The difference is survival. . . Drowning is a significant ... Near Drowning May …The difference is survival. . . Drowning is a significant cause of disability and death. The classic
Drowning is a significant cause of disability and death. The classic image of a victim helplessly gasping and thrashing in the water rarely is reported. A more ominous scenario of a motionless individual floating in the water or quietly disappearing beneath the surface is more typical. Colorado averages 84 people/ year who are victims of drowning or submersion injury. According to MV stats, we are dispatched to between 2-4 persons/year as drownings. And we’re getting into the season. . .
New Definitions. . .
• Drowning – The process of experiencing respiratory impairment from submersion/immersion in liquid. (WHO 2002)
• Outcome – Includes delayed morbidity/death; death; or life without morbidity.
E.F. van Beeck, C.M. Branche, D. Szpilman, et alBulletin of the World Health Organization 2005; 83:853-856
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In the mid 90’s, the World Health Organization and World Bank sponsored a study on the Global Burden of Disease, which found that drowning was a much underappreciated cause of death worldwide. The first World Conference on Drowning, held in Amsterdam in 2002, developed a new definition of drowning to simplify reporting of injuries and deaths due to immersion. The goal of standardizing definitions is to develop a more comprehensive and useful database. That data can then be used to improve prevention efforts. Eventually, Utstein-style data reporting may be required for EMS. That time isn’t here yet, but its coming. Until then, it is worth noting that drowning is defined as “respiratory impairment from submersion/immersion in a liquid”, versus water. This is to take into account submersions in agricultural substances, such as drownings in settling ponds, etc. Each year drownings in substances other than water occur in Iowa, Kansas, Nebraska, Oklahoma and Colorado. Outcomes include delayed morbidity and death; death; or life without morbidity. Morbidity refers to any deficit or medical problem that might result short of death. Examples include, brain damage, paralysis, permanent lung damage, etc. Think of mortality as death and morbidity as any type of disability.
National Facts:• 8000 deaths a year in the United States
1500 in young childrenTwo categories: 1) Water transport related & 2) Non
water transport related
• Submersion events estimated at 2-500 times documented drowning
• Second lead cause of death in children under 14 years
• Fifth cause of accidental death overall Swimming, Boating, Scuba, Motor vehicle, Unknown
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Drownings can be separated into two main categories: Water transport-related and Non-water transport-related. Water transport related drownings include those that occur as a result of submersion of a boat, kayak, tubing, rafting or other watercraft as well as those that occur when someone falls from, is ejected from, or is washed overboard. Non-water transport-related drownings may result from recreational activities (for example, waterskiing, diving, swimming, or playing in or near irrigation ditches, lakes and rivers), in swimming pools, or in bathtubs. Because non-fatal submersion events do not always medical attention, the actual number of non-fatal events is considered to be much higher.
What Happens In Colorado:
• Average of 46/year die from drowning• Average of 38/year are hospitalized for
submersion injury• 91% of drowning deaths and 98% of
submersion injury are non-water transport-related
• Non-Water transport-related drowning in CO (0.9/100,000) is slightly lower than the US rate (1.2/100,000)
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These are interesting statistics but don’t tend to mean much until we relate the numbers to the people. . .
Specific to Colorado:
• Last 2 Swimmers Recovered from the Colorado River (May 18, 2009)
• 2-Year-Old Boy Drowns In Creek In Vail, CO (June 28, 2009)
• Backcountry Snowboarder Drowns In Colorado (January 18th, 2010)
• CO Springs man saves two children from drowning (March 3, 2010)
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The two swimmers who were recovered were planning on swimming across the Colorado River. They disappeared after 15 minutes. The 2 y/o drowned when his mother was dealing with her other child. His body was recovered about 1 mile downstream. The snowboarder jumped from a helicopter, began snowboarding, fell backward into a creek and got her helmet stuck between two rocks. In CO Springs a man walking in the park noticed two young boys on the ice, when he turned around and discovered they disappeared he investigated, discovered they fell through the ice and pulled them out. These are just a few of the incidents that have occurred within the last 10 months. �
Facts to Keep in Mind• Boys more than girls; mostly
Males 12:1 over females in boatingMale 5:1 over females in non-boatingFemales 2:1 over males in bathtubs
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Nationally, males out number females 12 to 1 in boating incidences and 5 to 1 in non-boating drownings. In Colorado the rate is three times higher for males than for females. This gender difference is particularly true for water transport-related deaths. From 2001-2003, all 14 Coloradans who died in a water transport-related drowning were male.
Facts to Keep in Mind• Under 1 year
Toilets, Buckets, Bath tubs
• Age 1 – 4Swimming pools, Hot tubs, irrigation ditches, and creeks
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Infants most often drown in bathtubs when left unattended or when the supervising adult becomes distracted. Toddlers are more likely to drown in irrigation ditches (particularly in rural areas), swimming pools, hot tubs, ponds and creeks. Toddlers are curious near water, yet unable to comprehend the potential danger. They drown silently, not splashing or calling for help. Childhood drownings usually occur silently and quickly, typically within a matter of minutes. It takes only two minutes after submersion for a child to lose consciousness, and between four and six minutes for irreversible brain damage to occur. In Colorado, 35% of immersion episodes in children are fatal; 33% result in some degree of neurologic impairment.
Children ages 5 and older more often drown during recreation, particularly in open bodies of water such as lakes, rivers, and reservoirs. Nationally, alcohol is involved in an estimated 25-50% of adolescent and adult deaths associated with water recreation. In Colorado, alcohol use is a contributing factor in up to 50% of drownings involving adolescent boys.
More Facts (cont.)
• Peak incidentsChildren under 4 years of ageAdults 15 – 24 years40% Saturday and Sundays66% between May and August
• Costs$78,000 ED visit$4.5 million lifetime care$6.2 billion annually under 14 years of age
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We are getting into the peak season for drownings and submersion injury. According to our statistics from 2009, we can expect 2-4 submersions/drownings in 2010. How quickly a child is found and rescued after submersion is often the deciding factor in how favorable his or her outcome will be.
The WHO Definition Helps, But. . .
• Submersion Injury – Frequently used to indicate non-fatal injury from drowning event.
• Depth Injury – Used in scuba related injury and can include decompression sickness and barotrauma
• Terms No Longer Used – Secondary Drowning, Wet/Dry Drowning, Passive Drowning, etc.
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When concerning the medical aspects of submersion injury, there are a few more definitions to keep in mind. Secondary drowning is a term used to refer to death from complications of submersion injury that occurs more than 24 hours after the event. Immersion syndrome is a term used in cold water drownings. Depth injury is used in relation to diving. While depth injury is not typically a problem indigenous to Colorado, many residents in Colorado go diving and then return to Colorado, sometimes too soon. Terms such as secondary drowning, wet/dry drowning and passive drowning are no longer used.
Drowning and Submersion Injury differ only in the immediate result
•Submersion Injury–Non-fatal drowning events–Usually have secondary complications–Must have medical evaluation
•Drowning–Used for all outcomes, including death
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Secondary complications include atelectasis, pulmonary edema, hypoxemia/acidosis, hypotension, electrolyte imbalance and cardiac dysrhythmias. Therefore, when non-fatal drowning has occurred, at the very least, a 6 hour observation period is required. Remember, drowning refers to delayed morbidity or death; death; or life without morbidity.
In Any Case. . .
• Principle physiologic consequences:Prolonged hypoxemiaAcidosisMulti-organ effects of these processes
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In any case, when a drowning occurs, the principle physiologic consequences of drowning are prolonged hypoxemia, or lack of oxygen in the blood; acidosis, due to increased production of and inability to get rid of CO2; and the multi-organ effect of both these processes.
How it Starts. . .
• Immersion into waterFollowed by. . .
• Submersion under the waterUnable to rescue themselves
Fatigue, trauma, ETOH, medical event or condition, water currents, or any combination
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This entire process starts when someone gets in the water and can’t get themselves out. This may be due to fatigue, trauma, alcohol, a medical event (such as a seizure, Parkinsons’s, AMI, stroke, etc.), water currents or any combination. Then the process begins. . .
The Process• Gasping for air (possible aspiration)• Swallowing of water• Immersion stimulates hyperventilation • Voluntary apnea• Laryngospasm
– Variable degree and duration• Hypoxemia• Unconsciousness
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After initial gasping and possible aspiration, immersion stimulates hyperventilation, followed by voluntary apnea (holding breath) and a variable degree and duration of laryngospasm. This leads to hypoxemia.
Events after Loss of Consciousness
• After loss of consciousnessLaryngospasm relaxes• 10% - 15% remains until cardiac arrest • 85% - 90% Water enters lungs
Asphyxia leads to relaxation of the airway, which permits the lungs to take in water in many individuals (previously referred to as “wet drowning”), although most patients aspirate less than 4 ml/kg of fluid. Approximately 10-20% of individuals maintain tight laryngospasm until cardiac arrest occurs and inspiratory efforts have ceased. These victims do not aspirate any appreciable fluid (previously referred to as “dry drowning”). Metabolism continues and, in the absence of sufficient oxygen, severe metabolic acidosis occurs.
Involuntary Gasping (Aspiration of water into the larynx)
Laryngospasm (variable degree/duration)
Brain Injury/Brain Death
Cerebral Hypoxia/Acidosis/Cardiac Arrest
Dry 10-20% Wet
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Depending upon the degree of hypoxemia and resultant acidosis, the person may develop myocardial dysfunction and electrical instability, cardiac arrest, and central nervous system (CNS) ischemia. Most individuals are found after having been submerged in liquid for an unobserved period of time. In children, ingestion of large volumes of freshwater, rather than aspiration, is the likely cause of clinically significant electrolyte disturbances, such as hyponatremia.
Target Organ: Lungs
Aspiration of 1-3 ml/kg fluid significantly impairs gas exchange
Hypoxia and ischemic acidosis causes 2o injury to other systems
Aspirated fluid produces vagally mediated pulmonary vasoconstriction and hypertension
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The target organ of submersion injury is the lung. Aspiration of 1-3 ml/kg fluid leads to significantly impaired gas exchange. Injury to other systems is largely secondary to hypoxia and ischemic acidosis. Additional CNS insult may result from concomitant head or spinal cord injury. Fluid aspirated into the lungs produces vagally mediated pulmonary vasoconstriction and hypotension.
The Body’s Compensation
• Mammalian diving reflexWater under 70 Fahrenheit Slowed heart rate (up to 50%)Peripheral vasoconstriction Blood shift to thoracic cavity
• Allows longer survival without oxygen than similar times on dry land
Kids do this better than adults
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Human beings suddenly immersed in cold water (< 20o C), the mammalian diving reflex may occur and produce apnea, bradycardia, and vasoconstriction of nonessential vascular beds with shunting of blood to the coronary and cerebral circulation. This reaction works better in children than in adults, although its not uncommon in either age group. The end result is that individuals, particularly kids, may survive longer without oxygen than similar times on dry land.
Physiology of H2O in Lungs
• Fresh waterDestroys surfactant Alveolar instabilityAtelectasis with decreased compliance
Difficult to ventilateCardiac Arrest (2 – 3 minutes)
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Fresh water moves rapidly across the alveolar-capillary membrane into the microcirculation. Surfactant is destroyed, producing alveolar instability, atelectasis and decreased compliance with marked ventilation/perfusion mismatching. As much as 75A% of blood flow may circulate through hypoventilated lungs.
Physiology of H2O in Lungs (con.)
• Salt waterSurfactant wash-out Fluid moves into alveolar & pulmonary tissue
Pulmonary edemaFluid induced bronchospasm
Reduced pulmonary compliance
Difficulty ventilating
Cardiac Arrest (8 – 10 minutes)
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In salt water drowning, surfactant washout occurs, and protein-rich fluid moves rapidly into the alveoli and pulmonary space. Compliance is reduced, alveolar-capillary basement membrane is damaged directly, and shunting occurs. This results in rapidly induced serious hypoxia. Fluid-induced bronchospasm also may contribute to hypoxia. The distinction between fluid type is somewhat academic, as other than epidemiologic important, the initial treatment is similar.
Post Drowning Effects
• Acute Respiratory Distress Syndrome(AKA Post-Immersion Syndrome)High mortality & morbidity due to: • Neurologic insult• Multiple organ system failure
• Primary CNS Injury• Infection• Other
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Acute respiratory distress syndrome from altered surfactant effect and neurogenic pulmonary edema commonly complicates drowning in survivors. Commonly, these edematous noncompliant lungs may be further compromised by ventilator-associated lung injury. Primary CNS injury is a function of tissue hypoxia and ischemia. CNS injury has proven to be a major determinant of subsequent outcome. If the period of ischemia is limited or the individual rapidly develops core hypothermia, injury may be limited and the individual may recover with minor neurologic sequelae. Prolonged hypoxia and ischemia may lead to primary and secondary injury from sustained acidosis, edema, hyperglycemia, hypotension, reperfusion, release of excitatory neurotransmitter, impaired cerebral autoregulation and seizures. Infection includes sinus, pulmonary and CNS infections as well as other less common sites of infection that may result from unusual water-borne and soil organisms. This is especially common in the individual with a compromised immune system. Some infections may present late (1-3 wks later) and may be atypical presentations. This infections are difficult to treat and carry a high mortality rate. Other effects include rhabdomyolysis and acute tubular necrosis which are more common in those with severe metabolic acidosis and hypoxemia.
Factors Affecting Survival
• Cleanliness of Water (contaminants)• Length of Time Submerged• Victim’s Age and General Health• Associated medical causes• Associated trauma
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Cleanliness of the water contributes to mechanical occlusion of bronchi, bronchospasm, pneumonia, abscess formation and inflammatory damage to alveolar capillary membranes. Length of time submerged contributes to the degree of hypoxemia and metabolic acidosis. The victim’s age and general health may complicate recovery and render them more sensitive to the negative effects of hypoxemia and metabolic acidosis. Presence of associated medical causes increases mortality.
Associated Trauma
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Associated trauma has a profound effect on outcome. A – head injuries are more common when the victim has jumped, been ejected or has been caught in swift water. Hitting rocks, debris, bottom or side of a pool, boat or other recreational vehicle, dock, etc. are just a few of the causes of head injury. Helmets are designed to help prevent most head injuries so if a helmet is present, examine it closely and bring it with the patient. B – if the incident involved diving, an ejection or a fall; immobilizing the victim is always wise. In this case, the patient was diving in shallow water. C – pool drains remain an issue. Newer pools are required to have covers over pool drains, however older, private pools may not have the covers installed. This patient got caught in a pool drain. In large irrigation ditches or cement drain-off culverts, when high water is present, people may get caught by the current in drain off areas. These areas can be very dangerous.
Factors Affecting Survival
• Water TemperatureCold-water drowningMammalian diving reflex• 51 year old male• 45 minutes under ‘icy water’• Core temperature 27 Celsius (81 Fahrenheit)
• 2 year old female• 66 minutes under ‘cold water’• Core temperature 19 Celsius (66 Fahrenheit)
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Research suggests that the colder the water when the victim is submerged, the better the outcome. HOWEVER, just because the water is cold, does not ensure that the outcome will be good. The oldest survivor and the youngest survivor of cold water drowning is listed on the slide. The 51 y/o suffered some cognitive deficit. The 2 y/o was neurologically intact.
Drowningvictims should be resuscitated until core temperature has increased to 30° Celsius (86° Fahrenheit).
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Therefore, the old rule of thumb that a patient isn’t dead until they are warm and dead, still holds true. The temperature of 86o F is when the body starts to respond to defibrillation.
Interesting Findings Regarding Cold Water Drownings• Sudden immersion into cold water may
result in:Ventricular fibrillation Immediate death
ORAtrial fibrillation Instant loss of consciousness
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This phenomenal, formerly known as “immersion syndrome” results when submersion causes compression of peripheral vessels by the weight of water. Upon removal from the water, vasodilation occurs and blood is displaced. This causes a relative hypovolemia that can temporarily deprive the heart and brain of cardiac output. If the patient is in atrial fibrillation, the outcome tends to be more positive. If the patient presents in v-fib, treat as you would anyone else in v-fib.
Classification of Drowning Victims
• Asymptomatic• Symptomatic
Persistent coughAltered VSTachypnea, dyspnea or hypoxiaAltered mental statusNeurologic deficitNon-arrest dysrhythmias
A victim of drowning may be initially classified into 1 of the groups on the slide. Keep in mind that the final outcome will determine if they fall into the new defined groups of: death, delayed death or disability (mortality or morbidity) or no disability (morbidity). Providers can easily identify the patient in arrest and the patient that is obviously dead. The biggest challenge for EMS is identifying the symptomatic patient. The most overlooked symptom is the presence of a persistent cough. If that is present, the patient should be presumed to have suffered a submersion injury until proven otherwise. Wheezing may or may not be present. Altered VS includes tachycardia at rest and/or tachypnea at rest. Other assessment findings include poor O2 sats in spite of application of O2 and low EtCO2 values in the presence of a perfusing blood pressure. Altered mental status includes unreasonable anxiety. Neurologic deficit includes cognitive deficit which may manifest itself as confusion, poor decision making and lack of short term memory. Other neurologic deficits include ataxia, and stroke-like symptoms. Non-arrest dysrhythmias includes atrial fibrillation that may be intermittent, bradycardia, tachycardia, and frequent PACs/PVCs. Poor skin color is another finding that may be present.
Treatment
• Remove the patient from the water.
Attempt rescue only if properly trained and equipped.
• Immobilize head, neck and back• Airway support as soon as
possible Debris and emesis commonSuction as needed
• CPR as necessary
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Rescue breathing should begin as soon as possible, even while the patient is still in the water. Chest compressions should only be done when the patient is on a firm surface. Applying pressure to the chest or abdomen to clear water is not recommended. It doesn’t work, predisposes to aspiration, wastes time and may be harmful. Provide suction, turning the patient as necessary. Suction may involve suction in the ET tube as well as the oropharynx.
Treatment (con.)• High Flow O2
MNR at 15 LpmIntubation if necessary
• CPAP if possible• SaO2 monitoring
Aim for 90% or better• Capnography
Aim to maintain between 36-45 • Limit heat loss
Remove wet clothing and apply blankets
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As with all situations, the priorities do not change. The airway should be secured, suctioning as necessary and supplemental O2 provided. If spontaneous ventilations and a perfusing blood pressure are present, consider using CPAP. If ventilations are not adequate or blood pressure is hypotensive, assist ventilations using a BVM. Monitoring capnography is extremely valuable – using a nasal cannula in the case of spontaneous ventilations and side stream monitoring when the patient is intubated is recommended. Don’t forget to protect the patient from further heat loss. The first measure is to dry them off. An ambient temperature of 80o F is still colder than 98.6o F. Conduction of body heat is 30x faster when the body is wet.
Treatment (con.)
• IV of lactated Ringer’s or NSCheck for hypoglycemia/hyperglycemia
• Cardiac monitoring• Rhythm treatment?
ACLS guidelines
• Transport quickly and carefully
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Circulation should be supported and, if hypotension is present, administer fluid in 250 ml challenges and repeat as necessary to maintain a perfusing blood pressure. If the patient is hypoglycemic, administer D50. The cardiac rhythm should be monitored continuously. If an AMI is suspected, as 12-lead should be obtained. Any perfusion altering dysrhythmias should be treated according to ACLS guidelines.
Things to Consider
• BronchospasmAlbuterol if pt is conscious
• SeizuresBenzodiazepines
• Underlying causesHypoglycemia, AMI, Stroke or Seizures
• Get accurate history of events
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Bronchospasm is common and can be treated with albuterol. The combination of albuterol + atrovent, is not recommended. Wheezing may be due to contaminants versus mucous. Seizures should be controlled with Valium or Versed. Children may respond better to Versed. Evaluating blood glucose level, assessing for facial asymmetry and equal extremity movement, pupil size and reaction, and completing a physical assessment may help to determine the cause of the drowning event. For example, finding bruising on the side of the tongue suggests that a seizure may have been the original cause. An accurate history of events will help determine if immobilization is necessary.
Secondary Effects
• ARDS (“Secondary Drowning”) due to alveolar inj.
HypoxiaMetabolic Acidosis
• Absorption of water from GI system into blood
Hemodilution/HemolysisAcidosisMay cause death within 72 hours of event
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Every once in a while a patient may not contact EMS immediately after the event. Instead they may wait until something happens, usually difficulty breathing, and then call you. In the case of a delayed reaction, you may find a patient with increased work of breathing (due to atelectasis), wheezing may or may not be present, and abnormal EtCO2 values. Usually both tachycardia and tachypnea are present. Effects of absorption of water from the GI system are not common outside the hospital. If this does occur, it is more common in children and can result in electrolyte imbalances (hyponatremia and/or hyperkalemia), cardiac dysrhythmias, and seizures.
Other Secondary Events (con.)• Bacterial pneumonia
If any aspiration has occurred, ARDS and bacterial pneumonia usually results. Fresh water drownings that occur in ponds or lakes that drain farm land or that occur after a rain are known for contaminants such as organic waste, sand, silt, etc. Drownings that occur in pools run the risk of contamination from chlorine or bromine. If pneumonia does develop, sepsis is very common. While EMS does not have the ability to diagnose metabolic acidosis, it can be assumed that any patient that has suffered an episode of apnea or any degree of aspiration has metabolic acidosis. Treatment is to secure the airway and begin assisting ventilations. EtCO2 will help guide rate of ventilations. It is not common to be able to identify hyperkalemia in the drowning victim outside the hospital environment. That’s because it takes a severe imbalance of KI+ for signs to occur on the ECG. However, if tall peaked T waves are identified, and you are any distance from definitive care, administration of albuterol may temporarily help to correct the problem. Administering albuterol to control hyperkaemia is not in the protocol and requires physician authorization.
Other Secondary Events (con.)
• EvaluationWhen did the drowning occur?In what substance did the drowning occur?
Salt vs Fresh vs Pool vs Settling Pond
Persistent cough or wheezing?Loss of consciousness?Drug / alcohol use?Trauma?
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Critical information to obtain includes: Approximately when did the drowning occur (in real time)? What was the liquid, i.e. lake, pool, hot tub, etc. Is a persistent cough or wheezing present? Was there a loss of consciousness? Any drug or alcohol use? Any associated trauma? These should all be communicated on arrival at the ED and should also be documented in the PCR.
Major mistakes include failure to suspect and assess for trauma, resulting in failure to immobilize the patient. Missing hypoxia by failing to recognize tachypnea at rest and/or failing to recognize when ventilations need to be assisted. Missing acidosis by failing to recognize when oxygen needs to be provided and ventilations need to be assisted.
References:WHO Bulletin, 83:11, 801-880 found at: http://www.who.int/bulletin/volumes/83/11/vanbeeck1105abstract/en/index.htmlShepherd, S.M. & Shoff, M.H. June 9, 2009. Drowning. Found at:http://emedicine.medscape.com/article/772753CDPHE, (2009). Drowning and Submersion, Chapt. 8.; In Injury in Colorado: Colorado Department of Public Health and Environment. pp 107-114.Aehlert, B. (2010). Submersion Injuries: Drowning and Associated Conditions. In Paramedic Practice Today, vol 2. pp 553-558.
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If any questions, ask your resident paramedic or send me an email or call me on my cell.
