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Dissecting the Medical Issues in Pediatric Drowning
- 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
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- 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 atthe Beach
- 7. Pediatric Submersion Prevention Rescue Medical
- 8. A Similar Story Pregnancy 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
- 19. “Pool’s Gold” •3 year old male • Submerged in pool
- 20. Pediatric Drowning Let’s Startfrom the Beginning You are the Paramedic
- 21. Pediatric Drowning Timeline Child Child falls poolside EMS ED into 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?
- 22. PALS UPDATE Epinephrine 10 mL
- 23. PALS UPDATE Epinephrine • CPR • Epinephrine 10 mL
- 24. Epi in CardiacArrest
- 25. Epi in CardiacArrest 11.3 6 1.3 0.6 Epi No Epi Epi No Epi
- 26. Pediatric Drowning Critical Minutes Early • CPR • Epinephrine 10 mL
- 27. Pediatric Drowning Submersion Time
- 28. Pediatric Drowning CPR Duration
- 29. 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
- 30. 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 discharge Sirbaugh (Ann Emerg Med, 1999)
- 31. Pediatric Drowning Timeline Child Child falls poolside EMS ED into pool No Pulse Arrival Arrival 911 Call 0 5 min 13 min 22 min 9 Minutes
- 32. Pediatric Drowning Back to the Scene Paramedic Arrival
- 33. Putting the Tapeto the Test What Really Happens?
- 34. ACADEMIC EMERGENCY MEDICINE2012; 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
- 35. Ambulance Personnel Perceptionsof 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
- 36. Family Presence IT’SNOT THEM IT’S YOU
- 37. Is Epinephrine 1:10,000IV given to pediatric patients during out of hospital cardiac arrest?
- 38. Epinephrine Pediatric Cardiac Arrest 100.0 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
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- 41. Pediatric Drowning Back Even Further The 911 Phone Call
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- 43. If a 6Year Old Can Do It KILOGRAMS
- 44. Pediatric Drowning Allan’s Story
- 45. Bondi Beach Rescue “NotSo Good” CPR on Scene
- 46. Pediatric Drowning Treatment This could be you!
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- 49. 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
- 50. CPR “to thebeat”
- 52. Pediatric Drowning Hypothermia
- 53. Pediatric Drowning HypothermiaUpdate What is the latest research on hypothermia in pediatrics?
- 54. Pediatric Drowning Oxygen It’s Good, Right?
- 66. Pediatric Drowning ABC or CAB A B C D O2 O2
- 67. 5170 Peds Non-Cardiac Cardiac OK Cause of Cause of Arrest Arrest Hands Only 8.9% vs 9.9% 71% Totals 29%
- 68. 5170 Peds Conventional Hands Only CPR CPR 7.2% Survival 1.6%
- 69. 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
- 70. Thank You! PeterAntevy MD 954-707-2692 pantevy@mhs.net Handtevy.com
- 71. 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