Drowning: Submersion Emergencies

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Drowning Submersion Emergencies

• Presence Regional EMS
• June 2015 CE

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Objectives

• Define drowning
• Discuss the incidence, risk factors and
  prevention of drowning
• List the basic rules of providing water rescue
• Outline recovery techniques and resuscitation
  efforts required for submersion injuries

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Submersion Emergencies
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Introduction

• Drowning emergencies are emotionally traumatic
  for relatives and loved ones of the patients and
  emergency providers.
• Many drownings are preventable tragedies
  resulting from poor judgement, alcohol
  consumption and inadequate supervision of
  children.

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Incidence

• There are an estimated 4,500 drowning related
  deaths in the United States every year.
• For every drowning death
• 2 people drown and survive with no disability.
• 2 people drown and survive but have severe
  neurological impairment

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The Numbers May Not Be Accurate

• Victims of drownings from floods and other
  natural disasters are not counted in drowning
  deaths.
• Victims of boating accidents are not counted in
  drowning deaths.

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Who drowns?

• Children under the age of 4 years and adolescents
  and young adults aged 15 to 24 years make up the
  majority of drowning victims.
• Water sports and the use of alcohol and/or drugs
  while swimming increase ones chance of suffering
  a submersion related injury.

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Submersion Emergencies

• Immersion
• An incident in which a patients face and/or
  airway are covered in water
• Submersion
• An incident in which a patients entire body
  including the face and airway is submerged in
  water
• Water Rescue
• An incident in which a person is alert but
  experiences some distress while swimming with
  minimal or transient symptoms

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• Drowning
• An event in which a patient has primary
  respiratory impairment from immersion or
  submersion in a liquid. The patient may live or
  die after this event.
• Drowning Death
• An event of drowning in which the patient is
  pronounced dead within 24 hours of the event.
  Pronouncement may occur on scene or at the
  hospital.
• Drowning-related Death
• Incident in which a submersion patient dies more
  than 24 hours following the event.

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• The best treatment for drowning is prevention.

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Prevention

• Many drowning victims are infants and small
  children.
• Prevention can be a matter of following some
  common sense practices.

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Prevention of Drowning

• Keep only a few inches of water in the bathtub
  when bathing young children.
• Never leave young children unsupervised in
  bathtubs.
• Never leave children alone in or near a pool EVEN
  FOR A MOMENT regardless of safety precautions
  such as self locking gate and pool alarms.

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• Be sure that adults and adolescents are trained
  in CPR so that they can rescue a child if
  necessary.
• Surround pools on all 4 sides with a sturdy five
  foot fence. The house should not be one of the
  barriers to the pool if there is a doorway from
  the home to the pool area.
• Be sure that gates self-close and self-latch at a
  height that children cannot reach.

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• Keep rescue equipment (shepherds hook and life
  preserver) and a portable phone near the pool.
• Avoid inflatable swimming aids such as
  floaties. They are not a substitute for
  approved life vests and can give children a false
  sense of security.
• Whenever infants and toddlers are in or around
  water, an adult should be within arms length,
  providing touch supervision.

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Where People Drown
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Why Do Drownings Occur?

• Swimming/boating issues
• Exhaustion in the water
• Losing control or being swept into deep water
• Becoming tangled or entrapped while in the water
• Using poor judgment while in or near water
• Panicking while in water
• Losing a support such as a sinking boat

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• Precipitating Factors
• Using alcohol or drugs in or near the water
• Suffering a seizure, heart attack, or other
  debilitating condition while in or near water
• Becoming hypothermic while swimming
• Suffering trauma or a diving accident

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Pathophysiology of Drowning

1. Victims airway is below the surface of a liquid
2. Victim involuntarily holds breath
3. Water swallowing begins into posterior pharynx
   and into stomach
4. Involuntary laryngospasm (closing of vocal cords)
   due to liquids in the oropharynx.

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• Blood oxygen levels drop and carbon
• dioxide levels raise.
• Due to worsening low oxygen/high carbon dioxide
  and unconsciousness laryngospasm stops and vocal
  cords open.
• Gasp reflex if the victims head is out of the
  liquid may begin coughing and clearing airway

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1. If the victims head is still under the liquid,
   liquid enters the lungs.
2. Surfactant washout occurs
3. Worsening hypoxia
4. Cardiac arrest
5. DEATH

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Drowning Process
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Predicting the Outcome of Drowning

• Duration of submersion
• Severity of hypoxia
• Neurologic impairment due to lack of oxygen to
  the brain

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• Drowning victims who have spontaneous
  respirations and pulses in the field before
  arrival in the Emergency Department usually
  recover with good neurological outcomes.

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Surviving Drowning/Time
Duration of Submersion Likely to Survive without Neurological Damage
0 to up to 5 minutes 90
5 up to 10 minutes 44
10 up to 25 minutes 12
25 minutes or longer 0

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Surviving Drowning/Clinical Findings
Initial Clinical Findings Likely to Survive Without Neurological Damage
Some coughing, normal breath sounds 100
Coughing, with wet rales in one lung 99.4
Coughing, bilateral wet rales or pulmonary edema, good vital signs 95
Coughing, bilateral wet rales or pulmonary edema, low BP 80
No spontaneous respirations, pulse is present 56
Cardio/pulmonary arrest, no spontaneous breathing, no pulse 7
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Drowning Related Death

• People die in the hospital after a drowning
  incident because of
• Brain death from lack of oxygen
• Acute respiratory distress syndrome
• Multi-organ system failure
• Sepsis (system wide infection)

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Management of Submersion Emergencies
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Management

• Rescue
• Airway/Ventilation
• Hypothermia
• Associated Trauma

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Rescue

• Provider Safety
• Dont Jump in to Help if you Cant Swim!!!
• Make use of a conveyance device
• Boat
• Raft
• Floatation device

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If you are the only rescuer. . .

• If the victim is not breathing provide 2 minutes
  of rescue breaths before calling 911.
• If the victim is pulseless
• and not breathing provide
• 5 cycles of CPR (2 minutes)
• before calling 911.

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Airway/Ventilation

• The most dangerous consequence of submersion
  emergencies is lack of oxygen.
• Open the victims airway as soon as possible and
  begin assisted ventilations.
• Rescue breathing should begin as soon as a
  submersion victim is removed from the water.

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• Lets practice airway management
• Practice opening airway and BVM ventilation
• One rescuer and two rescuer

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THERE IS NO NEED TO DRAIN WATER FROM THE LUNGS

• Fluids in the airway and lungs of a submersion
  victim absorb quickly
• Most water will come from the stomach

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No Heimlich Maneuver!!

• Routine use of the Heimlich Maneuver or chest
  compressions to remove water only leads to
• Vomiting
• Aspiration
• Delay in beginning
• ventilations

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Vomiting

• 67 of submersion victims who require ventilation
  assistance vomit.
• 86 of submersion victims who require ventilation
  and chest compressions vomit
• If vomiting occurs turn the patient on their side
  and suction

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Body Temperature Hypothermia

• Body requires core temp of 98.6oF (37oC) for
  proper function.
• If core temp significantly rises above or falls
  below 98.6oF (37oC), the cells ability to
  function is impaired, especially those of the
  brain, heart, and kidneys.
• Can result in permanent disability and/or death
  of the patient.

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Submersion and Hypothermia

• Mammalian Diving Reflex
• The mammalian diving reflex activates when a
  person dives into cold water (lt70oF).
• Larynx spasms.
• Breathing is inhibited.
• Heart rate slows.
• Blood vessels constrict.
• Blood flow to the brain and heart are increased.
• Treat as Hypothermic Cardiac Arrest

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How will you manage hypothermia?

• Check for a pulse for at least 10 seconds
• Remove wet clothing
• Warm blankets
• Turn up heat in unit
• Prevent further loss of heat

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Associated Trauma

• Routine spinal motion restriction in submersion
  emergencies is not recommended.
• Applying SMR can delay opening the airway and
  ventilating the patient.

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Spinal Injuries in Submersion Incidents

• Suspect spinal injury if
• Submersion has resulted from a diving mishap or
  long fall.
• Patient is unconscious.
• Patient complains of weakness, paralysis, or
  numbness.
• You suspect the possibility of spinal injury.

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Immobilization in Water

• Turn the patient into the supine position.
• Restore the airway and begin breaths if needed.
• Float a spine board under the patient and secure
  the patient.
• Remove the patient from the water.

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Immobilization in Water
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• Lets practice immobilization
• Practice in the water if you can.

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Transport

• Not all submersion victims suffer cardiac or
  respiratory arrest.
• Some victims are able to cough and clear their
  airway, resuming normal ventilations on their
  own.
• All victims of drowning who require care by EMS,
  even if they are alert and demonstrate adequate
  breathing should be transported to the hospital
  for evaluation.

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Review

• Consider the following scenario and review
  questions as a group.
• If doing this CE individually, please e-mail your
  answers to
• Shelley.Peelman_at_presencehealth.org
• Use June 2015 CE in subject box.
• You will receive an e-mail confirmation. Print
  this confirmation for your records, and document
  the CE in your PREMSS CE record book.

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Submersion EmergenciesReview Questions

• 1. All of the following are causes of submersion
  emergencies except
• Exhaustion
• A full stomach
• Becoming entangled
• Use of alcohol and drugs
• Suffering trauma while in the water
• Have a medical emergency such as a heart attack
  in the water

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• What are the 3 main concerns in submersion
  emergencies?
• Rescue, C-spine injury, airway and heat
  exhaustion
• Rescuer safety, hyperthermia and fractures
• Airway, breathing and circulation
• Rescue, airway/ventilation, hypothermia and
  associated trauma

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• True or False
• Only specially trained rescuers should
• attempt to rescue and remove a submersion
• victim from deep water.

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• Suspect a C-spine injury in a submersion victim
  if they are
• Awake and talking but confused
• Unconscious
• Moving their arms and legs with no problem
• Complaining of chest pain

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• All but which of these happen to the body when
  the Mammalian Diving Reflex is activated in cold
  water?
• The patient becomes hyper-alert
• Heart rate slows
• Increased blood flow to the brain and heart
• Breathing is inhibited

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Case Study 1

• You respond with your department to a drowning at
  a hotel.
• On arrival you find a young adult male lying by
  the pool with 2 adults performing CPR.

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Scene Size Up

• The scene is safe
• The hotel pool does not have a life guard.
• Hotel personnel report that bystanders found the
  man at the bottom of the pool.
• Hotel personnel say he could not have been there
  for more than 10 minutes.
• The hotel does not have an AED.

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Initial Assessment

• Airway water is in the airway
• Breathing the man is not breathing
• Circulation a faint slow pulse is found at a
  rate of 30 beats/minute.
• How do you want to proceed?

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• Does the patient need an AED at this point?
• If a submersion victim needs an AED what safety
  precautions must be taken?

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SAMPLE History

• No one knows who the man is so no SAMPLE history
  is available.
• A hotel guest tells you that she thinks this man
  was diving off the edge of the pool earlier.
• How will this change your management of this
  patient?

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• What else could have caused a submersion
  emergency in a 20 year-old male?
• Do you need to do any other treatment or can this
  man be transported?

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Case Study 2

• You are called to a family home for an
  unresponsive toddler.
• On arrival you find a frantic young woman
  attempting CPR on a small child next to a childs
  wading pool.

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Scene Size Up

• It is a warm July day
• The wading pool has 8 inches of water in it
• The young woman is the mother of the victim
  Billy who is 3 years old.
• She states I went to get my cell phone. I was
  only gone for a few minutes. He was face down in
  the pool.

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• Do you need to assume spinal motion restriction?

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Initial Assessment

• Billy is unresponsive
• There is clear water in the airway
• Billy is not breathing
• Billy has a rapid carotid pulse.
• How do you want to proceed?
• Do you need an AED?

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SAMPLE

• Allergies none
• Medications none
• Past Medical History none healthy 3 year-old.
  Weighs 32 pounds
• Last meal Lunch 2 hours ago
• Events His mother let Billy get in the pool
  this afternoon to play. She left him for less
  than 5 minutes to get her cell phone from the
  house

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• After about 3 minutes of BVM ventilations Billy
  begins to cough.
• He vomits a large amount of clear water and
  begins to cry lustily.
• He holds out his arms for his mother.
• Pulse is 120, Respirations are 30 and deep.

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Head to Toe

• No DCAPP BLS TIC to
• Head
• Neck
• Chest
• Abdomen
• Legs, Arms Back

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Assessment Cont.

• Billy vomited about 500 cc of clear liquid.
• He has some soft rales in the bases of both
  lungs.
• He is able to be comforted by his mother.
• His lips are pale and he is shivering.

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• How is Billy doing?
• What additional care does Billy need?
• Does he need to be transported to the hospital?

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Answers

• 1. B
• 2. D
• 3. True
• 4. B
• 5. A

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• Case Study 1
• Suction airway
• Keep airway open (manual opening, oral pharyngeal
  airway)
• Ventilate with BVM with 15 liters 02 at one
  breath every 6-8 seconds.
• Begin chest compressions for slow pulse
• Begin passive rewarming (cover with dry blankets)

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• The patient does not need an AED at this point.
• Dry off his chest before attaching the AED pads.

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• If the patient was diving into the pool he may
  have a C-spine injury so Spinal Motion
  Restriction must be applied.

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• The submersion emergency could have been caused
  by
• Drug overdose
• Alcohol intoxication
• Seizures
• Cardiac episode

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• Continue CPR and transport.
• If ALS treat Bradycardia PEA and transport.

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• Case Study 2
• Spinal motion restriction is not indicated
• Suction Billys airway and begin BVM ventilations
  on 15 liters O2 at 1 breath every 6-8 seconds.
• No AED is indicated

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• Billy is doing better
• He needs
• passive rewarming with blankets
• Oxygen by Non-rebreather mask or blow by
• Reassurance
• He needs transport to the hospital.

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