Drowning Emergencies

Water Related Submersions Two common terms used in the past: drowning and near-drowning It is now recommended that all submersion incidents be referred to as a drowning: a submersion incident resulting in a primary respiratory impairment; the person may live or die

Drownings Third leading cause of accidental death Causes in age groups Conditions leading to submersion

Pathophysiology of Drowning

Drowning Process of experiencing respiratory impairment from submersion or immersion in liquid Outcomes include: Death Morbidity Near morbidity

Drowning Drowning continuum: Breath holding Laryngospasm Accumulation of carbon dioxide/inability to oxygenate lungs Respiratory and cardiac arrest from tissue hypoxia

Drowning Risk factors: Toddlers—bathtubs School-age children—pools Teens—lakes and rivers Comorbidities

Drowning Predictable sequences starting with inability to keep face out of liquid Length of breath holding depends on: State of health and fitness Level of panic Water temperature

Drowning Resuscitation is the same as for others in respiratory or cardiac arrest. Reaching victim—leave to those trained/experienced in water rescue

Drowning Treatment follows ABCs. Establish airway. Cervical spine precautions, especially if: History of diving or water slide Signs of injury Alcohol intoxication

Drowning Continue rescue breathing until on land. Once on solid surface: Start supplementary oxygen. Determine pulse. Continue to treat according to ABC guidelines.

Drowning Start chest compressions after two breaths. Establish IV access. Administer indicated medications. Perform cardiac monitoring. Defibrillate shockable rhythms. Do not perform manual abdominal thrusts. Suction to clear airway.

Drowning Most drowning victims receiving rescue breathing or compressions will vomit. Remove vomit from mouth via: Suction Finger swipes Other devices Consider placing on side.

Drowning Maintain some positive pressure at end of exhalation to: Keep alveoli open. Drive fluid accumulated in alveoli back into interstitium or capillaries.

Drowning Positive end-expiratory pressure (PEEP) Maintains some positive pressure at end of expiratory phase. Indicated for intubated patients with long transports Some devices allow PEEP via endotracheal tube. Portable ventilators usually have PEEP setting.

Drowning If ET tube inserted, insert nasogastric tube to decompress stomach. If pulse absent, implement ALS measures for cardiopulmonary arrest: IV access Epinephrine administration Cardiac monitoring, defibrillation if needed

Drowning Do not give up on submersion patient. Successful resuscitation with complete neurologic recover in more than 1 hour of submersion in icy water Hypothermia protects body and brain from hypoxia Hypothermia more often dangerous than protective

Drowning Search for comorbidities: Trauma Hypoglycemia Acute coronary syndrome Cerebrovascular accident

Drowning Major predictors of outcome: Length of submersion Response to field resuscitation If awake upon hospital arrival, likely a better outcome

Drowning Postresuscitation complications Occur hours to days after submersion: Adult respiratory distress syndrome Hypoxic brain injury Multiorgan failure Sepsis syndrome

Introduction Nearly 4,000 deaths occur annually from water accidents. The First Aider may find them self in a work-related or recreation-related activity when a water emergency occurs. Important to remember: never attempt a water rescue unless you are a specially trained and good swimmer who has donned a personal flotation device and has the help of others. © 2012 Pearson Education, Inc.

Drowning and Near-Drowning Definitions Drowning: death from suffocation due to submersion Near-Drowning: at least temporary survival from near soffocation due to submersion Most commonly happens to children under age 5, and people between 15 and 24 years of age May not occur in large bodies of water

Drowning and Near-Drowning Remain alert for signs of struggle. Sudden splashing Screams Calls for help Swimmer who is thrashing

Drowning and Near-Drowning Wet drowning occurs when the victim has aspirated fluid or a foreign body into the lungs. Dry drowning occurs when laryngeal spasms prevent fluid from entering the lungs, but the person still suffocates. Secondary drowning occurs when a resuscitated victim dies within 96 hours of the incident from aspiration pneumonia.

Progression of Drowning

Drowning and Near-Drowning Types of drowning refer to the victim’s activities prior to unresponsiveness and death Active drowning – victim is still trying to remain afloat and breathing with great energy expenditure Passive drowning – victim is not moving, is usually face down or submerged; drowning results from total expenditure of energy

The Role of Panic in Drowning

Drowning and Near-Drowning Resuscitating Cold Water Submersion Victims Cold water emergencies have a higher chance of survival (below 68 degrees F) Beneficial effects result from the mammalian diving reflex and the effects of cold water on the body’s metabolic rate Any cold water submersion victims should be resuscitated, even if submersion has been lengthy (over 30 minutes)

Drowning and Near-Drowning Ensuring your own safety Always act with your personal safety first. Never attempt a deep water rescue unless all of the criteria below apply: You’re a strong swimmer. You’ve had water rescue technique training. You’re wearing a personal flotation device. You’re accompanied by others to assist you.

Drowning and Near-Drowning Water rescue close to shore or in shallow water for a conscious victim Keep firm footing for yourself, don’t slip into the water. Lean backwards as you pull the victim out. Use an object (rope, oar, branch, etc.) for the victim to grab so you can pull them in. Use a shepherd's crook if available.

Drowning and Near-Drowning Water rescue for a conscious victim out of your reach Items to toss to victim: a ring buoy a heaving line a throw bag a heaving jug Shout to victim to get their attention. Stand on rope’s end before throwing. Swing underhand with intent of throwing device just past the victim.

Drowning and Near-Drowning Water rescue for an unconscious victim out of your reach If possible, make rescue attempt from a boat (not from in the water) Use a shepherd's crook if available. If rescuing from a boat, do not allow yourself to fall into the water. Follow standard techniques and safety criteria described previously.

Drowning and Near-Drowning Head or spinal injury concerns Suspect head or spinal injury if the victim is unconscious, or if known trauma has occurred. Goal is to support the back and stabilize the head in the water. Use the head-splint or the hip/shoulder support techniques.

Head Splint Technique

Drowning and Near-Drowning Head or spinal injury concerns Use hip/shoulder support technique. Position yourself aside the victim. With your arms under the hips and shoulders, lift the victim’s body just high enough that their face is out of the water. Remain in this position until medical help arrives. Attempt to keep the victim’s body horizontal.

Drowning and Near-Drowning Head or spinal injury concerns If you are not trained in water rescue do the following: Do not remove the victim from water. Keep the victim afloat on his or her back. Always support the head and neck, and keep them level with the back. Maintain the airway and support ventilation as possible. Maintain these maneuvers until medical help arrives.

Drowning and Near-Drowning The First Aider should Activate the EMS. Safely remove the victim from the water. Maintain immobilization in water, if possible, prior to removal of the unconscious victim. Once out of the water, assess and manage the airway, breathing, and circulation functions. Maintain care and support any lost functions until EMS arrives.

Drowning and Near-Drowning

Diving Emergencies Diving into shallow water Injuries to the head, neck, back, extremities, or chest can occur. Always assume spinal injuries have occurred and attempt rescue with immobilization techniques as described previously. If victim has left the water, proceed with standard care as you would for any victim with suspected neck or spinal injuries.

Diving Emergencies Deep-water diving Most serious complication is coma, which can result from asphyxiation, head injury, heart attack, air tank contamination, intoxication, or aspiration. Victim may be unconscious from air embolism or decompression sickness. A hyperbaric chamber for recompression may be needed at the hospital.

Diving Emergencies Air Embolism Often occurs from holding one’s breath while diving (into a pool, using scuba gear, etc.) Damage to lungs causes air to enter the vascular system Decompression sickness (the “bends”) Occurs when a diver ascends too rapidly from deep water and nitrogen bubbles form in the body Has gradual onset; symptoms can develop 12–24 hours after a dive.

Diving Emergencies First aid care for air embolism or decompression sickness In absence of trauma, place the victim on their left side in a 15 degree-head down position. Provide support to airway, breathing, and circulation functions as needed. Continue to monitor and care for the victim until EMS arrives.

Diving Emergencies Barotrauma (the “squeeze”) Occurs with rapid ascent or descent when air in the body’s cavities cannot equalize Can include mild or severe pain to affected areas with possible ear/nose discharge, dizziness, nausea, and disorientation Victim requires immediate care and transportation to a medical facility to prevent worsening of the condition

Summary Drowning and near-drowning victims have special rescue and treatment needs. Never attempt a water rescue unless you are equipped and trained to do so safely. Victims of water emergencies should still be seen by a physician, regardless of how they feel, for a complete evaluation. Always suspect and treat for neck and/or spinal injury for any victims of shallow water diving.