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Drowning - Peds

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I m wet behind the ears for a different reason! Lifeguard the Vancouver Beaches and pools for 35 years. Regularly provide training for many aquatic facilities. – PowerPoint PPT presentation

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Title: Drowning - Peds


1
The Latest Physiology and Management of
Drowned Patients
2
There were two other people with me!!
3
Im wet behind the ears for a different reason!
  • Lifeguard the Vancouver Beaches and pools for 35
    years.
  • Regularly provide training for many aquatic
    facilities.
  • Teach surf, waterfront, pool and waterpark
    lifeguarding.
  • I have taught lifeguarding in Hawaii, South
    Africa, Hong Kong and Bangkok.
  • Taught coast guard aquatic emergency care
    programs.
  • Teach remote pre-hospital care to northern
    fishing resorts.

4
The hardships of teaching in remote fishing camps
in Northern British Columbia looking over at the
tip of the Alaskan Pan Handle.
5
Im wet behind the ears for a different reason!
  • Lifeguard the Vancouver Beaches and pools for 35
    years.
  • Regularly provide training for many aquatic
    facilities.
  • Teach surf, waterfront, pool and waterpark
    lifeguarding.
  • I have taught lifeguarding in Hawaii, South
    Africa, Hong Kong and Bangkok.
  • Taught coast guard aquatic emergency care
    programs.
  • Teach remote prehospital care to northern fishing
    resorts.
  • Ive been a paramedic/paramedic educator in
    Vancouver, full time, since 1979.
  • Other water experience ice guarding, ski
    patrol, distance ocean swimming, triathlon
    medical coverage, polar bear swims.

6
Vancouver Polar Bear Swim
7
Fastest not the Longest
8
World Drowning Epidemiology
  • An estimated 500,000 people accidentally drown
    annually
  • 2nd leading cause of unintentional injury death
  • 97 occur in low middle income countries
  • Sex ratio MF 2.21
  • World rate per 100,000 6.8

9
World Drowning Epidemiology
  • 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).

10
United States Epidemiology
  • 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).

11
United States Epidemiology
  • 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).

12
United States Epidemiology
  • 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.

13
United States Epidemiology
  • 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)

14
Pediatric Drowning Epidemiology
  • Children under age 5 have the highest mortality
    rate.
  • Children less than one year of age most
    frequently drown in toilets, bathtubs and buckets
  • Drowning in young children is often associated
    with a lapse in supervision. Among children ages
    1 to 4 years, most drownings occur in residential
    swimming pools (Brenner et al. 2001). Most young
    children who drowned in pools were last seen in
    the home, had been out of sight less than five
    minutes, and were in the care of one or both
    parents at the time (Present 1987).

15
Pediatric Drowning Epidemiology
  • Children with seizure disorders and prolonged QT
    syndrome are significantly greater risk of
    drowning.

16
Prolonged QT syndrome
  • Prolonged QT syndrome, also known as long QT
    syndrome (LQTS), refers to a group of disorders
    that increase the risk for sudden death due to an
    abnormal heartbeat.
  • Long Q-T syndrome is an infrequent, hereditary
    disorder of the heart's electrical rhythm that
    can occur in otherwise-healthy people. It usually
    affects children or young adults.

17
Prolonged 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.

18
Prolonged QT syndrome
  • 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.

19
Prolonged QT syndrome
  • 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.

20
Canadian Drowning Epidemiology
21
Congress on Drowning 2002
22
Drowning - Definition
  • Drowning is the process of experiencing
    respiratory impairment from submersion/immersion
    in liquid
  • the definition should include cases of drowning
    from all kinds of liquid aspirations, except body
    fluids (vomit, saliva, milk, amniotic fluid)
  • Patients may live or die
  • Regardless of outcome the patient has been
    involved in a drowning incident

23
Drowning - Definition
  • Classifications should appear as
  • Drowning
  • Death, Morbidity or No Morbidity
  • Other features
  • Pre-existing condition
  • Hypothermic vs normothermic
  • Associated Trauma
  • Respiratory Arrest/Cardiac Arrest

24
Drowning Process
  • Airway in liquid
  • Breath holding
  • Liquid in oral pharynx and larynx
  • Laryngospasm
  • Hypoxia
  • Large swallowing of liquid
  • Aspiration of liquid (amounts variable)
  • Changes in lungs, body fluids, blood-gas
    tensions, acid-base balance, and electrolyte
    concentrations
  • Hypoxemia

25
Drowning Process
  • Surfactant washout
  • Pulmonary hypertension
  • Shunting
  • All contribute to Hypoxemia
  • The patient can be rescued from this cascade of
    hypoxia at any time during the drowning process

26
SEQUENCE OF EVENTS
  • Initial period
  • characteristics of a drowning person
  • panic
  • heart and metabolic rate increase
  • breath holding which leads to respiratory
    acidosis

27
Respiratory Acidosis
Normal body pH is 7.4
CO2 H20 H2CO3 HCO- H
28
SEQUENCE OF EVENTS
The Terminal Gasp Laryngospasm
Aspiration
29
  • laryngospasm
  • glottic spasm
  • hypoxia
  • child vs adult

30
  • aspiration
  • pulmonary edema
  • atelectasis
  • shunting

31
Pulmonary Edema
Reduced perfussion O2
CO2
Alveoli
O2
capillary
CO2
Interstitial fluid shift
32
Ischemia-Reperfusion
MECHANISMS
p-selectin
ß2 - Integrins
Adhesion
WBC
Tissue damage
endothelium
33
Atelectasis
collapsed alveoli
surfactant
Aspiration leads to collapse of the alveoli due
to loss of surfactant and pulmonary edema
normal alveoli
34
Metabolic Acidosis
  • Aerobic Metabolism (with O2)
  • glycolysis Krebs cycle
  • produces 38 ATP
  • Anaerobic Metabolism (without O2)
  • produces only 2 ATP (only glycolysis)
  • does not break down lactic pyruvic acid,
    lowers pH

35
Secondary Problems
  • aspiration may lead to -
  • unappreciated pulmonary edema
  • atelectasis
  • pulmonary infections (pneumonia)
  • ARDS

36
Preceding signs and symptoms
  • initial prolonged spasmodic coughing
  • dyspnea
  • inspiratory crackles on auscultation
  • signs of shock
  • reduced exercise tolerance
  • S.O.B. tachycardia

37
Other Complications or Factors
  • Hypothermia
  • Mammalian dive reflex
  • Drugs and alcohol
  • Hyponatremia
  • Cervical spine injuries
  • Seizures

38
Pulmonary Hypertension
  • When someone has PH, the pulmonary arteries
    become narrow or blocked. This means the heart
    has to work harder to push the blood through the
    lungs. Over time, the heart cannot keep up. Less
    blood flows through the lungs to pick up oxygen.
    This results in PH symptoms such as trouble
    breathing, dizziness, or feeling tired.

39
Drowning Process
  • Dry vs Wet
  • Traditionally this has been used to identify
    those who have aspirated liquid into the lung and
    those who have not.
  • Frequently it is not possible to make this
    determination
  • By definition all drowning occurs in liquid and
    therefore all drowning is wet.

40
Drowning Process
  • Active vs. Passive vs. Silent drowning
  • These terms should be abandoned in favor of the
    terms witnessed and unwitnessed

41
Drowning Process
  • Secondary Drowning
  • This term has been used to describe an unrelated
    event (seizure, spinal injury, or MI)
  • This term has also been used to describe the
    development of ARDS
  • This term should be abandoned

42
Drowning Process
  • Drowned and Near-drowned
  • Have been used for decades to describe outcomes
    dead or alive
  • The term near-drowning has been used to describe
    patients who have subsequently died from
    drowning.
  • Near-drowning should no longer be used
  • The term Drowned will continue to refer to
    persons who died from drowning

43
Understand the unique considerations for drowning
events in children
  • Drowning common etiology of pediatric
    out-of-hospital cardiac arrest.
  • Less pulmonary oxygen reserve due to smaller
    residual volumes
  • Develop hypoxia/hypoxemia faster due to higher
    metabolic rate.

44
Understand unique considerations for drowning
events in children
  • Children less likely to have pre-existing illness
  • Protective Hypothermia more likely in Children.
  • Effects of Hypothermia are more frequently
    negative.

45
Even if they dress for the part!
46
Vancouver Polar Bear Swim
47
Understand unique considerations for drowning
events in children
  • Outcomes often closely related to duration of
    submersion.
  • Poor outcomes with prolonged submersion
  • (gt25min)

48
Understand unique considerations for drowning
events in children
  • Adolescents tend to endanger themselves by high
    risk behaviors, including intoxication.
  • Drowning in children is often a shocking
    surprise, fast, and emotionally challenging.

49
Prevention of Pediatric Drowning
  • Educate adults about supervision
  • Seconds count
  • Educate our seizure disorder families
  • Swim and bath with close supervision
  • Fence or barrier, areas of water
  • Promote water safety and learn to swim
  • Train general population in resuscitation

50
Who needs further medical attention after rescue
from water?
  • The following should be sent to hospital
  • Any loss of consciousness
  • Any resuscitation (Rescue Breathing or CPR)
  • Any concurrent condition (seizure, spinal injury,
    asthma, etc)

51
Accidental Hypothermia
  • Epidemiologically more bad than good
  • Hypothermic protective effect when
  • Immersion in very cold (near freezing or below)
  • Rapid central cooling with a decline in cerebral
    metabolism before hypoxic-ischemic injury.
  • Hypothermia can not render a protective effect if
    it is preceded by hypoxemia

52
Accidental Hypothermia
  • Detrimental effects of Hypothermia
  • Arrhythmias
  • A core temp lt28c can induce VFib, which may be
    refractory to defib until temp has been raised.
  • Coagulopathy
  • Impaired immune function
  • Reduced myocardial function
  • Acidosis
  • Electrolyte abnormalities

53
Accidental Hypothermia
  • Treatment
  • Hemodynamically stable patients
  • Rewarm using warmed humidified inspired gases,
    warmed IV fluids, heating blankets, warm air
    surface mechanisms
  • Hemodynamically unstable patients
  • Rewarm using the above plus bladder irrigation,
    gastric and pleural lavage, peritoneal or
    hemodialysis with warmed fluids and
    Cardiopulmonary bypass (CPB)

54
Accidental Hypothermia
  • Practical points
  • Core temperature monitoring needed
  • rectal, esophageal or central line preferred
  • Ideal rate of temperature rise is unknown
  • Heat fluids in warmer or microwave to 37c for
    infusion

55
Therapeutic Hypothermia
  • Mild hypothermia (32-34c) may be helpful to
    improve cerebral function outcomes
  • This is case study data only
  • There has not been a trial in drowning
  • Trials in animal models, and case reports in
    children, infant and neonatal arrests suggest
    this might be helpful
  • Time to onset is unknown

56
Aquatic Session
  • How would you respond to a call at a hotel
    swimming pool, private pool, public pool, lake,
    river, ditch.
  • You dont 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

57
Treatment
  • 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

58
Treatment (contd)
  • Responsive struggling patient
  • Get patients head and shoulders above the water
  • Limit patients 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

59
Treatment (contd)
  • 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.

60
Inflammatory Response Attenuated by PPV
MECHANISMS
p-selectin
WBC
WBC
  • Reversible inhibition
  • of ß2 - Integrins by
  • positive pressure ventilation

61
Oxygenation
paO2
62
Treatment (contd)
  • Unresponsive patient
  • get patients head out of the water
  • assess ABCs, DO NOT perform the Heimlich
    maneuver or abdominal thrusts or break the
    patient
  • limit patients gross motor movements
  • if possible, remove from water immediately
  • ventilate patient when regurgitation can be
    managed (patients head or body repositioned to
    prevent aspiration) or if an extended time until
    removal

63
Treatment (contd)
  • Unresponsive patient (contd)
  • once removed, position in lateral position
    unless efficient suction and definitive airway
    maintenance is available
  • reassess circulation - manage ABCs
  • positive pressure ventilation
  • administer oxygen (high percentage)
  • protect from environment/ keep warm
  • be prepared for change in patient status

64
Near-Drowning Classification
  • 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)
65
NEAR-DROWNING/DROWNING - CLASSIFICATION and
TREATMENT - BLS
Check the victim - do you listen me ?
No
Yes
Warning if any suspect cervical trauma, be
careful while open airways - use special
techniques to do so.
Open airways - listen, feel and hear the
respiration
Yes
Check cough and/or foam in mouth/nose
No
BREATH PRESENT ?
Give 2 mouth to mouth and check the arterial
carotid pulse
Absent
LARGE AMOUT OF FOAM IN MOUTH/NOSE
Rescue
CAROTID PULSE ?
Evaluate and release from the accident site
without further medical care
Yes
No
RADIAL PULSE PALPABLE ?
Grade 6
Grade 5
Yes
No
SMALL AMOUNT OF FOAM IN MOUTH/NOSE
COUGH , WITHOUT FOAM IN MOUTH/NOSE
Start complete CPR with 15 external cardiac
compression and alternate with 2 mouth to mouth
until restore normal cardiopulmonary function, or
lifeguard exhaustion or EMS arrived.
Continue mouth to mouth at 12 to 20 p/min until
restore normal breath
Grade 4
Grade 3
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.
Grade 1
Grade 2
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. 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.
After restore spontaneous breathing and pulse
treat as grade 4
Basic Life Support Near-Drowning/Drowning
algorithm Szpilman 1998.
Hospitalization
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 victims airway, evaluate
breathing, and beginning mouth to mouth if
necessary without too many difficulties - In Deep
water The lifeguard should place the victims
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 victims
pulse or start compressions while in the water.
After the initial mouth to mouth check the
victims 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
victims 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.
66
Classification of Immersion Incidence
  • Group 1 No evidence of inhalation
  • Group 2 Clinical evidence of inhalation,
  • but with adequate ventilation
  • Group 3 Clinical evidence of inhalation
  • but inadequate ventilation
  • Group 4 Cardio-respiratory arrest

67
Group 1 2 - adequate ventilation
  • Criteria for 6 hour discharge
  • - No fever, no cough, no respiratory symptoms
  • - No crepitations in lungs
  • - Normal PaO2 on room air
  • - Normal chest x-ray

68
Group 3 compromised ventilation
  • Oxygen by mask or CPAP
  • Monitor Sa02 and PaO2
  • IV infusion of warmed fluids
  • Treat hypothermia and metabolic acidosis
  • Chest x-ray, CBC, Electrolytes, glucose
  • If further deterioration
  • Intubate and ventilate with 100 O2
  • IPPV and PEEP if necessary
  • ICU if necessary

69
Understand unique considerations for drowning
events in children
  • Nuances of Resuscitation
  • 4 phases
  • Pre-arrest phase
  • No-flow phase of untreated cardiac arrest
  • Low-flow phase which occurs during CPR
  • Post-resuscitation phase
  • Interventions need to focused to phase

70
Understand unique considerations for drowning
events in children
  • Pre-arrest phase
  • Stop the process by rescue and restore breathing
    of air
  • Consider pre-existing condition
  • Seizure disorder
  • Prolonged QT
  • Focus on Prevention
  • Supervision, fencing,

71
Understand unique considerations for drowning
events in children
  • No-Flow Phase
  • Prompt effective resuscitation is essential
  • Delay gt8 min is usually lethal
  • Hypoxic etiology (unlike most adult arrests)
  • Reversal of hypoxia is needed
  • Fluid in lungs may be low volume
  • Fluid in GI system is usually high volume
  • Aspiration is a large issue usually of GI
    origin

72
Understand unique considerations for drowning
events in children
  • Low-Flow Phase (CPR)
  • Bystander CPR essential for recovery
  • Encouraging all citizens to get first aid and CPR
    education
  • Fast start improves outcomes
  • Push hard, push fast and minimize interruptions.
  • Rates and ratios are less important than taking
    action.

73
Current Resuscitation Guidelines
74
Understand unique considerations for drowning
events in children
  • Post-Resuscitation Phase
  • VT VF do occur but rare
  • Except in severe hypothermia
  • Long QT syndrome should be considered
  • Rarely occurs prior to Cardiac Arrest
  • Reduces outcomes
  • Excessive hyperventilation
  • Hyper/hypocapnia
  • Hyperglycemia

75
Understand unique considerations for drowning
events in children
  • Interesting option issues
  • Not been directly shown to improve outcome in
    Drowning
  • Deep hypothermia not helpful
  • Hyperventilation not good
  • Prophylactic antibiotics not helpful
  • Steroids not helpful
  • Surfactant replacement may be helpful
  • Dobutamine is preferred inotrope

76
Understand unique considerations for drowning
events in children
  • Attempt resuscitation in all children unless
    clinical indicators of poor outcome are present
  • Rigor mortis
  • Documented to be submerged in non-icy water, for
    prolonged period (gt60min)
  • No response to resuscitation effort of 1 hour
    with core temperature above 32c.

77
References
  • Dr. Steve Beerman,
  • Department of General Practice, NRGH
  • Longstanding member/President International
    Lifesaving Federation
  • ILCOR Advisory Statement
  • Recommended guidelines for uniform reporting of
    data from drowning the Utstein style
  • Resuscitation 59 2003, 45-57
  • Handbook on Drowning
  • J Bierens, Springer Press, Jan 2006
  • International Lifesaving Federation
  • Medical Committee - Position Statements
  • www.ilsf.org
  • Lifesaving Society
  • National Drowning Trends Report July 2003
  • www.lifesaving.ca

78
  • 1. Scenario Practice
  • 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.

79
  • 2. Scenario Practice
  • 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.

80
  • 3. Scenario Practice
  • An obese (300 lbs.) male is discovered by his
    wife in their home indoor pool. He is
    unresponsive.

81
  • 4. Scenario Practice
  • 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.

82
  • 5. Scenario Practice
  • 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.

83
  • 6. Scenario Practice
  • 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.

84
  • 7. Scenario Practice
  • 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.

85
  • 8. Scenario Practice
  • 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
    ABCs 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.

86
Summary
  • Your own safety comes first. This can be
    difficult to consider when young children are
    involved! (VAC example)
  • Dont forget, cervical spinal injuries should be
    considered with young adults where jumping or
    diving was possible. ABCs still take priority!
    (Hawaii example, CGP example)
  • A patient who appears calm may in fact be
    suffering from severe aspiration problems. (White
    Cliff Scuba diving example)
  • 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)
  • Avoid gross motor movement, especially if
    hypothermic.
  • Drowning can be a very subtle and uneventful.
    (YMCA Pool example)
  • Come to the pool to put this into practice.

87
Super Granny Defender of Justice
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.
88
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.
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