Pre hospital military drowning treatment


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  • Utstein template style reporting
  • Explain location of these deaths.
  • The remaining 30% are trauma, hypothermia, CO poisoning, and other causes. Temporary Insanity II Impaled on Channel Marker Near Bay Bridge Marina on Kent Island: Just before 2 a.m., a 1992, 38-ft. Fountain power boat slammed into a fixed, channel marker, ripping a 17-ft. gash in the forward hull & becoming impaled on the steel piling holding the channel marker. A passenger suffered a broken arm & lacerations; a passing boater rescued the two men. DNR police cited the skipper, who "claimed to have been blinded by the lights of a sailboat", for negligence, traveling at an unsafe speed, & failure to maintain a proper lookout.
  • Jan 14 2011
  • 1831 cases
  • 1831 cases
  • 0.5% of 2244 submersion victims had c-spine injuries.
  • Pre hospital military drowning treatment

    1. 1. Drowning Justin Sempsrott, MD University of Nevada Emergency Medicine Residency [email_address]
    2. 2. Who am I?
    3. 3. History of drowning treatment The “Great of Aleppo” held upside down after drowning. 1237 B.C.E From the Pylon of the Ramesseum, Thebes. Photographed by Mr. W. M. F. Petrie
    4. 4. History of drowning treatment
    5. 5. History of drowning treatment
    6. 6. Dr. Frank Eve Popular Science July 1946
    7. 7. History of drowning treatment
    8. 8. Objectives <ul><li>Understand definition of drowning </li></ul><ul><li>Appreciate epidemiology </li></ul><ul><li>Management </li></ul><ul><li>Disposition of drowning patients </li></ul><ul><li>Don’t blow smoke up pt’s (or colleagues) asses </li></ul>
    9. 9. Definition <ul><li>Before 2002 </li></ul><ul><ul><li>33 Different Definitions </li></ul></ul>
    10. 10. Definition <ul><li>“ The process of experiencing respiratory impairment from submersion/immersion in liquid” </li></ul><ul><li>Only 3 outcomes – </li></ul><ul><ul><li>Death </li></ul></ul><ul><ul><li>No Morbidity </li></ul></ul><ul><ul><li>Morbidity </li></ul></ul>
    11. 11. Definition <ul><li>Old terms that should NOT be used </li></ul><ul><ul><li>Dry </li></ul></ul><ul><ul><li>Wet </li></ul></ul><ul><ul><li>Active </li></ul></ul><ul><ul><li>Passive </li></ul></ul><ul><ul><li>Secondary </li></ul></ul><ul><ul><li>Near  Especially </li></ul></ul><ul><li>No difference between salt, chlorine, and freshwater </li></ul>Lima, Peru, 2009
    12. 12. Who is Drowning? <ul><li>WHO Global Burden of Disease </li></ul><ul><ul><li>388,000 Drowning Deaths* </li></ul></ul><ul><ul><ul><li>97% in low to middle income countries </li></ul></ul></ul><ul><ul><ul><li>+1.55 million unreported drowning deaths </li></ul></ul></ul><ul><ul><ul><li>+6.08 million drowning “incidents” </li></ul></ul></ul><ul><ul><li>* 7.63 million Drowning persons </li></ul></ul>
    13. 13. Who is Drowning? <ul><li>2 nd leading cause of unintentional injury death (1 st is MVC’s) </li></ul><ul><li>~10 Deaths/Day in US </li></ul><ul><ul><li>10-20 Drown with morbidity </li></ul></ul><ul><ul><li>20-30 Drown w/o morbidity </li></ul></ul><ul><li>Male:Female 4:1 </li></ul>
    14. 14. Who is drowning? <ul><li>Disease of youth </li></ul><ul><ul><li>64% of deaths are<30 yrs </li></ul></ul><ul><ul><li>¼ of deaths are < 5 yrs </li></ul></ul><ul><li>Alaska , Arizona , California , Florida, Hawaii , Montana , Nevada , Oregon , Utah, & Washington </li></ul><ul><ul><ul><li>Drowning surpasses all other causes of death to children age 0-14 </li></ul></ul></ul><ul><ul><ul><li>Nationally, In 2007, of all children 1-4 years old who died, 30% died from drowning </li></ul></ul></ul>
    15. 15. Who is Drowning? <ul><li>Excludes Floods/Boating/Natural Disasters </li></ul><ul><ul><li>2006 USCG Responded to 4,967 incidents </li></ul></ul><ul><ul><ul><li>3,474 injuries </li></ul></ul></ul><ul><ul><ul><li>710 deaths </li></ul></ul></ul><ul><ul><ul><ul><li>70% Drowning </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>90% without lifejackets </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>50% (+) EtOH </li></ul></ul></ul></ul></ul>
    16. 17. Who is Drowning? <ul><li>Hurricane Katrina </li></ul><ul><li>4/6 Rio Flood </li></ul><ul><ul><li>200+ dead </li></ul></ul><ul><li>8/1 Pakistan Flood </li></ul><ul><ul><li>1100+ dead </li></ul></ul><ul><li>Indonesia Tsunami </li></ul><ul><ul><li>169,752 dead </li></ul></ul><ul><ul><li>127,294 missing </li></ul></ul> CDC MMWR March 10, 2006 / 55(09);239-242
    17. 18. So what?
    18. 19. “ His boots were weighing him down, and his uniform dragged and resisted the water as he tried to swim. He had trouble staying afloat and started making his way back to shore but couldn’t. He succumbed to the river.”
    19. 22. Pvt. Cody Hendrickson
    20. 25. Chief Special Warfare Operator (SEAL) Eric Shellenberger
    21. 28. <ul><li>16 y/o ♀ </li></ul><ul><ul><li>HPI </li></ul></ul><ul><ul><ul><li>Pulled from ocean </li></ul></ul></ul><ul><ul><ul><li>No LOC </li></ul></ul></ul><ul><ul><ul><li>+ Submersion </li></ul></ul></ul><ul><ul><li>PE </li></ul></ul><ul><ul><ul><li>A- Small foam at </li></ul></ul></ul><ul><ul><ul><li>mouth/nose </li></ul></ul></ul><ul><ul><ul><li>-Active cough </li></ul></ul></ul><ul><ul><ul><li>B- Tachypneic </li></ul></ul></ul><ul><ul><ul><li>C- Cool extremities </li></ul></ul></ul><ul><ul><ul><li>D- Combative </li></ul></ul></ul><ul><ul><ul><li>Confused </li></ul></ul></ul><ul><ul><ul><li>AYUDAME !!!!!! </li></ul></ul></ul>
    22. 29. <ul><li>15 y/o ♂ </li></ul><ul><ul><li>HPI </li></ul></ul><ul><ul><ul><li>Pulled from ocean </li></ul></ul></ul><ul><ul><ul><li>No LOC </li></ul></ul></ul><ul><ul><ul><li>+ Submersion </li></ul></ul></ul><ul><ul><li>PE </li></ul></ul><ul><ul><ul><li>A- Large foam at </li></ul></ul></ul><ul><ul><ul><li>mouth/nose </li></ul></ul></ul><ul><ul><ul><li>- Active cough </li></ul></ul></ul><ul><ul><ul><li>B- Tachypneic </li></ul></ul></ul><ul><ul><ul><li>C- Cool extremities </li></ul></ul></ul><ul><ul><ul><li>D- Confused, somnolent, </li></ul></ul></ul><ul><ul><ul><li>GCS – E2 V4 M5 </li></ul></ul></ul>
    23. 30. Maldito!! <ul><li>What next? </li></ul><ul><ul><li>Sick or Not Sick </li></ul></ul><ul><ul><li>Transport or </li></ul></ul><ul><ul><li>No Transport </li></ul></ul><ul><li>First, a review of physiology </li></ul>
    24. 31. Physiology of Drowning <ul><li>Breath holding during struggle </li></ul><ul><li>Attempt to inhale water results in laryngospasm </li></ul><ul><ul><li>Usually little (30mL) or NO fluid in lungs </li></ul></ul>
    25. 32. Physiology <ul><li>Water may enter (1-3mL/kg) </li></ul><ul><ul><li>Before laryngospam </li></ul></ul><ul><ul><li>Relaxation after unconsciousness </li></ul></ul>© 2009 Nucleus Medical Art, Inc.
    26. 33. Mechanism <ul><li>Surfactant wash-out </li></ul><ul><li>Direct cellular injury </li></ul><ul><li>Hypoxic Vasoconstriction </li></ul><ul><li>Bronchospasm </li></ul><ul><li>Inflammation </li></ul>
    27. 34. Physiology <ul><li>V/Q Mismatch </li></ul><ul><li>Compliance </li></ul><ul><li>O2 Delivery </li></ul><ul><li>to brain </li></ul>
    28. 35. Physiology <ul><li>Cause of death or morbidity </li></ul><ul><ul><li>Anoxic Brain Injury </li></ul></ul><ul><ul><li>Acidosis </li></ul></ul><ul><li>Treatment  </li></ul><ul><li>Oxygen to the Brain </li></ul>
    29. 36. Physiology <ul><li>&quot;A lack of oxygen does not simply involve stoppage of the engine, but total ruin of what we took to be the machinery. &quot;   </li></ul><ul><li>-JS. Haldane  </li></ul>“ The drum generally heals up; and if a hole remains in it, although one is somewhat deaf, one can blow tobacco smoke out of the ear in question, which is a social accomplishment.&quot;
    30. 37. When to Transport? <ul><li>41,729 oceanfront lifeguard rescues in </li></ul><ul><li>Rio de Janeiro from 1972 – 1991 </li></ul><ul><ul><li>93% Released at scene without further treatment </li></ul></ul><ul><ul><li>2,304 required additional medical care </li></ul></ul><ul><ul><ul><li>89% lived </li></ul></ul></ul><ul><ul><ul><li>11% died </li></ul></ul></ul>
    31. 38. 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 O 2 - Hospital 3 Large amt foam, normal BP (+radial pulse) 5.2% ETT/NRB O 2 - Hospital 4 Large amt foam, LOW BP (-radial pulse) 19.4% ETT/NRB O 2 , IV Fluids - Hospital 5 Respiratory Arrest 44% ETT/NRB O 2 , IV Fluids - Hospital 6 Cardiopulmonary Arrest 93% ETT/NRB O 2 , IV Fluids, AED – Hospital Do not resuscitate if down >1 hour
    32. 39. 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 O 2 – Hospital 3 Large amt foam, normal BP (+radial pulse) 5.2% ETT/NRB O 2 - Hospital
    33. 40. Do we transport? <ul><li>16 y/o ♀ </li></ul><ul><ul><li>HPI </li></ul></ul><ul><ul><ul><li>Pulled from ocean </li></ul></ul></ul><ul><ul><ul><li>No LOC </li></ul></ul></ul><ul><ul><ul><li>+ Submersion </li></ul></ul></ul><ul><ul><li>PE </li></ul></ul><ul><ul><ul><li>A- Small foam at </li></ul></ul></ul><ul><ul><ul><li>mouth/nose </li></ul></ul></ul><ul><ul><ul><li>-Active cough </li></ul></ul></ul><ul><ul><ul><li>B- Tachypneic </li></ul></ul></ul><ul><ul><ul><li>C- Cool extremities </li></ul></ul></ul><ul><ul><ul><li>D- Combative </li></ul></ul></ul><ul><ul><ul><li>Confused </li></ul></ul></ul><ul><li>15 y/o ♂ </li></ul><ul><ul><li>HPI </li></ul></ul><ul><ul><ul><li>Pulled from ocean </li></ul></ul></ul><ul><ul><ul><li>No LOC </li></ul></ul></ul><ul><ul><ul><li>+ Submersion </li></ul></ul></ul><ul><ul><li>PE </li></ul></ul><ul><ul><ul><li>A- Large foam at </li></ul></ul></ul><ul><ul><ul><li>mouth/nose </li></ul></ul></ul><ul><ul><ul><li>- Active cough </li></ul></ul></ul><ul><ul><ul><li>B- Tachypneic </li></ul></ul></ul><ul><ul><ul><li>C- Clammy extremities </li></ul></ul></ul><ul><ul><ul><li>D- Confused, somnolent, </li></ul></ul></ul><ul><ul><ul><li>GCS – E2 V4 M5 </li></ul></ul></ul>Grade Signs/Symptoms (s/sx) Mortality Treatment 2 Small amt foam in mouth or nose, +Rales 0.6% N/C O 2 – Hospital 3 Large amt foam, normal BP (+radial pulse) 5.2% ETT/NRB O 2 - Hospital
    34. 45. <ul><li>15 y/o ♂ </li></ul><ul><ul><li>“ Emergency Dept” “Treatment” </li></ul></ul><ul><ul><ul><li>O 2 N/C @ 2 LPM </li></ul></ul></ul><ul><ul><ul><li>1 mg IM Dexamethasone </li></ul></ul></ul><ul><ul><ul><li>B12 – 10,000 μ g IM </li></ul></ul></ul><ul><ul><ul><li>N-Acetylcysteine 20% IV </li></ul></ul></ul><ul><ul><ul><ul><li>30 mL (200mg/mL) </li></ul></ul></ul></ul>
    35. 47. Thomas Eakins' The Gross Clinic, (1875) “ A rude unhinging of the machinery of life”
    36. 48. You assume care of 16 y/o <ul><li>A- Patent, copius secretions </li></ul><ul><li>B- Tachypneic, RR 36, perioral cyanosis </li></ul><ul><li>C- Cool extremities – ST 130 bpm, thready </li></ul><ul><li>Critical Actions? </li></ul>
    37. 49. Airway <ul><li>Sedate and intubate </li></ul><ul><ul><li>Pediatric </li></ul></ul><ul><ul><li>Laryngospasm </li></ul></ul><ul><ul><ul><li>RSI, PPV, Jaw thrust </li></ul></ul></ul><ul><ul><ul><li>Cricothyrotomy, Lidocaine </li></ul></ul></ul><ul><ul><li>Airway obstruction? </li></ul></ul><ul><ul><ul><li>Sand, Mud, Del Taco </li></ul></ul></ul><ul><ul><li>Dec Compliance </li></ul></ul><ul><ul><li>Vomitus </li></ul></ul><ul><ul><ul><li>86% of Drowning resuscitations </li></ul></ul></ul>
    38. 50. Hypoxic Arrest <ul><li>Cardiac BLS/ACLS </li></ul><ul><ul><li>Heart stops, oxygen in blood needs circulating </li></ul></ul><ul><ul><li>C,A,B </li></ul></ul><ul><li>Drowning & Ped Arrest BLS/ACLS </li></ul><ul><ul><li>Heart stops because no oxygen in blood </li></ul></ul><ul><ul><li>A,B,C </li></ul></ul>
    39. 51. Survival <ul><li>Bottom Line </li></ul><ul><ul><li>Pt’s who make it to hospital alert, seldom die </li></ul></ul><ul><ul><li>Pt’s comatose on arrival are difficult to predict </li></ul></ul><ul><ul><li>Current guidelines </li></ul></ul><ul><ul><ul><li>Continue resuscitation for 25 total minutes of CPR </li></ul></ul></ul><ul><ul><ul><li>Continue if <1 hr submersion time </li></ul></ul></ul><ul><ul><ul><li>Continue to core temp 90°F </li></ul></ul></ul><ul><ul><ul><li>In Hospital - continue ICU care for 48 hours </li></ul></ul></ul>
    40. 52. Pre-Hospital Prognosis? <ul><ul><li>“ Resuscitation attempts should always be continued in the pre-hospital setting because of the difficulty of predicting outcome with sufficient accuracy at the scene” </li></ul></ul>Bangladesh, Lifeguards Without Borders, Aug2009
    41. 53. What about sending them home?
    42. 54. OK to send home after 4-6 hours <ul><li>Asymptomatic </li></ul><ul><ul><li>GCS >13 </li></ul></ul><ul><ul><li>Respiratory Efforts </li></ul></ul><ul><ul><li>SpO 2 > 95% on room air  </li></ul></ul><ul><ul><li>No ACLS PTA </li></ul></ul>
    43. 55. Special considerations
    44. 56. Hypothermia <ul><li>Hypothermia? </li></ul><ul><ul><li>Is it protective? Harmful? What about post-resus? </li></ul></ul><ul><ul><ul><li>Water at 91.4°F is thermally neutral </li></ul></ul></ul><ul><ul><ul><li>Conductivity is 25-30 x air </li></ul></ul></ul><ul><ul><li>Case Reports? </li></ul></ul><ul><ul><ul><li>21 y/o ♀ , 45 min 4°C </li></ul></ul></ul><ul><ul><ul><li>5 y/o ♂, 40 min 0°C </li></ul></ul></ul><ul><ul><ul><li>3 y/o ♀, 30 min 8°C </li></ul></ul></ul><ul><ul><ul><li>2.5 y/o ♀, 66 min (19°C) </li></ul></ul></ul>Special considerations
    45. 57. Hypothermia <ul><li>Hypothermia? </li></ul><ul><ul><li>Mammalian Diving Reflex </li></ul></ul><ul><ul><ul><li>15%-30% of Humans </li></ul></ul></ul><ul><ul><li>Cold and Dead? </li></ul></ul><ul><ul><ul><li>Rewarm </li></ul></ul></ul><ul><ul><li>What about post-resus? </li></ul></ul><ul><ul><ul><li>Therapeutic Hypothermia has been shown to decrease cerebral oxygen demand and improve neurologic outcomes </li></ul></ul></ul><ul><ul><ul><li>Area of active research </li></ul></ul></ul>Special considerations
    46. 58. Therapeutic Hypothermia <ul><li>Bottom line </li></ul><ul><ul><li>Warm pt to 90°F </li></ul></ul><ul><ul><ul><li>If dead, their dead </li></ul></ul></ul><ul><ul><ul><li>If not dead, stay there * </li></ul></ul></ul><ul><ul><ul><li>*Only if hospital protocols are in place </li></ul></ul></ul>Special considerations
    47. 59. C-Spine <ul><li>Less than 1% of Drowning patients, all with significant mechanism of injury </li></ul><ul><ul><li>Routine C-Spine immobilization is unnecessary </li></ul></ul>Special considerations
    48. 60. AED’s in Drowning <ul><li>V-Fib/V-Tach? </li></ul><ul><li>Rescuer Safety </li></ul><ul><li>Do not delay chest compressions </li></ul><ul><li>Minimize interruptions </li></ul>Special considerations
    49. 61. Heimlich Manuever <ul><li>Increased risk of aspiration </li></ul><ul><ul><li>Delays ventilation </li></ul></ul><ul><ul><li>Usually <30mL fluid in lungs </li></ul></ul><ul><ul><li>Watch for vomiting !!! </li></ul></ul>Special considerations
    50. 62. “ Do it by the book… but be the author.” Manual techniques of artificial respiration. Copyright 1950 American Medical Association.
    51. 63. “ Death is not the enemy but occasionally needs help with timing. ” Dr. Peter Safar (12 April 1924 – 2 August 2003)
    52. 64. Summary <ul><li>Understand definition of drowning </li></ul><ul><ul><li>Process, not an outcome </li></ul></ul><ul><li>Appreciate epidemiology </li></ul><ul><ul><li>Highly prevalent worldwide, children <4 </li></ul></ul><ul><li>Management </li></ul><ul><ul><li>O 2 O 2 O 2, Laryngospasm, Vomitus, warm pt to 90°F </li></ul></ul><ul><ul><li>Hypoxic vs Cardiac cause of arrest </li></ul></ul><ul><li>Disposition of drowning patients </li></ul><ul><ul><li>Home or ICU </li></ul></ul><ul><li>Don’t blow smoke up pt’s (or colleagues) asses </li></ul><ul><ul><li>Bring your “A” game, be able to back it up </li></ul></ul>
    53. 65. Discussion [email_address]
    54. 66. <ul><li>Part 12: Pediatric Advanced Life Support. Circulation. December 13, 2005 2005;112(24_suppl):IV-167-187. </li></ul><ul><li>Part 10.3: Drowning. Circulation. December 13, 2005 2005;112(24_suppl):IV-133-135. </li></ul><ul><li>Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. Apr 27 2004;109(16):1960-1965. </li></ul><ul><li>Bernius M, Thibodeau B, Jones A, et al. Prevention of Pediatric Drug Calculation Errors by Prehospital Care Providers. Prehospital Emergency Care. 2008;12(4):486 - 494. </li></ul><ul><li>Bierens JJ, Knape JT, Gelissen HP. Drowning. Curr Opin Crit Care. Dec 2002;8(6):578-586. </li></ul><ul><li>Bierens JJLM, Maatschappij tot Redding van Drenkelingen. Handbook on drowning : prevention, rescue treatment . Berlin ; New York: Springer; 2006. </li></ul><ul><li>Chochinov AH, Baydock BM, Bristow GK, et al. Recovery of a 62-year-old man from prolonged cold water submersion. Ann Emerg Med. Jan 1998;31(1):127-131. </li></ul><ul><li>Christensen DW, Jansen P, Perkin RM. Outcome and acute care hospital costs after warm water near drowning in children. Pediatrics. May 1997;99(5):715-721. </li></ul><ul><li>Ducharme MB, Lounsbury DS. Self-rescue swimming in cold water: the latest advice. Appl Physiol Nutr Metab. Aug 2007;32(4):799-807. </li></ul><ul><li>Giesbrecht GG, Pretorius T. Survey of public knowledge and responses to educational slogans regarding cold-wate immersion. Wilderness Environ Med. Winter 2008;19(4):261-266. </li></ul><ul><li>Hudson D, Ekman R, Svanstrom L. Survival of immersions during recreational boating events in Alaska, 1999-2004. Accid Anal Prev. May 2007;39(3):437-443. </li></ul><ul><li>Idris AH, Berg RA, Bierens J, et al. Recommended guidelines for uniform reporting of data from drowning: the &quot;Utstein style&quot;. Circulation. 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Quality of cause-of-death reporting using ICD-10 drowning codes: a descriptive study of 69 countries. BMC Med Res Methodol. 2010;10(1):30. </li></ul><ul><li>World Health Organization: Global Burden of Disease 2004 Update.   Available at:   Accessed Sepr 14, 2010. </li></ul><ul><li>Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2009) [cited 2009 Nov 24]. Available from: URL: </li></ul><ul><li>CDC MMWR March 10, 2006 / 55(09);239-242 </li></ul><ul><li>Modell JH, Graves SA, Ketover A. Clinical course of 91 consecutive near-drowning victims. Chest 1976; 70(2):231-238. </li></ul><ul><li>Martin TG: Near-drowning and cold water immersion, Ann Emerg Med 1984; 13:263 </li></ul><ul><li>Giammono ST, Modell JH. Drowning by total immersion. Effects on Pulmonary surfactant of distilled water, isotonic saline, and sea water. 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St. Louis, Mosby, 1986 </li></ul><ul><li>Orlowski JP: Drowning, near-drowning and ice-water submersions. Pediatr Clin North Am 1987;34:75 </li></ul><ul><li>Pearn J: Why children drown. Aust J Paediatr 1986;22:161 </li></ul><ul><li>Modell JH, Davis JH. Electrolyte changes in human drowning victims. Anesthesiology 1969;30:414-420. </li></ul>
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