pre hospital military drowning treatment

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Drowning Justin Sempsrott, MD University of Nevada Emergency Medicine Residency www.LifeguardsWithoutBorders.org [email protected]

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Page 1: Pre hospital military drowning treatment

Drowning Justin Sempsrott, MD

University of NevadaEmergency Medicine Residency

www.LifeguardsWithoutBorders.orgJustin@LifeguardsWithoutBorders.org

Page 2: Pre hospital military drowning treatment

Who am I?

Page 3: Pre hospital military drowning treatment

History of drowning treatment

The “Great of Aleppo” held upside down after drowning. 1237 B.C.EFrom the Pylon of the Ramesseum, Thebes. Photographed by Mr. W. M. F. Petrie

Page 4: Pre hospital military drowning treatment

History of drowning treatment

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History of drowning treatment

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Dr. Frank Eve

Popular Science July 1946

Page 7: Pre hospital military drowning treatment

History of drowning treatment

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Objectives

• Understand definition of drowning

• Appreciate epidemiology

• Management

• Disposition of drowning patients

• Don’t blow smoke up pt’s (or colleagues) asses

Page 9: Pre hospital military drowning treatment

Definition

•Before 2002– 33 Different Definitions

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Definition

•“The process of experiencing respiratory impairment from submersion/immersion in liquid”

•Only 3 outcomes – – Death– No Morbidity – Morbidity

http://publications.nigms.nih.gov/findings/mar07/otto_files/textmostly/slide9.html

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Definition• Old terms that should NOT be used

– Dry – Wet– Active– Passive– Secondary– Near Especially

• No difference between salt, chlorine, and freshwater

Lima, Peru, 2009

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Who is Drowning?

•WHO Global Burden of Disease– 388,000 Drowning Deaths*

• 97% in low to middle income countries+1.55 million unreported drowning deaths+6.08 million drowning “incidents”

* 7.63 million Drowning persons

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Who is Drowning?

•2nd leading cause of unintentional injury death (1st is MVC’s)

•~10 Deaths/Day in US– 10-20 Drown with morbidity– 20-30 Drown w/o morbidity

•Male:Female 4:1

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Who is drowning?

•Disease of youth– 64% of deaths are<30 yrs– ¼ of deaths are < 5 yrs

•Alaska, Arizona, California, Florida, Hawaii, Montana, Nevada, Oregon, Utah, & Washington

•Drowning surpasses all other causes of death to children age 0-14

•Nationally, In 2007, of all children 1-4 years old who died, 30% died from drowning

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Who is Drowning?

•Excludes Floods/Boating/Natural Disasters– 2006 USCG Responded to 4,967

incidents•3,474 injuries

•710 deaths– 70% Drowning

90% without lifejackets 50% (+) EtOH

http://nicedeb.files.wordpress.com/2008/05/sinking-boat.jpg

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Who is Drowning?

• Hurricane Katrina

• 4/6 Rio Flood– 200+ dead

• 8/1 Pakistan Flood– 1100+ dead

• Indonesia Tsunami– 169,752 dead– 127,294 missing

http://www.gearbits.com/images/banda_aceh_tsunami.jpg

CDC MMWR March 10, 2006 / 55(09);239-242

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So what?

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“His boots were weighing him down, and his uniform dragged and resisted the water as he tried to swim. He had trouble staying afloat and started making his way back to shore but couldn’t. He succumbed to the river.”

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Pvt. Cody Hendrickson

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Chief Special Warfare Operator (SEAL) Eric Shellenberger

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•16 y/o ♀– HPI

• Pulled from ocean

• No LOC

• + Submersion

– PEA- Small foam at

mouth/nose

-Active cough

B- Tachypneic

C- Cool extremities

D- Combative

Confused

AYUDAME !!!!!!

Page 29: Pre hospital military drowning treatment

•15 y/o ♂– HPI

• Pulled from ocean

• No LOC

• + Submersion

– PEA- Large foam at mouth/nose - Active coughB- TachypneicC- Cool

extremitiesD- Confused,

somnolent,GCS – E2 V4 M5

Page 30: Pre hospital military drowning treatment

Maldito!!

•What next?– Sick or Not Sick– Transport or

No Transport

•First, a review of physiology

Page 31: Pre hospital military drowning treatment

Physiology of Drowning

• Breath holding during struggle

• Attempt to inhale water results in laryngospasm– Usually little (30mL) or NO fluid in lungs

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Physiology

•Water may enter (1-3mL/kg)– Before laryngospam – Relaxation after unconsciousness

© 2009 Nucleus Medical Art, Inc.

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Mechanism

•Surfactant wash-out

•Direct cellular injury

•Hypoxic Vasoconstriction

•Bronchospasm

• Inflammation

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Physiology

•V/Q Mismatch

• Compliance

• O2 Delivery to brain

Page 35: Pre hospital military drowning treatment

Physiology

•Cause of death or morbidity – Anoxic Brain

Injury – Acidosis

•Treatment Oxygen to the

Brain

Page 36: Pre hospital military drowning treatment

Physiology

"A lack of oxygen does not simply involve stoppage of the engine, but total ruin of what we took to be the machinery."  

-JS. Haldane 

“The drum generally heals up; and if a hole remains in it, although one is somewhat deaf, one can blow tobacco smoke out of the ear in question, which is a social accomplishment."

Page 37: Pre hospital military drowning treatment

When to Transport?

•41,729 oceanfront lifeguard rescues in

Rio de Janeiro from 1972 – 1991– 93% Released at scene without further

treatment– 2,304 required additional medical care

•89% lived

•11% died

Page 38: Pre hospital military drowning treatment

When to Transport?Grade Signs/Symptoms (s/sx) Mortality Treatment

1 Cough, no foam at mouth/nose -LCTAB

0% Thorough history – Release home with education

2 Small amt foam in mouth or nose, +Rales

0.6% N/C O2 - Hospital

3 Large amt foam, normal BP (+radial pulse)

5.2% ETT/NRB O2 - Hospital

4 Large amt foam, LOW BP (-radial pulse)

19.4% ETT/NRB O2 , IV Fluids -

Hospital5 Respiratory Arrest 44% ETT/NRB O2 , IV Fluids -

Hospital6 Cardiopulmonary Arrest 93% ETT/NRB O2 , IV Fluids, AED –

HospitalDo not resuscitate if down >1 hour

Page 39: Pre hospital military drowning treatment

When to Transport?Grade Signs/Symptoms

(s/sx)Mortality Treatment

1 Cough, no foam at mouth/nose -LCTAB

0% Thorough history – Release home with education

2 Small amt foam in mouth or nose, +Rales

0.6% N/C O2 – Hospital

3 Large amt foam, normal BP (+radial pulse)

5.2% ETT/NRB O2 - Hospital

Page 40: Pre hospital military drowning treatment

Do we transport?•16 y/o ♀

– HPI• Pulled from

ocean

• No LOC

• + Submersion

– PEA- Small foam at

mouth/nose -Active coughB- TachypneicC- Cool

extremitiesD- Combative Confused

•15 y/o ♂

– HPI• Pulled from ocean

• No LOC

• + Submersion

– PEA- Large foam at mouth/nose - Active coughB- TachypneicC- Clammy

extremitiesD- Confused,

somnolent,GCS – E2 V4 M5

Grade Signs/Symptoms (s/sx) Mortality Treatment

2 Small amt foam in mouth or nose, +Rales

0.6% N/C O2 – Hospital

3 Large amt foam, normal BP (+radial pulse)

5.2% ETT/NRB O2 - Hospital

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• 15 y/o ♂– “Emergency Dept”

“Treatment”– O2 N/C @ 2 LPM

– 1 mg IM Dexamethasone– B12 – 10,000 μg IM– N-Acetylcysteine 20% IV

– 30 mL (200mg/mL)

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Page 47: Pre hospital military drowning treatment

Thomas Eakins' The Gross Clinic, (1875)

“A rude unhinging of the machinery of life”

Page 48: Pre hospital military drowning treatment

You assume care of 16 y/o

• A- Patent, copius secretions

• B- Tachypneic, RR 36, perioral cyanosis

• C- Cool extremities – ST 130 bpm, thready

• Critical Actions?

Page 49: Pre hospital military drowning treatment

Airway

• Sedate and intubate– Pediatric– Laryngospasm

• RSI, PPV, Jaw thrust Cricothyrotomy, Lidocaine

– Airway obstruction?• Sand, Mud, Del Taco

– Dec Compliance– Vomitus

• 86% of Drowning resuscitations

http://www.emsresponder.com/article/photos/1130360989690_10.jpg

Page 50: Pre hospital military drowning treatment

Hypoxic Arrest

•Cardiac BLS/ACLS– Heart stops, oxygen in blood needs

circulating– C,A,B

•Drowning & Ped Arrest BLS/ACLS– Heart stops because no oxygen in blood– A,B,C

Page 51: Pre hospital military drowning treatment

Survival

• Bottom Line – Pt’s who make it to hospital alert, seldom die– Pt’s comatose on arrival are difficult to predict– Current guidelines

• Continue resuscitation for 25 total minutes of CPR

• Continue if <1 hr submersion time

• Continue to core temp 90°F

• In Hospital - continue ICU care for 48 hours

Page 52: Pre hospital military drowning treatment

Pre-Hospital Prognosis?

– “Resuscitation attempts should always be continued in the pre-hospital setting because of the difficulty of predicting outcome with sufficient accuracy at the scene”

Bangladesh, Lifeguards Without Borders, Aug2009

Page 53: Pre hospital military drowning treatment

What about sending them home?

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OK to send home after 4-6 hours

•Asymptomatic– GCS >13– Respiratory Efforts

– SpO2 > 95% on room air 

– No ACLS PTA

Page 55: Pre hospital military drowning treatment

Special considerations

Page 56: Pre hospital military drowning treatment

Hypothermia

•Hypothermia?– Is it protective? Harmful? What about post-

resus?

•Water at 91.4°F is thermally neutral

•Conductivity is 25-30 x air

– Case Reports?

•21 y/o ♀, 45 min 4°C

•5 y/o ♂, 40 min 0°C

•3 y/o ♀, 30 min 8°C

•2.5 y/o ♀, 66 min (19°C)

Special considerations

Page 57: Pre hospital military drowning treatment

Hypothermia

• Hypothermia?

– Mammalian Diving Reflex• 15%-30% of Humans

– Cold and Dead?• Rewarm

– What about post-resus?• Therapeutic Hypothermia has been shown to decrease

cerebral oxygen demand and improve neurologic outcomes• Area of active research

Special considerations

Page 58: Pre hospital military drowning treatment

Therapeutic Hypothermia

•Bottom line– Warm pt to

90°F•If dead, their

dead

•If not dead, stay there *

*Only if hospital protocols are in place

Special considerations

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C-Spine

•Less than 1% of Drowning patients, all with significant mechanism of injury– Routine C-Spine

immobilization is unnecessary

Special considerations

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AED’s in Drowning

•V-Fib/V-Tach?

•Rescuer Safety

•Do not delay chest compressions

•Minimize interruptions

Special considerations

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Heimlich Manuever

• Increased risk of aspiration– Delays ventilation– Usually <30mL fluid in lungs– Watch for vomiting !!!

Special considerations

Page 62: Pre hospital military drowning treatment

“Do it by the book… but be the author.”

Manual techniques of artificial respiration. Copyright 1950 American Medical Association.

Page 63: Pre hospital military drowning treatment

“Death is not the enemy but occasionally needs help with timing. ”

http://lifeinthefastlane.com/2009/04/laws-for-the-navigation-of-life/

Dr. Peter Safar (12 April 1924 – 2 August 2003)

Page 64: Pre hospital military drowning treatment

Summary

• Understand definition of drowning– Process, not an outcome

• Appreciate epidemiology – Highly prevalent worldwide, children <4

• Management– O2 O2 O2, Laryngospasm, Vomitus, warm pt to 90°F

– Hypoxic vs Cardiac cause of arrest

• Disposition of drowning patients– Home or ICU

• Don’t blow smoke up pt’s (or colleagues) asses– Bring your “A” game, be able to back it up

Page 65: Pre hospital military drowning treatment

Discussion

[email protected]

Page 66: Pre hospital military drowning treatment

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Bell TS, Ellenberg L, McComb JG: Neuropsychological outcome after severe pediatric near-drowning. Neurosurgery 1985;17:604-608. Nussbaum E: Prognostic variables in nearly drowned, comatose children. Am J Dis Child 1985;139:1058-1059. Simcock AD: Treatment of near drowning: A review of 130 cases. Anaesthesia 1986;41:643-648. Weinberg HD: Prognostic variables in nearly drowned, comatose children (letter). Am J Dis Child 1986;140:329. Allman FD, Nelson WB, Pacentine GA, et al: Outcome following cardiopulmonary resuscitation in severe pediatric near-drowning. Am J Dis Child 1986;140:571-575. Nichter MA, Everett PB: Childhood near-drowning: Is cardiopulmonary resuscitation always indicated? Crit Care Med 1989;17:993-995. Nagel FO, Kibel SM, Beatty DW: Childhood near-drowning factors associated with poor outcome. S African Med J 1990;78:422-425. Quan L, Wentz KR, Gore EJ, et al: Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County, Washington. Pediatrics 1990;86:586-593. Bierens JJLM, van der Velde EA, van Berkel M, et al: Submersion in the Netherlands: Prognostic indicators and results of resuscitation. Ann Emerg Med 1990;19:1390-1395. Ashwal S, Schneider L, Thompson J: Prognostic implications of hyperglycemia and reduced cerebral blood flow in childhood near-drowning. Neurology 1990;40:820-823. Kemp AM, Sibert JR: Outcome in children who nearly drown: A British Isles study. BMJ 1991;302:931-933. Quan L, Kinder D: Pediatric submersions: Prehospital predictors of outcome. Pediatrics 1992;90:909-913. Lavelie JM, Shaw KN: Near drowning: Is emergency department cardiopulmonary resuscitation or intensive care unit cerebral resuscitation indicated? Crit Care Med 1993;21:368-373.Christensen DW, Jansen P, Perkin RM. Outcome and acute care hospital costs after warm water near drowning in children [erratum appears in Pediatrics 1998; 101(1 Pt 1):105]. Pediatrics 1997; 99(5):715-721.   Simcock A:  Hospital Treatment: Treatment Protocols - Emergency Room.  In Bierens JJLM (ed): Handbook on drowning: prevention, rescue, treatment, Berlin, Springer, 2006, pp 392-6. Causey AL, Tilelli JA, Swanson ME. Predicting discharge in uncomplicated near-drowning. Am J Emerg Med 2000;18(1):9-11.

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