DROWNING CLASSIFICATION SYSTEM FOR RESCUERS International Lifesaving Federation Medical Committee...

DROWNING CLASSIFICATION SYSTEM FOR RESCUERS

DROWNING CLASSIFICATION SYSTEM FOR RESCUERS

International Lifesaving Federation

Medical Committee

International Lifesaving Federation

Medical CommitteePrimary author: Dr David Szpilman (Brazil) Member<[email protected]>

Approved: Dr. Steve Beerman (Canada), Chair Dr. Peter Wernicki (USA), Vice ChairDr. Tony Handley (UK), SecretaryDr. Joost Bierens (Netherlands), MemberDr. John Pearn (Australia), MemberDr. Lorenzo Marugo (Italy), Associate MembersDr. Zaid Chelvaraj Abdullah (Malaysia), Associate Members

Primary author: Dr David Szpilman (Brazil) Member<[email protected]>

Approved: Dr. Steve Beerman (Canada), Chair Dr. Peter Wernicki (USA), Vice ChairDr. Tony Handley (UK), SecretaryDr. Joost Bierens (Netherlands), MemberDr. John Pearn (Australia), MemberDr. Lorenzo Marugo (Italy), Associate MembersDr. Zaid Chelvaraj Abdullah (Malaysia), Associate Members

26, Gemeenteplein, Leuven 3010

Belgium Tel:32-16-35-35-00

Fax: 32-16-35-01-02,

Email: [email protected]

26, Gemeenteplein, Leuven 3010

Belgium Tel:32-16-35-35-00

Fax: 32-16-35-01-02,

Email: [email protected]

ESTABLISHED FOR ALL LIFEGUARDS:ESTABLISHED FOR ALL LIFEGUARDS:

These cases compose 0.5% of all cases

rescued by lifeguards at the beach

These cases compose 0.5% of all cases

rescued by lifeguards at the beach

Respiratory arrest = Start artificial ventilation immediately.Respiratory arrest = Start artificial ventilation immediately.

Cardiopulmonary arrest = Start CPR immediately.Cardiopulmonary arrest = Start CPR immediately.

Basic Life Support (BLS) - Drowning - Szpilman 2004

What about 99.5% of all cases rescued atthe beach, what should be done?

What about 99.5% of all cases rescued atthe beach, what should be done?

How are we to know which cases need an EMT or an MD? How are we to know which cases need an EMT or an MD?

?Should we give oxygen in all cases? , if so, how much?Should we give oxygen in all cases? , if so, how much?

Should we call an ambulance?Should we call an ambulance?

Should we transport all of them to a hospital?Should we transport all of them to a hospital?

Should we release or keep them a while in observation? Should we release or keep them a while in observation?

How are we to know the prioritization on a busy day?, andHow are we to know the prioritization on a busy day?, and


Do you need to know how to act

appropriately and confidently

in those cases?

Do you need to know how to act

appropriately and confidently

in those cases?

On a busy day, as a lifeguard, would you get

medical support as quickly as you needed?

On a busy day, as a lifeguard, would you get

medical support as quickly as you needed?

oror


That´s why rescuers need a

DROWNING CLASSIFICATION SYSTEM

That´s why rescuers need a


It allows Lifeguards and MD teams to speak the same languageIt allows Lifeguards and MD teams to speak the same language

It gives the exact severity of the caseIt gives the exact severity of the case

It gives exactly what approach should be taken It gives exactly what approach should be taken

It advises when to call an ambulanceIt advises when to call an ambulance

It advises when to call an EMT or a MDIt advises when to call an EMT or a MD

It reassures lifeguard’s in front of the population, andIt reassures lifeguard’s in front of the population, and



How it was created and applied


How it was created and applied

It was recently (2001) validated by a 10 year study with 46,060 rescues, of which 930 (2%) were drownings attended at the DrowningResuscitation center (DRC)

It was recently (2001) validated by a 10 year study with 46,060 rescues, of which 930 (2%) were drownings attended at the DrowningResuscitation center (DRC)

It was updated in 1997 to a new medical perspectiveIt was updated in 1997 to a new medical perspective

It was based on the evaluation of 41,279 rescuesIt was based on the evaluation of 41,279 rescues

The final group evaluated came from 1,831 medical reportsThe final group evaluated came from 1,831 medical reports

It was based on beach and hospital attendanceIt was based on beach and hospital attendance

Only clinical parameters were considered to facilitate the useOnly clinical parameters were considered to facilitate the use

It was adapted to be understood by lifeguardsIt was adapted to be understood by lifeguards

It’s been used since 1973 by more than 3,000 lifeguards in Rio de JaneiroIt’s been used since 1973 by more than 3,000 lifeguards in Rio de Janeiro

It was created in 1972 by MD and lifeguards working togetherIt was created in 1972 by MD and lifeguards working together

LifeguardRescue Begins

Victim in DangerVictim in DangerVictim in DangerVictim in Danger

------Resquest

ACLS help

PWCPWCPWCPWC

LifeguardBeach support

HelicopterHelicopterHelicopterHelicopter

Boat Boat Boat Boat

Szpilman 2000

The lifeguard system The lifeguard system

ACLS


Call for Call for Back upBack up

Yes

Check COUGH and FOAM

in mouth & nose

SMALL

AMOUNT

OF FOAM

Yes

Give 2 mouth-to-mouth ventilations and check signs

of circulation

Signs of Circulation ?

Check victim’s response - Can you hear me?

Absent

Open airways - look, listen, and feel respiration

COUGH WITHOUT

FOAM

No Yes

No

RADIAL PULSE ?

No

BREATHINGPRESENT?

CSI ?

GREAT AMOUNT

OF FOAM

yesNo

Drowning Classification - BLSBased on evaluation of 1,831 cases - CHEST - September 1997

On shoreline or Pool Deck

Call for Help

Basic Life Support (BLS) - Drowning - Szpilman 2004 Click on numbers to see treatment

NO COUGH or FOAM IN MOUTH or NOSEMortality - 0%

NO COUGH or FOAM IN MOUTH or NOSEMortality - 0%


Evaluate and release from the accident site without

further medical care

Evaluate and release from the accident site without

further medical care


COUGH , WITHOUT FOAM in MOUTH or NOSE

MORTALITY - 0%

COUGH , WITHOUT FOAM in MOUTH or NOSE

MORTALITY - 0%


1. Warm and calm the victim. 2. Advanced medical attention or oxygen not usually required

1. Warm and calm the victim. 2. Advanced medical attention or oxygen not usually required


1. Oxygen - 5 liter / min by nasal cannula. 2. Warm and calm the victim. 3. Hospital observation from 6 to 48 hours.

1. Oxygen - 5 liter / min by nasal cannula. 2. Warm and calm the victim. 3. Hospital observation from 6 to 48 hours.


SMALL AMOUNT of FOAM in MOUTH or NOSE

MORTALITY - 0.6%

SMALL AMOUNT of FOAM in MOUTH or NOSE

MORTALITY - 0.6%



LARGE AMOUNT of FOAM in MOUTH & NOSERADIAL PULSE PALPABLE (normal blood pressure)

MORTALITY - 5.2%

LARGE AMOUNT of FOAM in MOUTH & NOSERADIAL PULSE PALPABLE (normal blood pressure)

MORTALITY - 5.2%

1. 15 liters / min of oxygen by face mask at the accident site.2. Right side recovery position.3. ACLS and hospitalization in ICU required.

1. 15 liters / min of oxygen by face mask at the accident site.2. Right side recovery position.3. ACLS and hospitalization in ICU required.


1. 15 liters/min of oxygen by face mask.

2. Monitor breathing with care (may stop breathing).

3. Right side recovery position.

4. ACLS immediate with mechanical ventilation and I.V fluids.

5. Urgent hospitalization in ICU required

1. 15 liters/min of oxygen by face mask.

2. Monitor breathing with care (may stop breathing).

3. Right side recovery position.

4. ACLS immediate with mechanical ventilation and I.V fluids.

5. Urgent hospitalization in ICU required


LARGE AMOUT of FOAM in MOUTH & NOSE

NO RADIAL PULSE (low blood pressure)

MORTALITY – 19.4%

LARGE AMOUT of FOAM in MOUTH & NOSE

NO RADIAL PULSE (low blood pressure)

MORTALITY – 19.4%


1. Start artificial ventilation immediately and keep it at a rate

of 12 to 20 per min. Check signs of circulation regularly.

2. If possible use 15 liters/min of oxygen

3. After restoring ventilation, follow guideline for grade 4


ISOLATED RESPIRATORY ARREST

MORTALITY - 44%

ISOLATED RESPIRATORY ARREST

MORTALITY - 44%


1. Start and continue CPR.

2. Use External Automatic Defibrilator if possible.3. No one is considered dead if hypothermic4. Do not resuscitate if submersion time over 1 hour or obvious physical evidence of death. 5. After successful CPR, victim should be followed as closely as possible and treat as grade 4.


CARDIOPULMONARY ARREST

MORTALITY - 93%

CARDIOPULMONARY ARREST

MORTALITY - 93%


Basic Life Support - DROWNING CLASSIFICATION and TREATMENT Based on evaluation of 1,831 cases - CHEST - Sep 1997

Grade 4 (19.4%)Grade 3 (5.2%)

Reaction to ventilation or any movement?

Yes

No

Grade 6 (93%)

Grade 5 (44%)

Yes

Check for cough and/or foam in mouth/nose

Grade 1(0.0%)

SMALL AMOUNTOF FOAM

IN MOUTH/NOSE

Grade 2 (0.6%)

LARGE AMOUTOF FOAM

IN MOUTH/NOSE

RADIAL PULSE PALPABLE ?Yes

COUGH , WITHOUT FOAM IN

MOUTH/NOSE

No

Algorithm BLS: Near each grade the general mortality (%) is shown. Heimlich maneuver is only indicated with strong suspicion of foreign body obstruction; There is no difference in basic life support between different types of water drowning. (*)If the victim is grade 5, ventilation in-water can reduce mortality by almost 50%. CPA (Cardiopulmonary Arrest). References with the author <[email protected]> <www.szpilman.com>

Give 2 mouth to mouth breaths and check for signs of circulation

Start complete CPR with 15 external chest compressions and

alternate with 2 breaths until normal cardiopulmonary function is restored, ambulance arrives or

lifeguard exhaustion. After successful CPR, the victim should be followed as close as possible because

another CPA may occur.

Continue mouth to mouth at 12 to

20 p/min until restore normal

breath

Check the victim responseNo Yes

BREATH PRESENT?Absent

Rescue (0.0%)

Evaluate and release from the accident site without further

medical care

1. Warm and calm the victim. 2. Advanced

medical attention or oxygen not

normally required

1. Oxygen - 5 L/min by nasal

cannula. 2. Warm and calm the

victim. 3. Hospital observation from 6

to 48 hours.

No

1.15 liters/min of oxygen by face

mask at the accident site. 2.

Right side recovery position. 3. ACLS and hospitalization

in ICU required.

1. 15 liters/min of oxygen by face mask. 2. Monitor breathing with care (may still stop breathing). 3. Right side recovery position. 4. ACLS immediately with

mechanical ventilation and I.V fluids. 5.

Hospitalization in ICU required

After restoring spontaneous

breathing and pulse, treat as grade 4

Warning: if any suspicion of cervical

spine injury(0,5%), be careful while open

airways - use special techniques to do so.

Hospitalization

Check for breathing - Open airways - look, listen and feel for respiration

Check the victim in-waterConscious victim: bring back to shore/pool deck.; Unconscious victim - Shallow water: open victim’s airway, evaluate breathing, and begin mouth to mouth if necessary. Deep water: place the victim face up and open airway.

If no spontaneous breathing, start mouth-to-mouth ventilation immediately at a rate of 12 to 20/min until reaching shore/swimming pool deck*. Mouth-to-mouth is possible in the water with 2 lifeguards or 1 lifeguard with lifesaving equipment. Do not check victim’s pulse while in the water. If no signs of circulation, don’t start chest compressions in-water, urgently bring the victim back to shore without further procedures.

On shore/pool deck - victim’s trunk and head should be at same level, even in sloping sitesDo not spend time trying to drain water from the lungs. Victim position of head lower than trunk will increase the occurrence of vomit or regurgitation. On sloping beaches all the victims should be put initially parallel to the waterline, in

dorsal position. Lifeguard with his back to the sea with the victim’s head turned to lifeguard´s left side. This facilitates the rescuers CPR maneuvers so that he does not fall over the victim and makes placing the victim in right lateral decubitus easier.

Victim transport to shore/pool deck should be with head up (except for hypothermic victim)

Submersion time over 1 hour or obvious physical evidence of death (rigor mortis,

putrefaction or dependent lividity).

NoYes

DeadDo not

resuscitateMORGUE

Szpilman 2001 - Published in:Circulation 2000, 102 (suppl I):I-233-36 &

Pediatric Clinics of North America, June 2001

ONE TEAM, ONE GOALONE TEAM, ONE GOAL

LIFEGUARDS and MEDICAL STAFFLIFEGUARDS and MEDICAL STAFF

ONE WORLD

, ONE DROWNING L

ANGUAGE

ONE WORLD

, ONE DROWNING L

ANGUAGE

ONE WORLD

, ONE DROWNING L

ANGUAGE

ONE WORLD

, ONE DROWNING L

ANGUAGE

WE CARE ABOUTWE CARE ABOUTIls Medical ComissionIls Medical Comission

The End?

BIBLIOGRAPHICAL REFERENCIES

1. Orlowski JP, Szpilman D, “Drowning - Rescue, Resuscitation, and

Reanimation” Pediatric Critical Care: A New Millennium, W. B. Saunders

Company Pediatric Clinics Of North America - V48, N3, June 2001. Review.

2. Cummins RO, Szpilman D. Submersion. In: Cummins RO, Field JM, Hazinski

MF, Editors. ACLS - The Reference Textbook. Volume II: ACLS for Experienced

Providers. Dallas, Tx: American Heart Association; 2003:97-107.

3. Szpilman D. Near-drowning and drowning classification: a proposal to stratify

mortality based on the analysis of 1831 cases. Chest. 1997 Sep;112(3):660-5.

4. Adult Basic Life Support. Guidelines for cardiopulmonary resuscitation and

emergency cardiac care (ECC). Circulation 2000;102:I22–59.

The End?

BIBLIOGRAPHICAL REFERENCIES

1. Orlowski JP, Szpilman D, “Drowning - Rescue, Resuscitation, and

Reanimation” Pediatric Critical Care: A New Millennium, W. B. Saunders

Company Pediatric Clinics Of North America - V48, N3, June 2001. Review.

2. Cummins RO, Szpilman D. Submersion. In: Cummins RO, Field JM, Hazinski

MF, Editors. ACLS - The Reference Textbook. Volume II: ACLS for Experienced

Providers. Dallas, Tx: American Heart Association; 2003:97-107.

3. Szpilman D. Near-drowning and drowning classification: a proposal to stratify

mortality based on the analysis of 1831 cases. Chest. 1997 Sep;112(3):660-5.

4. Adult Basic Life Support. Guidelines for cardiopulmonary resuscitation and

emergency cardiac care (ECC). Circulation 2000;102:I22–59.

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