR• Family members performed CPR in 20% of cases• 65 received bystander CPR prior to paramedic arrival• 41/63 breathing and with pulses when EMS arrived• All 41 survived to hospital dischargeSirbaugh (Ann Emerg Med, 1999)
  • 30. Pediatric Drowning Timeline ChildChild falls poolside EMS EDinto pool No Pulse Arrival Arrival 911 Call 0 5 min 13 min 22 min 9 Minutes
  • 31. Pediatric Drowning Back to the Scene Paramedic Arrival
  • 32. Putting the Tape to the Test What Really Happens?
  • 33. ACADEMIC EMERGENCY MEDICINE 2012; 19:37–47• Incorrect Weight Estimates• Incorrect Broselow Tape Use• Drug Calculation Errors - mg to mL conversion - Wrong mg/kg dose for route - Math difficult under stress• IV/IM/IN doses of same drug different depending on route
  • 34. Ambulance Personnel Perceptions of Near Misses and Adverse Events in Pediatric Patients Cushman October/December 2010, Volume 14 Number 4. 61 Events 12 Peds 8 2 2 Normal Injury Death
  • 35. Family Presence IT’S NOT THEM IT’S YOU
  • 36. Is Epinephrine 1:10,000 IV given to pediatric patientsduring out of hospital cardiac arrest?
  • 37. Epinephrine Pediatric Cardiac Arrest100.0 75.0 50.0 25.0 32% 28% 0% EPI EPI EPI 0 Region 1 Region 2 Region 3 n = 2500 n = 100 n = 200
  • 38. Customizing Resuscitation
  • 39. Pediatric Drowning Back Even Further The 911 Phone Call
  • 40. Early• CPR• Epinephrine
  • 41. If a 6 Year Old Can Do It KILOGRAMS
  • 42. Pediatric Drowning Allan’s Story
  • 43. Bondi Beach Rescue“Not So Good” CPR on Scene
  • 44. Pediatric Drowning Treatment This could be you!
  • 45. PALS UPDATE Infant CPR
  • 46. PALS UPDATE Child CPR
  • 47. Pediatric Drowning CPR• Lift chin Give 2 breaths• Check for a pulse• Chest compressions : 100 times per minute – 30:2 if one rescuer – 15:2 if 2 rescuers• Remember the BeeGees….or Queen
  • 48. CPR “to the beat”
  • 49. Pediatric Drowning Hypothermia
  • 50. Pediatric Drowning Hypothermia UpdateWhat is the latest research on hypothermia in pediatrics?
  • 51. Pediatric Drowning Oxygen It’s Good, Right?
  • 52. Pediatric Drowning ABC or CABA B C D O2 O2
  • 53. 5170 Peds Non-Cardiac Cardiac OK Cause of Cause of Arrest Arrest Hands Only 8.9% vs 9.9%71% Totals 29%
  • 54. 5170 Peds Conventional Hands Only CPR CPR7.2% Survival 1.6%
  • 55. Pediatric Drowning Take Home Points• Look at Every Step With a Microscope – 911 Call – CPR Early (Family and EMS) – Resuscitation ON SCENE (2 minutes then move) – Epinephrine ON SCENE (My 6 YO knows the dose!) – Customize Resuscitation – Limit Oxygen Toxicity – Airway Breathing Circulation (NOT CAB)• Waiting on Hypothermia Data
  • 56. Thank You! Peter Antevy MD 954-707-2692pantevy@mhs.net Handtevy.com
  • 57. Pediatric Submersion Peter Antevy MD Davie Fire Rescue, Medical Director American Ambulance, Medical Director Miramar Fire Rescue, Asst. Medical Director Broward College EMS, Medical Director JDCH, Pediatric Emergency Medicine