Dissecting the Medical Issues in Pediatric Drowning

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Dissecting the Medical Issues in Pediatric Drowning

  1. 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. 2. Pediatric Submersion Disclosure• Pediatric Emergency Standards, Inc. – Founder and CEO – Consulting – Pediatric Resuscitation System
  3. 3. Pediatric Submersion
  4. 4. Pool Danger 4
  5. 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. 6. A Day at the Beach
  7. 7. Pediatric Submersion Prevention Rescue Medical
  8. 8. A Similar StoryPregnancy Delivery Life
  9. 9. Pediatric Drowning Allan’s Story
  10. 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. 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. 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. 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. 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. 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. 16. Pediatric Drowning Allan’s Story
  17. 17. Pediatric Drowning Allan
  18. 18. “Pool’s Gold” • 3 year old male • Submerged in pool
  19. 19. Pediatric DrowningLet’s Start from the Beginning You are the Paramedic
  20. 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. 21. PALS UPDATE Epinephrine10 mL
  22. 22. PALS UPDATE Epinephrine • CPR • Epinephrine10 mL
  23. 23. Epi in Cardiac Arrest
  24. 24. Epi in Cardiac Arrest 11.3 6 1.3 0.6 Epi No Epi Epi No Epi
  25. 25. Pediatric Drowning Critical Minutes Early • CPR • Epinephrine10 mL
  26. 26. Pediatric Drowning Submersion Time
  27. 27. Pediatric Drowning CPR Duration
  28. 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. 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. 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. 31. Pediatric Drowning Back to the Scene Paramedic Arrival
  32. 32. Putting the Tape to the Test What Really Happens?
  33. 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. 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. 35. Family Presence IT’S NOT THEM IT’S YOU
  36. 36. Is Epinephrine 1:10,000 IV given to pediatric patientsduring out of hospital cardiac arrest?
  37. 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. 38. Customizing Resuscitation
  39. 39. Pediatric Drowning Back Even Further The 911 Phone Call
  40. 40. Early• CPR• Epinephrine
  41. 41. If a 6 Year Old Can Do It KILOGRAMS
  42. 42. Pediatric Drowning Allan’s Story
  43. 43. Bondi Beach Rescue“Not So Good” CPR on Scene
  44. 44. Pediatric Drowning Treatment This could be you!
  45. 45. PALS UPDATE Infant CPR
  46. 46. PALS UPDATE Child CPR
  47. 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. 48. CPR “to the beat”
  49. 49. Pediatric Drowning Hypothermia
  50. 50. Pediatric Drowning Hypothermia UpdateWhat is the latest research on hypothermia in pediatrics?
  51. 51. Pediatric Drowning Oxygen It’s Good, Right?
  52. 52. Pediatric Drowning ABC or CABA B C D O2 O2
  53. 53. 5170 Peds Non-Cardiac Cardiac OK Cause of Cause of Arrest Arrest Hands Only 8.9% vs 9.9%71% Totals 29%
  54. 54. 5170 Peds Conventional Hands Only CPR CPR7.2% Survival 1.6%
  55. 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. 56. Thank You! Peter Antevy MD 954-707-2692pantevy@mhs.net Handtevy.com
  57. 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

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