I’m wet behind the ears for a different reason! Lifeguard the Vancouver Beaches and pools for 35...

I’m wet behind the ears for I’m wet behind the ears for a different reason!a different reason!

• Lifeguard the Vancouver Beaches and pools for 35 Lifeguard the Vancouver Beaches and pools for 35 years.years.

• Regularly provide training for many aquatic facilities.Regularly provide training for many aquatic facilities.

• Teach surf, waterfront, pool and waterpark lifeguarding.Teach surf, waterfront, pool and waterpark lifeguarding.

• I have taught lifeguarding in Hawaii, South Africa, Hong I have taught lifeguarding in Hawaii, South Africa, Hong Kong and Bangkok.Kong and Bangkok.

• Taught coast guard aquatic emergency care programs.Taught coast guard aquatic emergency care programs.

• Teach remote pre-hospital care to northern fishing Teach remote pre-hospital care to northern fishing resorts.resorts.

The hardships of teaching in remote fishing camps in Northern British Columbia looking over at the tip of the Alaskan Pan Handle.

I’m wet behind the ears for I’m wet behind the ears for a different reason!a different reason!

• Lifeguard the Vancouver Beaches and pools for 35 Lifeguard the Vancouver Beaches and pools for 35 years.years.

• Regularly provide training for many aquatic facilities.Regularly provide training for many aquatic facilities.

• Teach surf, waterfront, pool and waterpark lifeguarding.Teach surf, waterfront, pool and waterpark lifeguarding.

• I have taught lifeguarding in Hawaii, South Africa, Hong I have taught lifeguarding in Hawaii, South Africa, Hong Kong and Bangkok.Kong and Bangkok.

• Taught coast guard aquatic emergency care programs.Taught coast guard aquatic emergency care programs.

• Teach remote prehospital care to northern fishing Teach remote prehospital care to northern fishing resorts.resorts.

• I’ve been a paramedic/paramedic educator in Vancouver, I’ve been a paramedic/paramedic educator in Vancouver, full full time, since 1979.time, since 1979.• Other water experience: ice guarding, ski patrol, distance Other water experience: ice guarding, ski patrol, distance ocean ocean swimming, triathlon medical coverage, polar swimming, triathlon medical coverage, polar bear swims.bear swims.

World Drowning World Drowning EpidemiologyEpidemiology

• An estimated 500,000 people An estimated 500,000 people accidentally drown annuallyaccidentally drown annually– 22ndnd leading cause of unintentional injury leading cause of unintentional injury

deathdeath– 97% occur in low & middle income 97% occur in low & middle income

countriescountries– Sex ratio M:F 2.2:1Sex ratio M:F 2.2:1– World rate per 100,000 = 6.8World rate per 100,000 = 6.8

World Drowning World Drowning EpidemiologyEpidemiology• 65% are healthy and under 35 years.• 35% are good swimmers.• 90% occur within 10 yards of safety.• 80-90% of near-drowning patients aspirate.• Various studies report alcohol involvement

in 20-79% of cases. In the US, Alcohol use is involved in about 25% to 50% of adolescent and adult deaths associated with water recreation (Howland et al. 1995; Howland and Hingson 1988). Alcohol influences balance, coordination, and judgment, and its effects are heightened by sun exposure and heat (Smith and Kraus 1988).

• 65% are healthy and under 35 years.• 35% are good swimmers.• 90% occur within 10 yards of safety.• 80-90% of near-drowning patients aspirate.• Various studies report alcohol involvement

in 20-79% of cases. In the US, Alcohol use is involved in about 25% to 50% of adolescent and adult deaths associated with water recreation (Howland et al. 1995; Howland and Hingson 1988). Alcohol influences balance, coordination, and judgment, and its effects are heightened by sun exposure and heat (Smith and Kraus 1988).

United States United States EpidemiologyEpidemiology

• In 2002, there were 3,447 unintentional drownings in the United States, averaging nine people per day. This figure does not include drownings in boating-related incidents (CDC 2004).

• In 2002, there were 3,447 unintentional drownings in the United States, averaging nine people per day. This figure does not include drownings in boating-related incidents (CDC 2004).


•For every child 14 years and younger who drowns, three receive emergency department care for nonfatal submersion injuries. More than 40% of these children require hospitalization (CDC 2004). Nonfatal incidents can cause brain damage that result in long-term disabilities ranging from memory problems and learning disabilities to the permanent loss of basic functioning (i.e., permanent vegetative state).

•For every child 14 years and younger who drowns, three receive emergency department care for nonfatal submersion injuries. More than 40% of these children require hospitalization (CDC 2004). Nonfatal incidents can cause brain damage that result in long-term disabilities ranging from memory problems and learning disabilities to the permanent loss of basic functioning (i.e., permanent vegetative state).


• Boating carries risks for injury. • In 2003, the U.S. Coast Guard received

reports for 5,438 boating incidents; 3,888 participants were reported injured

and 703 killed in boating incidents.

• Among those who drowned, 86% were not wearing life jackets.

• Boating carries risks for injury. • In 2003, the U.S. Coast Guard received

reports for 5,438 boating incidents; 3,888 participants were reported injured

and 703 killed in boating incidents.

• Among those who drowned, 86% were not wearing life jackets.


• Most boating fatalities from 2003 (70%) were caused by drowning; the remainder were due to trauma, hypothermia, carbon monoxide poisoning, or other causes.

• Alcohol was involved in 31% of reported boating fatalities.

• Open motor boats were involved in 42% of all reported incidents, and personal watercraft were involved in another 27% (USCG 2003)

• Most boating fatalities from 2003 (70%) were caused by drowning; the remainder were due to trauma, hypothermia, carbon monoxide poisoning, or other causes.

• Alcohol was involved in 31% of reported boating fatalities.

• Open motor boats were involved in 42% of all reported incidents, and personal watercraft were involved in another 27% (USCG 2003)

Pediatric Drowning Pediatric Drowning EpidemiologyEpidemiology• Children under age 5 have the highest mortality Children under age 5 have the highest mortality

rate.rate.• Children less than one year of age most

frequently drown in toilets, bathtubs and buckets• Drowning in young children is often associated Drowning in young children is often associated

with a lapse in supervision. with a lapse in supervision. Among children ages Among children ages 1 to 4 years, most drownings occur in residential 1 to 4 years, most drownings occur in residential swimming pools (Brenner et al. 2001). Most swimming pools (Brenner et al. 2001). Most young children who drowned in pools were last young children who drowned in pools were last seen in the home, had been out of sight less than seen in the home, had been out of sight less than five minutes, and were in the care of one or both five minutes, and were in the care of one or both parents at the time (Present 1987).parents at the time (Present 1987).

• Children under age 5 have the highest mortality Children under age 5 have the highest mortality rate.rate.

• Children less than one year of age most frequently drown in toilets, bathtubs and buckets

• Drowning in young children is often associated Drowning in young children is often associated with a lapse in supervision. with a lapse in supervision. Among children ages Among children ages 1 to 4 years, most drownings occur in residential 1 to 4 years, most drownings occur in residential swimming pools (Brenner et al. 2001). Most swimming pools (Brenner et al. 2001). Most young children who drowned in pools were last young children who drowned in pools were last seen in the home, had been out of sight less than seen in the home, had been out of sight less than five minutes, and were in the care of one or both five minutes, and were in the care of one or both parents at the time (Present 1987).parents at the time (Present 1987).

Pediatric Drowning Pediatric Drowning EpidemiologyEpidemiology

• Children with seizure disorders and Children with seizure disorders and prolonged QT syndrome are prolonged QT syndrome are significantly greater risk of significantly greater risk of drowning.drowning.

Prolonged QT syndromeProlonged QT syndrome • Prolonged QT syndrome, also known as long Prolonged QT syndrome, also known as long

QT syndrome (LQTS), refers to a group of QT syndrome (LQTS), refers to a group of disorders that increase the risk for sudden disorders that increase the risk for sudden death due to an abnormal heartbeat.death due to an abnormal heartbeat.

• Long Q-T syndrome is an infrequent, hereditary Long Q-T syndrome is an infrequent, hereditary disorder of the heart's electrical rhythm that can disorder of the heart's electrical rhythm that can occur in otherwise-healthy people. It usually affects occur in otherwise-healthy people. It usually affects children or young adults.children or young adults.

Prolonged QT syndromeProlonged QT syndrome

• Problems exist in diagnosing LQTS.

• Although the method of diagnosis is the electrocardiogram, most young, healthy people do not routinely undergo this test, and, thus, their first, and possibly fatal, episode of LQTS comes without warning.

• In some cases, a non-fatal episode is mistakenly treated as a seizure, and, therefore, a follow-up assessment

does not include an electrocardiogram.

• Problems exist in diagnosing LQTS.

• Although the method of diagnosis is the electrocardiogram, most young, healthy people do not routinely undergo this test, and, thus, their first, and possibly fatal, episode of LQTS comes without warning.

• In some cases, a non-fatal episode is mistakenly treated as a seizure, and, therefore, a follow-up assessment

does not include an electrocardiogram.


• In addition, some cases of LQTS cannot be diagnosed by a routine electrocardiogram. That is, the QT interval is not found to be prolonged in routine testing.

• If LQTS is suspected either because of a previous episode of syncope or because of a family member with LQTS, an exercise electrocardiogram should be performed.

• In addition, some cases of LQTS cannot be diagnosed by a routine electrocardiogram. That is, the QT interval is not found to be prolonged in routine testing.

• If LQTS is suspected either because of a previous episode of syncope or because of a family member with LQTS, an exercise electrocardiogram should be performed.


• In all instances where an individual is diagnosed with LQTS, family members should be thoroughly evaluated, and a detailed family history should be taken noting any individuals with episodes of sudden loss of consciousness and any cases of unexplained sudden death.

• In all instances where an individual is diagnosed with LQTS, family members should be thoroughly evaluated, and a detailed family history should be taken noting any individuals with episodes of sudden loss of consciousness and any cases of unexplained sudden death.

Canadian Drowning Canadian Drowning EpidemiologyEpidemiology

Congress on Drowning 2002Congress on Drowning 2002

Drowning - DefinitionDrowning - Definition

DrowningDrowning is the process of experiencing is the process of experiencing respiratory impairment from respiratory impairment from submersion/immersion in liquidsubmersion/immersion in liquid

– ““the definition should include cases of the definition should include cases of drowning from all kinds of liquid drowning from all kinds of liquid aspirations, except body fluids (vomit, aspirations, except body fluids (vomit, saliva, milk, amniotic fluid)”saliva, milk, amniotic fluid)”

– Patients may live or diePatients may live or die– Regardless of outcome the patient has Regardless of outcome the patient has

been involved in a drowning incidentbeen involved in a drowning incident

Drowning - DefinitionDrowning - Definition

• Classifications should appear asClassifications should appear as::– DrowningDrowning

•Death, Morbidity or No MorbidityDeath, Morbidity or No Morbidity

•Other featuresOther features–Pre-existing conditionPre-existing condition–Hypothermic vs normothermicHypothermic vs normothermic–Associated TraumaAssociated Trauma–Respiratory Arrest/Cardiac ArrestRespiratory Arrest/Cardiac Arrest

Drowning ProcessDrowning Process

Airway in liquid Airway in liquid •Breath holdingBreath holding•Liquid in oral pharynx and larynxLiquid in oral pharynx and larynx

– LaryngospasmLaryngospasm

•Hypoxia Hypoxia •Large swallowing of liquidLarge swallowing of liquid•Aspiration of liquid (amounts variable)Aspiration of liquid (amounts variable)•Changes in lungs, body fluids, blood-gas Changes in lungs, body fluids, blood-gas

tensions, acid-base balance, and electrolyte tensions, acid-base balance, and electrolyte concentrationsconcentrations

•HypoxemiaHypoxemia


– Surfactant washoutSurfactant washout– Pulmonary hypertensionPulmonary hypertension– ShuntingShunting

•All contribute to HypoxemiaAll contribute to Hypoxemia

• The patient can be rescued from this The patient can be rescued from this cascade of hypoxia at any time cascade of hypoxia at any time during the drowning processduring the drowning process

SEQUENCE OF EVENTSSEQUENCE OF EVENTS

Initial period

• characteristics of a drowning person

• panic

• heart and metabolic rate increase

• breath holding which leads to respiratory acidosis

Respiratory AcidosisRespiratory Acidosis

CO2 + H20 H2CO3 HCO- + H+

Normal body pH is ~7.4

SEQUENCE OF EVENTSSEQUENCE OF EVENTS

The Terminal Gasp

Laryngospasm Aspiration

• laryngospasm

• glottic spasm

• hypoxia

• child vs adult

• aspiration

• pulmonary edema

• atelectasis

• shunting

Pulmonary EdemaPulmonary Edema

capillary

Interstitial fluid shift

AlveoliO2

CO2

Reduced perfussion

O2 CO2

Ischemia-Ischemia-ReperfusionReperfusion

p-selectin

ß2 - Integrins

Tissue damage

WBC

Adhesion

MECHANISMSMECHANISMS

endothelium

AtelectasisAtelectasis

Aspiration leads to

collapse of the alveoli due to loss

of surfactant and

pulmonary edema

normal

alveoli

surfactant

collapsed alveoli

Metabolic AcidosisMetabolic Acidosis

Aerobic Metabolism (with O2)

• = glycolysis + Kreb’s cycle

• produces 38 ATP

Aerobic Metabolism (with O2)

• = glycolysis + Kreb’s cycle

• produces 38 ATP

Anaerobic Metabolism (without O2)

• produces only 2 ATP (only glycolysis)

• does not break down lactic & pyruvic acid, lowers pH

Secondary ProblemsSecondary Problems

aspiration may lead to -

• unappreciated pulmonary edema

& atelectasis

• pulmonary infections (pneumonia)

• ARDS

Preceding signs and Preceding signs and symptomssymptoms

• initial prolonged spasmodic coughing

• dyspnea

• inspiratory crackles on auscultation

• signs of shock

• reduced exercise tolerance

> S.O.B. & tachycardia

Other Complications or Other Complications or FactorsFactors

• HypothermiaHypothermia

• Mammalian dive reflexMammalian dive reflex

• Drugs and alcohol Drugs and alcohol

• HyponatremiaHyponatremia

• Cervical spine injuriesCervical spine injuries

• SeizuresSeizures

Pulmonary Pulmonary HypertensionHypertensionPulmonary Pulmonary HypertensionHypertension

• When someone has PH, the pulmonary When someone has PH, the pulmonary arteries become narrow or blocked. arteries become narrow or blocked. This means the heart has to work This means the heart has to work harder to push the blood through the harder to push the blood through the lungs. Over time, the heart cannot lungs. Over time, the heart cannot keep up. Less blood flows through the keep up. Less blood flows through the lungs to pick up oxygen. This results in lungs to pick up oxygen. This results in PH symptoms such as trouble PH symptoms such as trouble breathing, dizziness, or feeling tired.breathing, dizziness, or feeling tired.

• When someone has PH, the pulmonary When someone has PH, the pulmonary arteries become narrow or blocked. arteries become narrow or blocked. This means the heart has to work This means the heart has to work harder to push the blood through the harder to push the blood through the lungs. Over time, the heart cannot lungs. Over time, the heart cannot keep up. Less blood flows through the keep up. Less blood flows through the lungs to pick up oxygen. This results in lungs to pick up oxygen. This results in PH symptoms such as trouble PH symptoms such as trouble breathing, dizziness, or feeling tired.breathing, dizziness, or feeling tired.


•Dry vs WetDry vs Wet– Traditionally this has been used to Traditionally this has been used to

identify those who have aspirated liquid identify those who have aspirated liquid into the lung and those who have not.into the lung and those who have not.

– Frequently it is not possible to make Frequently it is not possible to make this determinationthis determination

– By definition all drowning occurs in By definition all drowning occurs in liquid and therefore all drowning is wet.liquid and therefore all drowning is wet.


• Active vs. Passive vs. Silent Active vs. Passive vs. Silent drowningdrowning– These terms should be abandoned in These terms should be abandoned in

favor of the terms “witnessed” and favor of the terms “witnessed” and “unwitnessed”“unwitnessed”

• Active vs. Passive vs. Silent Active vs. Passive vs. Silent drowningdrowning– These terms should be abandoned in These terms should be abandoned in

favor of the terms “witnessed” and favor of the terms “witnessed” and “unwitnessed”“unwitnessed”


•Secondary DrowningSecondary Drowning– This term has been used to describe an This term has been used to describe an

unrelated event (seizure, spinal injury, unrelated event (seizure, spinal injury, or MI) or MI)

– This term has also been used to This term has also been used to describe the development of ARDSdescribe the development of ARDS

– This term should be abandonedThis term should be abandoned

•Secondary DrowningSecondary Drowning– This term has been used to describe an This term has been used to describe an

unrelated event (seizure, spinal injury, unrelated event (seizure, spinal injury, or MI) or MI)

– This term has also been used to This term has also been used to describe the development of ARDSdescribe the development of ARDS

– This term should be abandonedThis term should be abandoned


• Drowned and Near-drownedDrowned and Near-drowned– Have been used for decades to describe Have been used for decades to describe

outcomes – dead or aliveoutcomes – dead or alive– The term near-drowning has been used The term near-drowning has been used

to describe patients who have to describe patients who have subsequently died from drowning.subsequently died from drowning.

– Near-drowning should no longer be usedNear-drowning should no longer be used– The term The term DrownedDrowned will continue to will continue to

refer to persons who died from drowningrefer to persons who died from drowning

• Drowned and Near-drownedDrowned and Near-drowned– Have been used for decades to describe Have been used for decades to describe

outcomes – dead or aliveoutcomes – dead or alive– The term near-drowning has been used The term near-drowning has been used

to describe patients who have to describe patients who have subsequently died from drowning.subsequently died from drowning.

– Near-drowning should no longer be usedNear-drowning should no longer be used– The term The term DrownedDrowned will continue to will continue to

refer to persons who died from drowningrefer to persons who died from drowning

Understand the unique considerations Understand the unique considerations for drowning events in childrenfor drowning events in children

– Drowning – common etiology of Drowning – common etiology of pediatric out-of-hospital cardiac pediatric out-of-hospital cardiac arrest.arrest.

– Less pulmonary oxygen reserve due Less pulmonary oxygen reserve due to smaller residual volumes to smaller residual volumes

– Develop hypoxia/hypoxemia faster Develop hypoxia/hypoxemia faster due to higher metabolic rate.due to higher metabolic rate.

– Drowning – common etiology of Drowning – common etiology of pediatric out-of-hospital cardiac pediatric out-of-hospital cardiac arrest.arrest.

– Less pulmonary oxygen reserve due Less pulmonary oxygen reserve due to smaller residual volumes to smaller residual volumes

– Develop hypoxia/hypoxemia faster Develop hypoxia/hypoxemia faster due to higher metabolic rate.due to higher metabolic rate.

Understand unique considerations Understand unique considerations for drowning events in childrenfor drowning events in children

• Children less likely to have pre-Children less likely to have pre-existingexisting illnessillness

• Protective Hypothermia more Protective Hypothermia more likely in Children.likely in Children.

• Effects of Hypothermia are more Effects of Hypothermia are more frequently negative.frequently negative.


• Outcomes often closely related Outcomes often closely related to duration of submersion.to duration of submersion.

• Poor outcomes with prolonged Poor outcomes with prolonged submersionsubmersion– (>25min)(>25min)


• Adolescents tend to endanger Adolescents tend to endanger themselves by high risk behaviors, themselves by high risk behaviors, including intoxication.including intoxication.

• Drowning in children is often a Drowning in children is often a shocking surprise, shocking surprise, fastfast, and , and emotionally challengingemotionally challenging..

Prevention of Pediatric Prevention of Pediatric DrowningDrowning

• Educate adults about supervisionEducate adults about supervision•Seconds countSeconds count

• Educate our seizure disorder familiesEducate our seizure disorder families•Swim and bath with close supervisionSwim and bath with close supervision

• Fence or barrier, areas of waterFence or barrier, areas of water

• Promote water safety and learn to swimPromote water safety and learn to swim

• Train general population in resuscitationTrain general population in resuscitation

Who needs further medical Who needs further medical attention after rescue from attention after rescue from water?water?

• The following should be sent to The following should be sent to hospitalhospital– Any loss of consciousnessAny loss of consciousness– Any resuscitation (Rescue Breathing or Any resuscitation (Rescue Breathing or

CPR)CPR)– Any concurrent condition (seizure, spinal Any concurrent condition (seizure, spinal

injury, asthma, etc)injury, asthma, etc)

Accidental HypothermiaAccidental Hypothermia

• Epidemiologically more bad than goodEpidemiologically more bad than good• Hypothermic protective effect when:Hypothermic protective effect when:

– Immersion in very cold (near freezing or Immersion in very cold (near freezing or below)below)

– Rapid central cooling with a decline in Rapid central cooling with a decline in cerebral metabolism before hypoxic-cerebral metabolism before hypoxic-ischemic injury.ischemic injury.

– Hypothermia can not render a protective Hypothermia can not render a protective effect if it is preceded by hypoxemiaeffect if it is preceded by hypoxemia


• Detrimental effects of HypothermiaDetrimental effects of Hypothermia– ArrhythmiasArrhythmias

•A core temp <28c can induce VFib, which may A core temp <28c can induce VFib, which may be refractory to defib until temp has been be refractory to defib until temp has been raised.raised.

– CoagulopathyCoagulopathy– Impaired immune functionImpaired immune function– Reduced myocardial functionReduced myocardial function– AcidosisAcidosis– Electrolyte abnormalitiesElectrolyte abnormalities


• TreatmentTreatment– Hemodynamically stable patientsHemodynamically stable patients

• Rewarm using warmed humidified inspired gases, Rewarm using warmed humidified inspired gases, warmed IV fluids, heating blankets, warm air surface warmed IV fluids, heating blankets, warm air surface mechanismsmechanisms

– Hemodynamically unstable patientsHemodynamically unstable patients• Rewarm using the above plus bladder irrigation, Rewarm using the above plus bladder irrigation,

gastric and pleural lavage, peritoneal or hemodialysis gastric and pleural lavage, peritoneal or hemodialysis with warmed fluids and Cardiopulmonary bypass with warmed fluids and Cardiopulmonary bypass (CPB)(CPB)


• Practical pointsPractical points– Core temperature monitoring Core temperature monitoring

neededneeded•rectal, esophageal or central line rectal, esophageal or central line

preferredpreferred

– Ideal rate of temperature rise is Ideal rate of temperature rise is unknownunknown

– Heat fluids in warmer or microwave Heat fluids in warmer or microwave to 37c for infusionto 37c for infusion

Therapeutic HypothermiaTherapeutic Hypothermia

• Mild hypothermia (32-34c) may be Mild hypothermia (32-34c) may be helpful to improve cerebral function helpful to improve cerebral function outcomesoutcomes

• This is case study data onlyThis is case study data only• There has not been a trial in drowningThere has not been a trial in drowning• Trials in animal models, and case Trials in animal models, and case

reports in children, infant and neonatal reports in children, infant and neonatal arrests suggest this might be helpfularrests suggest this might be helpful

• Time to onset is unknown Time to onset is unknown

How would you respond to a call at a hotel swimming pool, private pool, public pool,

lake, river, ditch.

You don’t have to be able to swim

All you have to do is wade to participate

Shorts and a T-shirt are acceptable

Drowning, heart attack, cardiac arrest, fractures, spinals, seizures, hypothermia, missing person

TreatmentTreatment

The Initial Response

• Consider hazards and the environment

• Consider mechanism of injury (C-spine?)

• Back-up or assistance?

• Reach-throw-row-go-tow

• High level of emotional involvement in these cases

Treatment Treatment (cont’d)(cont’d)

Responsive struggling patient

• Get patient’s head and shoulders above the water

• Limit patient’s gross motor movements

• Put patient in most comfortable position, usually semi-sitting

• Assist (positive pressure ventilation PRN*) with oxygen (high percentage)

• Be prepared for a change in patient status


*PEEP, CPAP, BiPAP (positive end expiratory pressure, continuous positive airway pressure, biphasic PAP)

• Has been shown to improve ventilation patterns in the non-compliant lung in several ways: by shifting interstitial pulmonary water into the capillaries; by increasing lung volume via prevention of expiratory airway collapse; by providing better alveolar ventilation and decreasing capillary blood flow; and by increasing the diameter of both small and large airways to improve distribution of ventilation.

Inflammatory Inflammatory Response Attenuated Response Attenuated by PPVby PPV

p-selectin

WBC

Reversible inhibition

of ß2 - Integrins by positive pressure ventilation

WBC

MECHANISMSMECHANISMS

OxygenatioOxygenationn

paO2

pO2

O2

absorption

Treatment (cont’d)Treatment (cont’d) Unresponsive patient

• get patient’s head out of the water

• assess ABC’s, DO NOT perform the Heimlich maneuver or abdominal thrusts or “break the

patient”

• limit patient’s gross motor movements

• if possible, remove from water immediately

• ventilate patient when regurgitation can be managed (patient’s head or body repositioned to

prevent aspiration) or if an extended time until removal


Unresponsive patient (cont’d)

• once removed, position in lateral position unless efficient suction and definitive airway maintenance is available

• reassess circulation - manage ABC’s

• positive pressure ventilation

• administer oxygen (high percentage)*

• protect from environment/ keep warm

• be prepared for change in patient status

Near-Drowning Near-Drowning ClassificationClassification

• Normal without cough

• Grade 1 - normal with cough

• Grade 2 - abnormal, some aspiration/crackles

• Grade 3 - acute pulmonary edema/crackles

• Grade 4 - “ “ “ and shock/hypotension

• Grade 5 - not breathing with a pulse

• Grade 6 - cardiac arrest(Szpilman 1998)

NEAR-DROWNING/DROWNING - CLASSIFICATION and TREATMENT - BLS

Grade 4Grade 3

CAROTID PULSE ?

YesNo

Grade 6 Grade 5

Yes

Check cough and/or

foam in mouth/nose

Grade 1

SMALL AMOUNT OF FOAM

IN MOUTH/NOSE

Grade 2

LARGE AMOUT OF FOAM

IN MOUTH/NOSE

RADIAL PULSE PALPABLE ?

YesCOUGH , WITHOUT

FOAM IN MOUTH/NOSE

No

Notes: 10 - Start evaluation in water: conscious victim rescue back to shore/pool deck should be made as soon as possible, and the victim ABC is usually unnecessary to be done in water; unconscious victim - In Shallow water lifeguard should open the victim’s airway, evaluate breathing, and beginning mouth to mouth if necessary without too many difficulties - In Deep water – The lifeguard should place the victim’s face up, extending the neck to open the airway. This can be accomplished with an aid of lifesaving equipment with only one lifeguard, or without a lifesaving equipment with 2 or more lifeguards. In case of no spontaneous breathing start immediately mouth to mouth ventilation in a rate of 16 to 20 per minute until reaching shore/swimming pool deck. Do not check victim’s pulse or start compressions while in the water. After the initial mouth to mouth check the victim’s pulse only if the distance are far to shore or if in shallow water. In those cases if no pulse was feeling it is urgent to bring the victim back to shore without doing any more ABC procedures. This in-water procedure can reduces the mortality in almost 50%. 20. Do not spend time to begin CPR trying drain the water from lungs,and increasing the occurrence of vomits or regurgitation, using the position of head lower than trunk or other maneuver. On sloping beaches all the victims should be put initially in position parallel to the waterline, in dorsal position to the beginning of breathing checking, and the lifeguard back to the sea with the victim’s head turned to his left side, as to facilitate the rescuers CPR maneuvers without falling over the victim, and making easier the posterior placement of the victim in right recumbent lateral position.; 30. The Heimlich maneuver is only indicated if a strong suspicious of foreign body obstruction of airways exist 40. After successful CPR the victim should be followed as close as possible because another CPA may occur in first 30 minutes.

Give 2 mouth to mouth andcheck the arterial carotid pulse

Start complete CPR with 15

external cardiac compression and alternate

with 2 mouth to mouth until

restore normal cardiopulmonar

y function, or lifeguard

exhaustion or EMS arrived.

Continue mouth to mouth at 12 to

20 p/min until restore normal

breath

Check the victim - do you listen me ?No Yes

BREATH PRESENT ?

Absent

RescueEvaluate and release from the accident site without further medical

care

1. Rest, warm and calm the victim. 2. Advanced

medical attention or oxygen administration

should not normally be required

1. Oxygen - 5 liters/min by nasal cannula. 2. Warm, rest and calm the

victim. 3. Hospital observation from 6 to 48 hours.

No

1.15 liters/min of oxygen by facial mask in the accident site. 2. Right

recumbent lateral position. 3. ACLS attendance and

hospitalization (ICU) required.

1. 15 liters/min of oxygen by facial mask. 2. Monitor breathing with

careful (as still could stop breathing). 3. Right lateral

recumbent position. 4. ACLS immediately for mechanical

ventilation and I.V fluid infusion. 5. Hospitalization (ICU) required.

After restore spontaneous breathing and pulse treat as grade 4

Warning if any suspect cervical trauma, be careful while open airways - use special techniques to do so.

Hospitalization

Open airways - listen, feel and hear the respiration

Basic Life SupportNear-Drowning/Drowning algorithmSzpilman 1998.

Classification of Immersion Classification of Immersion IncidenceIncidence

• Group 1 – No evidence of inhalationGroup 1 – No evidence of inhalation

• Group 2 – Clinical evidence of Group 2 – Clinical evidence of inhalation, inhalation,

but with adequate ventilationbut with adequate ventilation

• Group 3 – Clinical evidence of inhalation Group 3 – Clinical evidence of inhalation

but inadequate ventilationbut inadequate ventilation

• Group 4 – Cardio-respiratory arrestGroup 4 – Cardio-respiratory arrest

Group 1 & 2 - adequate Group 1 & 2 - adequate ventilationventilation

Criteria for 6 hour dischargeCriteria for 6 hour discharge::

- No fever, no cough, no respiratory - No fever, no cough, no respiratory symptomssymptoms

- No crepitations in lungs- No crepitations in lungs

- Normal PaO2 on room air- Normal PaO2 on room air

- Normal chest x-ray- Normal chest x-ray

Group 3 – compromised Group 3 – compromised ventilationventilation

• Oxygen by mask or CPAPOxygen by mask or CPAP• Monitor Sa02 and PaO2Monitor Sa02 and PaO2• IV infusion of warmed fluidsIV infusion of warmed fluids• Treat hypothermia and metabolic acidosisTreat hypothermia and metabolic acidosis• Chest x-ray, CBC, Electrolytes, glucoseChest x-ray, CBC, Electrolytes, glucose• If further deteriorationIf further deterioration

– Intubate and ventilate with 100% O2Intubate and ventilate with 100% O2– IPPV and PEEP if necessaryIPPV and PEEP if necessary– ICU if necessaryICU if necessary


• Nuances of ResuscitationNuances of Resuscitation– 4 phases4 phases

•Pre-arrest phasePre-arrest phase

•No-flow phase of untreated cardiac arrestNo-flow phase of untreated cardiac arrest

•Low-flow phase which occurs during CPRLow-flow phase which occurs during CPR

•Post-resuscitation phasePost-resuscitation phase

– Interventions need to focused to phaseInterventions need to focused to phase


• Pre-arrest phasePre-arrest phase– Stop the process by rescue and restore Stop the process by rescue and restore

breathing of airbreathing of air– Consider pre-existing conditionConsider pre-existing condition

•Seizure disorderSeizure disorder

•Prolonged QTProlonged QT

– Focus on PreventionFocus on Prevention•Supervision, fencing, Supervision, fencing,


• No-Flow PhaseNo-Flow Phase

– Prompt effective resuscitation is essentialPrompt effective resuscitation is essential• Delay >8 min is usually lethalDelay >8 min is usually lethal

– Hypoxic etiology (unlike most adult arrests)Hypoxic etiology (unlike most adult arrests)• Reversal of hypoxia is neededReversal of hypoxia is needed• Fluid in lungs may be low volumeFluid in lungs may be low volume• Fluid in GI system is usually high volumeFluid in GI system is usually high volume

– Aspiration is a large issue – usually of GI originAspiration is a large issue – usually of GI origin


• Low-Flow Phase (CPR)Low-Flow Phase (CPR)– Bystander CPR essential for recoveryBystander CPR essential for recovery

•Encouraging all citizens to get first aid and Encouraging all citizens to get first aid and CPR educationCPR education

•Fast start improves outcomesFast start improves outcomes

– Push hard, push fast and minimize Push hard, push fast and minimize interruptions.interruptions.•Rates and ratios are less important than Rates and ratios are less important than

taking action.taking action.

Current Resuscitation Current Resuscitation GuidelinesGuidelines


• Post-Resuscitation PhasePost-Resuscitation Phase– VT & VF do occur but rareVT & VF do occur but rare

• Except in severe hypothermiaExcept in severe hypothermia

• Long QT syndrome should be consideredLong QT syndrome should be considered

• Rarely occurs prior to Cardiac ArrestRarely occurs prior to Cardiac Arrest

– Reduces outcomesReduces outcomes• Excessive hyperventilation Excessive hyperventilation

• Hyper/hypocapniaHyper/hypocapnia

• HyperglycemiaHyperglycemia


• Interesting option issuesInteresting option issues– Not Not been directly shown to improve outcome in been directly shown to improve outcome in

DrowningDrowning

• Deep hypothermia not helpfulDeep hypothermia not helpful

• Hyperventilation not goodHyperventilation not good

• Prophylactic antibiotics not helpfulProphylactic antibiotics not helpful

• Steroids not helpfulSteroids not helpful

• Surfactant replacement may be helpfulSurfactant replacement may be helpful

• Dobutamine is preferred inotrope Dobutamine is preferred inotrope


• Attempt resuscitation in all children unless Attempt resuscitation in all children unless clinical indicators of poor outcome are clinical indicators of poor outcome are present:present:

– Rigor mortisRigor mortis– Documented to be submerged in non-icy Documented to be submerged in non-icy

water, for prolonged period (>60min)water, for prolonged period (>60min)– No response to resuscitation effort of 1 hour No response to resuscitation effort of 1 hour

with core temperature above 32c.with core temperature above 32c.

ReferencesReferencesDr. Steve Beerman, Dr. Steve Beerman, Department of General Practice, NRGHDepartment of General Practice, NRGHLongstanding member/President International Lifesaving FederationLongstanding member/President International Lifesaving Federation

ILCOR Advisory StatementILCOR Advisory StatementRecommended guidelines for uniform reporting of data from drowning: the Utstein styleRecommended guidelines for uniform reporting of data from drowning: the Utstein styleResuscitation 59 2003, 45-57Resuscitation 59 2003, 45-57

Handbook on DrowningHandbook on DrowningJ Bierens, Springer Press, Jan 2006J Bierens, Springer Press, Jan 2006

International Lifesaving FederationInternational Lifesaving FederationMedical Committee - Position StatementsMedical Committee - Position Statementswww.ilsf.orgwww.ilsf.org

Lifesaving Society Lifesaving Society National Drowning Trends Report – July 2003National Drowning Trends Report – July 2003www.lifesaving.cawww.lifesaving.ca

World Health OrganizationWorld Health OrganizationFacts about Injuries – DrowningFacts about Injuries – Drowning www.who.int/violence_injury_preventionwww.who.int/violence_injury_prevention

http://www.ilsf.org/

http://www.lifesaving.ca/

1. Scenario 1. Scenario PracticePractice• A 3 year old child pulled out of a pool by a

parent. You arrive as the child is beginning to rouse after being given one breath and vomiting.

2. Scenario 2. Scenario PracticePractice• A 17 year old male was drinking beer and

fooling around in the pool. He was performing antics for humor. When they looked back they saw him face down.

3. Scenario 3. Scenario PracticePractice

• An obese (300 lbs.) male is discovered by his wife in their home indoor pool. He is unresponsive.


• A 21 year old swim coach was trying to swim under water further than his friends. He had

been performing antics after a few drinks. When they looked as him he was still underwater then began to splash and wiggle like a seal. He then stopped moving and the other coaches pulled him out.


• A 35 year old is seen on the bottom of a public pool by a lifeguard and is removed. The patient is unresponsive and the lifeguards have been performing CPR for what they estimate to be 5 minutes.


• An 8 year old girl is found on the bottom of an outdoor public swimming pool. The guards have just put her on a spine board and are attempting to provide mouth to mask and remove her. They did not see her and are concerned she may

have dived in and broke her neck. The patient is regurgitating repeatedly.


• A 28 year old man was taking a scuba class and was on an dive. He spat out his regulator by mistake on his assent. He was coughing at the surface but inflated his buoyancy compensator and swam to shore with others. He is now sitting almost finished taking his gear off.


• A 70 year old man was seen to stop moving in a public swimming pool. Having not witness event, the lifeguard turned the patient over immobilizing his neck. The second guard, the supervisor, asked the wife who was watching her husband, “What happened”. She replied that he was just skin diving (had swim goggles on) and went limp by the pool edge. The guard asked if the patient had dived in the pool. The wife said no. The lifeguards change their focus to the ABC’s and it took a few minutes to open his mouth and start breathing. As you arrive they are just laying the patient out onto the pool deck.

SummarySummary1. Your own safety comes first. This can be difficult to

consider when young children are involved! (VAC example)

2. Don’t forget, cervical spinal injuries should be considered with young adults where jumping or diving was possible. ABC’s still take priority! (Hawaii example, CGP example)

3. A patient who appears calm may in fact be suffering from severe aspiration problems. (White Cliff Scuba diving example)

4. With anyone short of breath from a immersion or submersion episode, do not hesitate to assist with their breathing using high flow oxygen. (Failure example)

5. Avoid gross motor movement, especially if hypothermic.

6. Drowning can be a very subtle and uneventful. (YMCA Pool example)

7. Come to the pool to put this into practice.

1. Your own safety comes first. This can be difficult to consider when young children are involved! (VAC example)

2. Don’t forget, cervical spinal injuries should be considered with young adults where jumping or diving was possible. ABC’s still take priority! (Hawaii example, CGP example)

3. A patient who appears calm may in fact be suffering from severe aspiration problems. (White Cliff Scuba diving example)

4. With anyone short of breath from a immersion or submersion episode, do not hesitate to assist with their breathing using high flow oxygen. (Failure example)

5. Avoid gross motor movement, especially if hypothermic.

6. Drowning can be a very subtle and uneventful. (YMCA Pool example)

7. Come to the pool to put this into practice.

An elderly Florida lady did her shopping and, upon returning to her car, found four males in the act of leaving with her vehicle. She dropped her shopping bags and drew her handgun, proceeding to scream at them at the top of her voice, "I have a gun and I know how to use it! Get out of the car, you scumbags!" The four men didn't wait for a second invitation, but got out and ran like mad, whereupon the lady, somewhat shaken, proceeded to load her shopping bags into the back of the car and get into the driver's seat.

She was so shaken that she could not get her key into the ignition. She tried and tried and then it dawned on her why. A few minutes later she found her own car parked four or five spaces farther down. She loaded her bags into her car and drove to the police station. The sergeant, to whom she told the story, nearly tore himself in two with laughter and pointed to the other end of the counter, where four pale white males were reporting a car jacking by a mad elderly woman described as white, less than 5' tall, glasses, and curly white hair carrying a large handgun. No charges were filed.

I’m wet behind the ears for a different reason! Lifeguard the Vancouver Beaches and pools for 35...

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