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Drowning - DAN Diver Medical Technician

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Drowning resuscitation lecture for Divers Alert Network Diver Medical Technician course. Philadelphia, Sep 23, 2013.

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Drowning - DAN Diver Medical Technician

  1. 1. Drowning Justin Sempsrott, MD Executive Director Lifeguards Without Borders Justin@LifeguardsWithoutBorders.org
  2. 2. 2 Disclosure • Air Travel Paid by DAN • Honorarium paid to LWB • Graphic images of fatal and non-fatal drowning patients
  3. 3. Who am I?
  4. 4. 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
  5. 5. History of drowning treatment
  6. 6. History of drowning treatment
  7. 7. History of drowning treatment
  8. 8. Dr. Frank Eve Popular Science July 1946
  9. 9. 9999
  10. 10. History of drowning treatment
  11. 11. Objectives • Understand definition of drowning • Appreciate epidemiology • Management • Disposition of drowning patients • Don’t blow smoke up pt’s (or colleagues) asses
  12. 12. Definition • Before 2002 – 33 Different Definitions
  13. 13. Definition • “The process of experiencing respiratory impairment from submersion/immersion in liquid” • Only 3 outcomes – – Death – No Morbidity – Morbidity Bangladesh, Lifeguards Without Borders, Aug2009
  14. 14. 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
  15. 15. 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*
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. • 16 y/o ♀ – HPI • Pulled from ocean • No LOC • + Submersion – PE A- Small foam at mouth/nose B-Active cough C- +Radial Pulse
  21. 21. • 15 y/o ♂ – HPI • Pulled from ocean • No LOC • + Submersion – PE A- Large foam at mouth/nose B-Active cough C- +Radial Pulse
  22. 22. Maldito!! • What next? – Sick or Not Sick – Transport or No Transport • First, a review of physiology Lima, 2012
  23. 23. Physiology of Drowning • Breath holding during struggle • Attempt to inhale water results in ?laryngospasm –Usually little (<30mL) or NO fluid in lungs –Reflex Swallowing
  24. 24. Physiology • Water may enter (1-3mL/kg) – Relaxation after unconsciousness © 2009 Nucleus Medical Art, Inc.
  25. 25. Mechanism • Surfactant wash-out • Direct cellular injury • Hypoxic Vasoconstriction • Bronchospasm • Inflammation
  26. 26. Physiology • Compliance • O2 Delivery to brain
  27. 27. Physiology • Cause of death or morbidity – Anoxic Brain Injury – Acidosis • Treatment  Oxygen to the Brain
  28. 28. Physiology Alive Dead Dose Response Curve Response Dose
  29. 29. 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
  30. 30. 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 – Hospital Do not resuscitate if down >1 hour
  31. 31. 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
  32. 32. Do we transport? • 16 y/o ♀ – HPI • Pulled from ocean • No LOC • + Submersion – PE A- Small foam at mouth/nose B-Active cough C- + Radial Pulse • 15 y/o ♂ – HPI • Pulled from ocean • No LOC • + Submersion – PE A- Large foam at mouth/nose B- Active cough C- +Radial Pulse
  33. 33. • 15 y/o ♂ – “Emergency Dept” “Treatmen – O2 N/C @ 2 LPM – 4 mg IM Dexamethasone – B12 – 10,000 μg IM – N-Acetylcysteine 20% IV – 30 mL (200mg/mL)
  34. 34. 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?
  35. 35. 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
  36. 36. 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
  37. 37. What about sending them home?
  38. 38. OK to send home after 4-6 hours • Asymptomatic – GCS ≥14 – Normal Respiratory Efforts – SpO2 ≥ 96% on room air  – No ACLS
  39. 39. Special considerations
  40. 40. In Water Resuscitation • 3X Increased Survival Special considerations
  41. 41. Special considerations
  42. 42. Special considerations • Immersion / Swimming Pulmonary Edema – Overhydration – Cold Water – Healthy • Treatment – Oxygen, Oxygen, Oxygen – ?Antibiotics
  43. 43. 4545 C-Spine • Less than 1% of Drowning patients, all with significant mechanism of injury – Routine C-Spine immobilization is unnecessary Special considerations
  44. 44. 4646 AED’s in Drowning • V-Fib/V-Tach? • Rescuer Safety • Do not delay Oxygenation / Ventilation • Minimize interruptions 5858 Special considerations
  45. 45. 4747 Heimlich Manuever • Increased risk of aspiration – Delays ventilation – Usually <30mL fluid in lungs – Watch for vomiting !!! Special considerations
  46. 46. 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
  47. 47. 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 Special considerations
  48. 48. 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
  49. 49. 5151 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
  50. 50. 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
  51. 51. Discussion Justin@LifeguardsWithoutBorders.org

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