drowning - dan diver medical technician
DESCRIPTION
Drowning resuscitation lecture for Divers Alert Network Diver Medical Technician course. Philadelphia, Sep 23, 2013.TRANSCRIPT
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22
Disclosure
•Air Travel Paid by DAN
•Honorarium paid to LWB
•Graphic images of fatal and non-fatal drowning patients
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Who am I?
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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
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History of drowning treatment
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History of drowning treatment
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History of drowning treatment
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Dr. Frank Eve
Popular Science July 1946
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9999
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History of drowning treatment
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Objectives
• Understand definition of drowning
• Appreciate epidemiology
• Management
• Disposition of drowning patients
• Don’t blow smoke up pt’s (or colleagues) asses
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Definition
•Before 2002– 33 Different Definitions
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Definition
•“The process of experiencing respiratory impairment from submersion/immersion in liquid”
•Only 3 outcomes – – Death– No Morbidity – Morbidity
Bangladesh, Lifeguards Without Borders, Aug2009
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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
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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*
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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
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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
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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
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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
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•16 y/o ♀– HPI
• Pulled from ocean
• No LOC
• + Submersion
– PEA- Small foam at
mouth/nose
B-Active cough
C- +Radial Pulse
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•15 y/o ♂– HPI
• Pulled from ocean
• No LOC
• + Submersion
– PEA- Large foam at
mouth/nose
B-Active cough
C- +Radial Pulse
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Maldito!!
•What next?– Sick or Not Sick– Transport or
No Transport
•First, a review of physiology
Lima, 2012
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Physiology of Drowning
• Breath holding during struggle
• Attempt to inhale water results in ?laryngospasm–Usually little (<30mL) or NO fluid in lungs
–Reflex Swallowing
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Physiology
•Water may enter (1-3mL/kg)– Relaxation after unconsciousness
© 2009 Nucleus Medical Art, Inc.
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Mechanism
•Surfactant wash-out
•Direct cellular injury
•Hypoxic Vasoconstriction
•Bronchospasm
• Inflammation
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Physiology
• Compliance
• O2 Delivery to brain
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Physiology
•Cause of death or morbidity – Anoxic Brain
Injury – Acidosis
•Treatment Oxygen to the
Brain
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Physiology
Alive
DeadDose Response Curve
Res
pons
e
Dose
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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
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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 – HospitalDo not resuscitate if down >1 hour
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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
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Do we transport?•16 y/o ♀
– HPI• Pulled from ocean• No LOC• + Submersion– PEA- Small foam at mouth/nose B-Active coughC- + Radial Pulse
•15 y/o ♂
– HPI• Pulled from ocean• No LOC• + Submersion– PEA- Large foam at mouth/noseB- Active coughC- +Radial Pulse
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• 15 y/o ♂– “Emergency Dept”
“Treatment”– O2 N/C @ 2 LPM
– 4 mg IM Dexamethasone– B12 – 10,000 μg IM– N-Acetylcysteine 20% IV– 30 mL (200mg/mL)
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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?
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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
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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
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What about sending them home?
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OK to send home after 4-6 hours
•Asymptomatic– GCS ≥14– Normal Respiratory Efforts
– SpO2 ≥ 96% on room air
– No ACLS
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Special considerations
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In Water Resuscitation
•3X Increased Survival
Special considerations
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Special considerations
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Special considerations
• Immersion / Swimming Pulmonary Edema– Overhydration– Cold Water– Healthy
•Treatment– Oxygen, Oxygen, Oxygen– ?Antibiotics
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4455
C-Spine
•Less than 1% of Drowning patients, all with significant mechanism of injury– Routine C-Spine
immobilization is unnecessary
Special considerations
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4466
AED’s in Drowning
•V-Fib/V-Tach?
•Rescuer Safety
•Do not delay Oxygenation / Ventilation
•Minimize interruptions
5858
Special considerations
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4477
Heimlich Manuever
• Increased risk of aspiration– Delays
ventilation– Usually <30mL
fluid in lungs– Watch for
vomiting !!!
Special considerations
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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
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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
•Area of active research
Special considerations
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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
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5511
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
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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
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