1. Environmental Emergency “A Swimmer Disappears”1

2. 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.

3. 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?

4. 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.

5. Pond Depths
Swim Area

6. 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.

7. 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.

8. 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.”

9. 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?

10. 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

11. 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

12. 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

13. 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%

14. 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

15. 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?

16. 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)