Environmental Emergency “A Swimmer Disappears” 1

Learning Objectives After completing this discussion we should be able to: Discuss potential complications of near-drowning, which may cause cardiopulmonary arrest or a prearrest condition Manage a case scenario describing the resuscitation and stabilization (ACLS) appropriate for a near-drowning victim Captains: Use this Powerpoint to discuss with your crew a unfortunate casualty of summer, drowning or near-drowning. You can use this as a table top discussion for either BLS or ALS participants. If a medic is in attendance, ask him/her to help lead the discussions and answer some questions that may arise.

The case: 24-year-old victim 24-year-old man disappeared after diving into water from a platform near the edge of Klineline Pond He was submerged for several minutes before being found by friends and pulled to shore At the scene he was unresponsive, without respiratory effort, and pulseless Bystander CPR begun, 911 activated You are responding to the above incident. Reports come in that the subject may be out of the water. If not, discuss what an engine company or squad crew can do without entering the water. What resources do you have readily available? Can you enter the water? Do you need to don PFD’s?

Klineline park, located off NE 117th Street is a county park frequented by the young and old, either as fishermen or to swim in the shallow waters near the shore line. NO LIFE GUARDS ARE ON DUTY.

Pond Depths Swim Area

Drowning / Near-Drowning Definition and Classification Drowning: submersion resulting in immediate death or death within 24 hours Near-drowning: submersion, no immediate death or death within 24 hours Submersion liquid: contamination and chemical irritants more relevant than salt vs fresh water Note: Duration of hypoxia, rather than submersion liquid, affects outcome Read the slide for the definitions of drowning versus near-drowning Submersion liquid: contamination and chemical irritants more relevant than salt vs fresh water ( relates to what they drowned in if the liquids are contaminated with pollutants or chemicals rather than if the liquid is saltwater versus fresh water. No saltwater exists near Clark county.

Near-Drowning Pathophysiology Hypoxemia is the major insult; duration determines outcome Rule out associated conditions: trauma, alcohol intoxication, hypothermia Potential neurologic insults: hypoxia, trauma Potential pulmonary insults: pulmonary edema, intrapulmonary shunting, surfactant inactivation, ARDS, aspiration Read bullet points. Be sure to be a detective and try to determine the associated conditions possible with drowning ARDS = Adult Respiratory Distress Syndrome Occurs when fluid builds up in the alveoli in the lungs. More fluid in the lungs means less oxygen can reach the bloodstream. This deprives the organs of the oxygen they need to function.

Near-Drowning BLS at Scene Treat as traumatic event; immobilize cervical spine Immediate BLS required Hypoxia leads to respiratory and cardiac arrest (bradycardia or VT/VF) Begin conventional BLS (airway, breathing, circulation) Routine use of maneuvers to relieve foreign-body airway obstruction NOT recommended Here’s what the AHA has to say about resuscitation of a drowning victim: “Attempts to remove water from the breathing passages by any means other than suction (e.g. abdominal thrusts or the Heimlich maneuver) are unnecessary and potentially dangerous.  The routine use of abdominal thrusts or the Heimlich maneuver for drowning victims is not recommended.” “There is no evidence that water acts as an obstructive foreign body.  Maneuvers to relieve FBAO [Foreign Body Airway Obstructions] are not recommended for drowning victims because such maneuvers are not necessary and they can cause injury, vomiting and aspiration and delay CPR.”

Near-Drowning Victim On Medic Arrival Call-to-scene interval: 8 minutes On Fire arrival: victim out of water; unresponsive, apneic, and pulseless CPR is producing chest rise, good pulse What should ACLS providers do first?

Primary ABCD Survey C: Circulation — Assess breathing as you approach. Check for pulse, if no pulse, turn “on” LP12 and begin chest compressions A: Open the airway Always use c-spine precautions B: Breathing Not breathing (CPR continues) Ventilate with 100% O2 via BVM D: Defibrillation Dry victim’s chest Apply “FAST” patches = asystole If an all BLS crew, attach AED and allow to analyze. AED says “ NO SHOCK ADVISED” Does this patient meet ALPS inclusion criteria?? Non-traumatic cardiac death …. yes

Is advanced support needed? Secondary ABCD Survey Is advanced support needed? A = Airway: intubate at once if indicated Intubation indicated to protect airway (8.0-mm tube successfully placed) Vomiting occurs frequently: prepare suction B = Breathing: Is advanced support needed? Is support effective? Verify tube placement Monitor chest expansion, breath sounds, oxygenation

Secondary ABCD Survey C = Circulation, advanced support Check pulse frequently; continue CPR if needed Insert two 14- to 16-gauge IVs; infuse 500 mL 0.9% NaCl or normal saline Check rhythm: follow ACLS asystole protocol D = Differential Diagnosis Asphyxia (including cerebral ischemia) Trauma to cervical spine, head Seizure or other cause of fall into water Aspiration pneumonia Hypothermia from submersion and heat loss

Third Quadrad O2 –IV–Monitor–Fluids Oxygen Continue to deliver oxygen Ensure effective oxygenation and ventilation Verify proper tube placement and patency IV Insert 2 large-bore catheters Monitor Determine rhythm (asystole) Verify ETT placement, evaluate temperature Fluids Infuse NS (warm if the patient is cold) Until ROSC occurs, use high flow oxygen during resuscitation. However, once pulses restore, maintain oxygen saturation >94% but less than 100%

Case Progression Response to EMS Treatment Airway and breathing: 8-mm ETT in place, bilateral chest expansion, lungs compliant Circulation: epinephrine administered, pulses return Vital signs: HR = 139 bpm, BP = 94/74 mm Hg, RR = 14/min (hand ventilation), temp = 35°C (95°F) axillaries Transport: Spine immobilized with cervical collar

Case Progression Arrival in ED Airway and breathing: spontaneous respiratory efforts detected Circulation: normal sinus rhythm (88/min), good perfusion, BP = 110/68 mm Hg Neurologic evaluation: pupils equal and reactive, no spontaneous movement See next slide for answer What actual or potential problems may exist?

Summary: ACLS Management of Near-Drowning Near-drowning creates severe hypoxic insult Must restore oxygenation and ventilation Key: drowning is trauma; immobilize cervical spine Perform Primary and Secondary ABCD Surveys (consider factors that may complicate submersion)