Submersion Incidents: Drowning and Diving Emergencies

Submersion Incidents: Drowning and Diving Emergencies
Chapter 25 Submersion Incidents: Drowning and Diving Emergencies Advance Preparation Review local protocols for assessment and treatment of patients with submersion and deep-water diving emergencies. If available locally, arrange a field trip to a hyperbaric treatment facility. Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich • Keith J. Karren Copyright ©2010 by Pearson Education, Inc. All rights reserved.

Objectives Define key terms introduced in this chapter (slides 14-15).
Discuss ways to reduce the risk of submersion incidents (slides 12-13). Describe factors that can lead to submersion incidents in infants, children, adolescents, and adults (slides 17-19). Explain factors that affect the likelihood of survival from submersion incidents (slides 20-21). Describe the pathophysiology of drowning (slides 22-23). Discuss the association between shallow water diving and spinal injuries (slides 24-25). The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Objectives 7. Explain actions you should take to protect your own safety when responding to a water emergency (slides 26-27). Explain the necessity of taking spinal precautions to any swimmer or diver who may have suffered trauma (slides 28-29). Given a scenario in which a patient has suffered a submersion incident, explain how to provide resuscitative care (slides 30-31). Explain the assessment-based approach to drowning and other water-related injuries, including emergency medical care for the drowning victim (slides 32-41). The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Objectives Explain the formation and relief of gastric distention in patients involved in submersion incidents (slides 38-39). Describe laws of physics as they relate to scuba or deepwater diving, including (slides 44-45): Boyle law Dalton law Henry law Charles law Explain the pathophysiology of decompression sickness (slides 46-47). The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Objectives Recognize the signs, symptoms, and patient history associated with (slides 48-49): Type I decompression sickness Type II decompression sickness Arterial gas embolism Explain the pathophysiology of barotrauma injuries (slides 50-51). Describe the emergency medical care of patients suffering from air embolism, decompression sickness, and barotrauma (slides 52-53). The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Multimedia Directory Slide 16 Submersions and Drowning Animation
Slide 19 Drowning Video The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Topics Water-Related Emergencies
Scuba or Deep Water Diving Emergencies Planning Your Time Plan 100 to 120 minutes for this chapter as follows: Water-Related Emergencies (60 minutes) Scuba or Deep Water Diving Emergencies (45 minutes) Note: The total teaching time recommended is only a guideline.

CASE STUDY Dispatch Case Study Discussion
The following case study is intended to challenge your students to think about how to manage a submersion incident. Present the case in a way that your students will imagine being on the call and feel challenged by the circumstances of the incident. If appropriate, briefly relate a personal experience you’ve had running a similar call and how you managed it.

EMS Unit 631 Case Study Discussion, continued You and your partner are working on EMS Unit 631 today. You’ve been dispatched to a submersion incident at 99 Wolf Road in the Delmar Hotel. The manager stated a 25-year-old male is in trouble in the pool. Police are en route at this time. Time out is 2132 hours. Respond to 99 Wolf Road in the Delmar Hotel for a 25-year-old male in trouble in the pool. Police are en route. Time out 2132

Upon Arrival Manager states an intoxicated male did a jack-knife in the shallow end of the pool Find male floating supine in the pool with support of a hotel employee Patient states he cannot feel his arms or legs Case Study Discussion, continued Your ambulance arrives at the same time as the police unit. You are met at the hotel entrance by a frantic man who identifies himself as the manager. He leads you back to the pool, saying on the way, “I told them they couldn’t have alcohol in the pool area. But they’re so smart. They sneak it in anyway. Then they come running into the office, drunk, yelling for help. One of them thinks he can do a jack-knife into the shallow end. Idiots.” As you reach the pool area, you note a small crowd of young men and women on the deck. Some of them are yelling, “Come on, Robby! Get out, man! Come on!” A couple of paper bags and carry-alls are tipped over near the deck chairs, and empty beer bottles have rolled out from them. The police move the bystanders back and quiet them down. With the scene secure, you approach the edge of the pool and observe a young man floating supine with the support of a hotel employee. The young man appears very scared and tells you he cannot feel his arms or legs.

How would you proceed to assess and care for this patient?
Case Study Discussion, continued What types of problems can you identify from the description of the incident? What are your priorities in the management of this patient? How would you proceed to assess and care for this patient?

Water-Related Emergencies
Teaching Time 60 minutes Points to Emphasize Water-related deaths are tragic because so many of them could have been prevented. Alcohol and activities in or near water do not mix. Back to Topics

Water Related Emergencies
Some drownings related to swimming Many caused by diving, deep-water exploration, boating and water skiing Precautions for water safety Fence pools Supervise children Do not mix alcohol and water activities Use personal flotation devices and life preservers Talking Points Drownings related to swimming are responsible for a small number of deaths. The rest are caused mostly by diving and deep-water exploration, boating, and water skiing. Some deaths may result from motor vehicle accidents. Drownings do not always occur in large bodies of water. Common-sense precautions to reduce the risk of drowning include: – Fence all pools. – Constantly supervise children if they are around water. – Do not mix water activities and alcohol. – Always wear life preservers or personal flotation devices. – Avoid diving into shallow or unexplored bodies of water. – If you have a seizure disorder, be careful when around bodies of water. Class Activity Assign a type of body of water to each of several groups of students. Ask each group to come up with a drowning prevention plan. Back to Objectives

Definitions Back to Objectives Point to Emphasize
Drowning occurs when someone is submerged or immersed in a liquid, and it results in a primary respiratory impairment. Back to Objectives

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 Talking Points The terms used to describe water-related submersions and deaths vary. Two common terms that have been used in the past, but are commonly misunderstood, are drowning and near-drowning. According to the 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, much confusion has surrounded the terms used when describing submersion incidents. Because of the confusion and the need for consistent reporting of submersion incidents, drowning is now the only recommended term to describe a submersion event. A drowning is an incident in which someone is submersed or immersed in a liquid that results in a primary respiratory impairment. The liquid prevents the patient from breathing air. The patient may live or die from the event. Regardless of the outcome, it is termed a drowning.

Submersions and Drowning
Animation Information about Submersions and Drowning What happens to a patient after his submersion in water? What is a laryngospasm? Why does hypoxemia occur as a result of a submersion? Discuss what is meant by a dry drowning. Click here to view an animation about submersions and drowning. Return to Directory

Incidence of Drowning Back to Objectives Teaching Tip
Describe local bodies of water where drowning is a public health concern. Discussion Question Why are adolescent males more prone to water-related emergencies? Back to Objectives

Third leading cause of accidental death Causes in age groups
Conditions leading to submersion Talking Points Approximately 4,500 drowning deaths per year occur in the United States, making drowning the third most common cause of accidental death. In children less than one year of age, the bathtub is the most common location of drowning. In children one to five years of age, the highest incidence of drowning occurs in swimming pools. Adolescents and young adults most often drown in ponds, lakes, rivers, and oceans. Alcohol and recreational drugs may also put the adolescent or young adult at greater risk for drowning. In the adult patient, consider underlying medical conditions or trauma that may have lead to the submersion. Water sports also pose a hazard of submersion and drowning.

Click here to view a video on the topic of drowning.
Video Clip Information about Drowning What is the most common cause of drowning? Who has the greatest risk of drowning? On what days of the week do most drownings occur? Discuss how an EMT should interact with the parent of a child who has drowned. Click here to view a video on the topic of drowning. Return to Directory

Prognostic Predictors
Point to Emphasize Quick rescue from submersion and early resuscitation are the most critical factors associated with better patient outcomes. Discussion Question Is a patient’s outcome affected by whether it is a dry or wet drowning? Back to Objectives

Orlowski score: the more predicators present, the less likely a patient will survive
Talking Points The following characteristics are part of the Orlowski score that predicts likelihood that a patient will survive neurologically intact. The Orlowski predictors of survival are: Patient is three years of age or older. Patient was submersed for greater than five minutes. Resuscitation did not begin for more than ten minutes after rescue. Patient is comatose on delivery to emergency department. Patient’s arterial blood is very acidic (pH less than 7.10). Moderate body core hypothermia associated with submersion is thought to provide a protective mechanism that reduces brain and other organ damage in children. Critical Thinking Discussion If you were to design a research project on improving survival from drowning, how would you go about it?

Pathophysiology of Drowning
Point to Emphasize Drowning results in asphyxia, whether or not water enters the lungs. Back to Objectives

Emergency medical care
Primary injury Second injury Surfactant Emergency medical care Talking Points The most important factor in any drowning is the duration of the submersion and the consequent severity of the hypoxia. The severe hypoxia associated with the initial drowning event (primary injury) could produce prolonged effects that continue to damage tissue and organs and create an ongoing hypoxia (secondary injury). Both types of drowning have a tendency to wash out surfactant, a substance that maintains surface tension in the alveoli to keep them from collapsing. Theoretically, differences exist between salt-water and fresh-water aspiration; however, clinically the resuscitation and emergency medical care you provide are the same. Critical Thinking Discussion How does surfactant work to keep the lungs open?

Diving Emergencies Back to Objectives Point to Emphasize
If a submersion event involved diving into the body of water, suspect spine injury. Back to Objectives

Talking Points Drowning incidents can be additionally complicated in cases where diving is involved. Patients who dive into water from a diving board, shore, poolside, boat, or dock often sustain injuries to the head and spine and fractures of the arms, legs, and ribs. Always assume that a diver has sustained neck and spine injuries even if the diver is still responsive. If the patient is still in the water, provide the emergency care as described for a submersion patient. If the patient has left the water, provide emergency care, including resuscitation if necessary, as you would for any other trauma or submersion patient. You should always assume that a diver has sustained neck and spine injuries.

Safety Measures in Water-Related Emergencies
Discussion Question Under what conditions should you attempt to rescue a patient still in the water? Back to Objectives

Safety around water Criteria to enter Reach, throw, row, go
Talking Points In a water-related emergency, reach the patient, but do it with the utmost concern for your own safety. Certain deep-water accidents require specialized equipment to correct medical complications. Unless a water emergency occurs in open, shallow water that has a stable, uniform bottom, never go out into the water to attempt a rescue unless you meet all of the following criteria: – You are a good swimmer, and . . . – You are specially trained in water rescue techniques, and . . . – You are wearing a personal flotation device, and . . . – You are accompanied by other rescuers. If the patient is responsive and close to shore, use the reach, throw, row, go strategy to help pull him to shore. Safety around water Criteria to enter Reach, throw, row, go

Possible Spine Injury Back to Objectives Discussion Question
What is the relationship between drowning and spine injury? Back to Objectives

When to suspect spine injuries
Emergency care Talking Points If the swimmer may have been involved in a diving accident or may have been struck by a boat, water skier, surfboard, or other object, suspect possible spine injury. Also suspect spine injury in any swimmer or diver who has been diving, using a water slide, is suspected of being intoxicated, or has evidence of traumatic injury. In the case of possible spine injury, support the back and stabilize the head and neck as other care is given. It is important to stabilize the patient properly in the water. The American Red Cross suggests that the patient not be removed from the water until a backboard or other rigid support can be applied to the patient for stabilization.

Resuscitation Back to Objectives Points to Emphasize
For the purposes of resuscitating a drowned patient, cold water is water that is 70 degrees Fahrenheit and below. Discussion Question What is the relationship between hypothermia and survival from drowning? Back to Objectives

Mammalian diving reflex Cold-water versus warm-water drowning
Talking Points A cold-water drowning and a warm-water drowning have a significant difference. When a person dives into cold water (below 70 degrees Fahrenheit or 21 degrees Celsius), the mammalian diving reflex may drastically slow down metabolism and make the patient more likely to be resuscitated, even after prolonged submersion. Controversy surrounds the actual benefits of the mammalian diving reflex. As a guideline, you should attempt resuscitation on any pulseless, nonbreathing patient who has been submerged in cold water. Hypothermic patients are not pronounced dead until after both rewarming and resuscitation have been performed. Some experts advise providing resuscitation to every drowning patient. Seek medical direction and follow local protocol. Class Activity Have students research and report on the most recent evidence regarding the mammalian diving reflex. Mammalian diving reflex Cold-water versus warm-water drowning

Assessment-Based Approach: Drowning and Water-Related Emergencies
Scene Size-Up Back to Objectives

Scene Size-Up Safety Critical in water-related emergencies
Assistance from other departments Talking Points The scene size-up is especially critical in water-related emergencies. Anytime you are within ten feet of the water’s edge, consider wearing a personal flotation device. If you choose to go into the water to rescue a patient, be sure you are capable of swimming; do not put yourself in danger. Decide if you will need any additional assistance, such as a dry team to work on shore and a wet team to immobilize the patient in the water. Be aware that rescues in white water or swift water require specialized techniques and training. If you are not qualified to undertake a rescue, be prepared to contact rescue teams that are. Survey the scene to determine the number of patients. Usually there will be just one patient, but in some circumstances, such as a car in the water or victims struck by a moving boat, there could be more. Call for any extra or expert assistance that may be required. Scene Size-Up

Primary Assessment

Primary Assessment General impression Level of responsiveness ABCs
CPR if necessary Transport priority Talking Points Form a general impression of the patient. Assess the level of responsiveness and document it. Assess the airway, and provide in-line stabilization. Check the breathing. Provide positive pressure ventilation and supplemental oxygen as necessary. Check the circulation to make sure that the patient has a pulse and no life-threatening external bleeding that needs to be controlled. Provide CPR if necessary. Assess for signs or symptoms of internal bleeding or hypoperfusion (shock). Make a decision on the priority of the patient. Identify as high priority patients those who have high spine injuries affecting respirations, who are found in respiratory distress, or who are unresponsive. Primary Assessment

Secondary Assessment Point to Emphasize Drowning patients fall into four categories: asymptomatic, symptomatic, cardiac arrest, and obviously dead.

Secondary Assessment Signs and symptoms Asymptomatic Symptomatic
Cardiac arrest Obviously dead Talking Points Perform a rapid secondary assessment, obtain a history, and assess baseline vital signs. Look for signs and symptoms of any underlying injuries or medical problems. The drowning patient can be placed into one of the following four categories: – Asymptomatic: The patient displays no signs or symptoms of the drowning event. – Symptomatic: The patient exhibits signs and symptoms as a result of the drowning. – Cardiac arrest: The patient is unresponsive, pulseless, and apneic. – Obviously dead: The patient exhibits rigor mortis or dependent lividity. Secondary Assessment

Emergency Medical Care Points to Emphasize For patients in cardiac arrest who are older than one year, follow the usual AED protocol but keep in mind that the patient may be hypothermic. Anticipate gastric distension. Be prepared to decompress the stomach and suction the airway. Discussion Question What are the management priorities for drowning patients? Back to Objectives

Emergency Medical Care
Remove patient from water Backboard in water if necessary Place patient on left side if no spine injury suspected Prepare to suction Ventilate if necessary Begin CPR, if needed Provide gastric distention relief Manage other conditions Transport quickly Talking Points Follow these steps in caring for a drowning patient: Remove the patient from the water as safely as possible. If a spine injury is suspected, maintain in-line stabilization and then secure the patient to a backboard before removing him from the water . If you do not suspect spine injury, place the patient on his left side. Be prepared to suction as these patient often have water in the airways and have a tendency to vomit because of the water that has been swallowed. Establish an open airway and begin positive pressure ventilation with supplemental oxygen. If the patient is pulseless and apneic and is older than one year of age, begin CPR, apply the AED, and proceed with the AED protocol. Apply pressure only if the gastric distention interferes with your ability to ventilate the patient effectively. Manage any other medical or trauma conditions associated with the drowning. Always transport a drowning patient.

Reassessment

Reassessment Monitor for changes
Every five minutes for unstable patient Every 15 minutes for stable patient Talking Points During reassessment, be especially alert for signs the patient is deteriorating into respiratory or cardiac arrest, especially if you previously resuscitated this patient. Perform reassessment (repeating the primary assessment, repeating the secondary assessment, repeating vital signs, and checking interventions) every five minutes if the patient is unstable and every 15 minutes if the patient is stable. Knowledge Application Given a series of scenarios, students should be able to assess and manage drowning patients. Reassessment

Scuba- or Deep-Water Diving Emergencies
Teaching Time 45 minutes Point to Emphasize EMTs everywhere may face managing a patient with a diving emergency, regardless of location. Back to Topics

Availability of scuba or deep-water diving sites Complications
Talking Points People who take part in scuba or deep-water diving may become victims of drowning incidents. The growing popularity of recreational and commercial diving has led to an increase in the incidence of diving incidents and emergencies. You may not practice as an EMT in or around oceans, but accidents involving diving may occur anywhere. Many people dive in quarries, lakes, rivers, and caves. Air travel has made it easy to dive for an hour, board a plane, and be in a central location away from the ocean within hours. All EMTs must be prepared to recognize and manage a diving emergency. A major complication of deep-water diving emergencies is coma, which may result from asphyxiation, head injury, heart attack, air-tank contamination, intoxication, or aspiration. It can also result from decompression sickness, arterial gas embolism, or barotrauma.

Basic Laws of Physics Related to Scuba- or Deep-Water Diving Emergencies
Points to Emphasize Dysbarism results from the effects of changes in ambient pressure to which the body is exposed. The physics of gases plays a major role in producing dysbarism. Teaching Tip If teaching in cold weather, blow up a balloon at the beginning of class and place it outside. (If the weather is warm, put the balloon in a refrigerator). Have the class go outside on breaks and after class to observe what happens to the balloon to demonstrate Charles’s law. Discussion Questions What is meant by the partial pressure of a gas? Use Boyle’s law to explain what happens when a diver holds his breath on ascent. Back to Objectives

Dysbarism Boyle’s Law Dalton’s Law Henry’s Law Charles’s Law
Talking Points Dysbarism is a medical condition that results from the effects on the body of changes in ambient pressure. The laws of physics that are associated with diving emergencies are: – Boyle’s law: At a constant temperature, the volume of a gas is inversely related to the pressure. – Dalton’s law: The total pressure of a mixture of gases equals the sum of the partial pressures of the individual gases that make up the mixture. – Henry’s law: At a constant temperature, the amount of gas that dissolves in a liquid it is in contact with is proportionate to the pressure of the gas around it. – Charles’s law: All gases will expand equally upon being heated. Class Activity Have students search the Internet to get ideas for quick science fair-type experiments to demonstrate relevant gas laws. Critical Thinking Discussion Use gas laws to explain how a recompression (hyperbaric) chamber works.

Decompression Sickness
Pathophysiology Discussion Question How does decompression sickness occur? Point to Emphasize Decompression sickness occurs when nitrogen in the blood is rapidly decompressed, resulting in nitrogen bubbles in the blood and tissues. Back to Objectives

Pathophysiology Effects on body Predisposing factors
Predisposing physical characteristics Environmental factors Talking Points Decompression sickness occurs as the result of the bubbles formed from the expansion of nitrogen in the blood and tissues. The bubbles act as emboli and cause obstruction in the circulation. They also compress or stretch the blood vessels and nerves. Factors that increase the risk of developing decompression sickness include going to a high altitude too soon; failing to take safety stops; inadequate surface intervals; inadequate decompression; diving at depths for too long a period of time; and diving repeatedly on the same day. Physical characteristics or conditions that predispose an individual to decompression sickness include obesity, age, dehydration, heart or lung conditions, and preexisting musculoskeletal injury. Other environmental factors that put the diver at risk include cold water, rough sea conditions, heavy diving suits, and heavy work. Critical Thinking Discussion How does flying immediately after deep water diving increase the risk for dysbarism?

Categories of Decompression Sickness Point to Emphasize The spectrum of severity of decompression sickness runs from “the bends” to arterial gas embolism. Back to Objectives 48

Categories of Decompression Sickness
Type I decompression sickness Type II decompression sickness Arterial gas embolism Talking Points Decompression sickness (DCS) is divided into three categories: – Type I decompression sickness (mild) – Type II decompression sickness (serious) – Arterial gas embolism (AGE) The pain characteristically associated with decompression sickness has caused this disorder to be nicknamed “the bends.” It usually results from a diver ascending too rapidly from a deep, prolonged dive. The onset of DCS may occur up to 72 hours following the dive.

Barotrauma Point to Emphasize Barotrauma occurs when air pressure in body cavities becomes too great. Back to Objectives 50

Barotrauma Cause Signs and symptoms Complications Talking Points
Sometimes called “the squeeze,” barotrauma occurs during ascent or descent when air pressure in the body’s air cavities becomes too great. As a result, the air pressure injures the air cavity tissues. Divers with upper respiratory infection or allergy are at increased risk of barotrauma. Signs and symptoms of the condition include the following: – Mild to severe pain in the affected area – Clear or bloody discharge from the nose or ears – Extreme dizziness – Nausea – Disorientation Patients suffering from barotrauma must be cared for at a medical facility immediately to prevent permanent deafness, residual dizziness, or the inability to dive in the future.

Emergency Medical Care Back to Objectives 52

Emergency Medical Care
Establish in-line spine stabilization Open airway Initiate CPR and apply AED Transport Talking Points Follow these steps in caring for a patient whom you suspect has an air embolism, decompression sickness, or barotrauma: If any suspected spine injury exists, establish in-line spine stabilization. Do not place the patient in a Trendelenburg or head-down position. Open the airway and assess for adequate breathing. Provide high-flow, high-concentration oxygen. Begin positive pressure ventilation if necessary. Assess the circulation. Initiate CPR and apply the AED if needed. Transport the patient immediately. If it is a diving emergency, try to obtain the patient’s diving log and transport it with him to the hospital. Contact medical direction to consider transport to a facility with a recompression chamber. Continue to provide oxygen during transport. Knowledge Application Given several scenarios involving dysbarism, students should be able to assess and manage patients.

CASE STUDY Follow-Up Case Study Follow-Up Discussion
This case study is continued from the beginning of the presentation. Briefly remind students that they are dispatched to a submersion incident at 99 Wolf Road in the Delmar Hotel. Your unit and the police arrive at the same time. You are led to the pool by the hotel manager, who complains that the young man and his friends have been drinking. A crowd of intoxicated bystanders has gathered around the pool and are shouting comments. The police move to clear the crowd. With the only obvious hazard under control, the scene is secure and you approach the pool.

CASE STUDY Primary Assessment
Enter into pool; partner takes manual in-line stabilization Patient’s speech is disconnected and slurred No signs of shock or major bleeding Case Study Follow-Up Discussion, continued A hotel employee has been supporting the patient in a supine position in the water, keeping his head, neck, and spine in alignment. Your general impression is of an adult male in no obvious distress except for his chief complaint, the inability to move his feet. You both slip into the pool with the appropriate equipment. Your partner takes over manual in-line stabilization while you assess the airway, breathing, and pulse. The patient’s speech is somewhat disconnected and slurred. He knows his name, Robby Ash, but not exactly where he is or what day it is. With Robby’s airway and breathing adequate and no signs of major bleeding or shock, you maneuver the float board into position. 55

CASE STUDY Primary Assessment Board patient in water
Remove patient from water Administer O2 at 15 lpm via a nonrebreather mask when out of water Case Study Follow-Up Discussion, continued You immobilize his torso, apply the collar, and immobilize his head to the board. Then you gently push the board to the side of the pool. With the assistance of the employee and two police officers, you remove the board and Robby, as a unit, from the water and set them down on the deck. You and your partner climb out and begin to administer oxygen at 15 lpm via a nonrebreather mask. Since the patient is responsive with an adequate airway and breathing, he is not a high priority for rapid transport. You proceed to the secondary assessment at the poolside. 56

CASE STUDY Secondary Assessment
Contusion on top of head; point tenderness on neck; no other trauma Patient cannot move either set of limbs; sensation absent; pulses present Case Study Follow-Up Discussion, continued A physical assessment reveals no other injuries aside from a contusion on the top of the head and some point tenderness in the neck. Because of Robby’s complaint that he cannot feel his feet, you pay particular attention to the assessment of pulses and motor and sensory function in the extremities. In the upper extremities, radial pulses are present and strong. Robby cannot grip your fingers on command and cannot identify which of his fingers you are touching or pinching. In the lower extremities, pedal pulses are present. Robby cannot move his feet or toes on your command and cannot identify the location of a touch or pinch to any part of either foot. 57

CASE STUDY Secondary Assessment
BP: 112/72; HR: 78; RR: 15; SpO2: 99 percent Pupils equal and reactive to light Case Study Follow-Up Discussion, continued You take a set of vital signs; they show blood pressure 112/72; a heart rate of 78; and a respiration rate of 15. The SpO2 reading is 99 percent. The patient’s overall skin color appears normal, but because of his extended time in the pool, you cannot accurately assess the temperature of the skin or whether it would be wet or dry if he had not just been removed from the water. His pupils are equal in size and reactive to light. While your partner prepares the patient for transport, you ask the history questions and find out that Robby’s only symptom is the lack of feeling in his feet. He has an allergy to penicillin, is taking no medications, and has no pertinent past medical history. His last solid meal was two hours ago. He has been drinking beer all night long, which, he agrees, probably led him to attempt the dive into shallow water. When your partner finishes preparing the patient, you load him into the ambulance and begin transport. 58

Treatment and Reassessment
CASE STUDY Treatment and Reassessment ABCs Keep patient warm BP: 112/72; HR: 76; RR: 15; SpO2: 99 percent Patient vomits; suctioned and turned on board to left Case Study Follow-Up Discussion, continued The focus of your care en route to the hospital is to monitor Robby’s ABCs and keep him warm. You take another set of vital signs: blood pressure is still 112/72; heart rate is now 76; and respirations 15. His skin is normal color but still feels cool and damp. The SpO2 remains at 99 percent. You check to be sure that the nonrebreather mask is secure, oxygen is flowing adequately, and Robby is well secured to the long spine board. Because you know Robby has been drinking heavily and probably swallowed a fair amount of pool water, you are prepared for the possibility of vomiting and have suctioning equipment ready. And, in fact, he soon says, “I feel real sick, man.” You remove the nonrebreather mask and with your partner’s help, turn the board so that Robby is on his left side. You apply suction to clear his mouth and airway as he vomits. You return him to the normal position just as you arrive at the hospital. 59

Treatment and Reassessment
CASE STUDY Treatment and Reassessment Upon arrival, give report Take ambulance out of service to change uniforms Case Study Follow-Up Discussion, continued Upon arrival, you give an oral report to the emergency nurse, being sure to mention the vomiting incident and the latest set of vital signs taken in the ambulance. You fill out the prehospital care report while your partner cleans up and restocks the ambulance. The emergency doctor tells you that he is not optimistic about the possibility that Robby will walk again. As you pull away from the hospital, you contact dispatch and announce that you are temporarily out of service. You are going back to base so that you can change into dry uniforms. Case Study Follow-Up Discussion Questions Should you anticipate any additional complications due to the patient’s ingestion of alcohol? Could his vital signs change as a result of the probable spinal injury? If so, what might you see? 60

Critical Thinking Scenario
Four-year-old male reported victim of a near drowning incident It’s February, and the outside temperature is 34 degrees Fahrenheit Upon arrival, you’re directed to the back of the house where the patient is on the sidewalk next to a swimming pool Critical Thinking Discussion This critical thinking scenario is intended to challenge your students to think about assessing and managing a drowning patient. The scenario continues on the next slide.

Critical Thinking Scenario
Family states he was outside playing in the snow and suddenly disappeared After 15 minutes of searching, they found the pool cover displaced and the patient at the bottom of the shallow end of the pool The patient is extremely pale, cyanotic, and not moving He is pulseless and apneic Critical Thinking Discussion, continued Ask students to briefly discuss the scenario before moving on to the series of questions on the next slide.

Critical Thinking Questions
How would you proceed with the emergency care of the patient? Would you apply the AED and proceed with defibrillation? What are some other special considerations when managing this patient? Critical Thinking Discussion, continued Answers: After immediately removing the patient from the cold environment and removing his wet clothes, place him on his left side so that any water, vomitus, or secretions can drain from his upper airway. Then place him back into a supine position and suction as necessary. Next, establish an airway using a head-tilt, chin-lift maneuver or a jaw-thrust maneuver if you suspect spine injury, insert an oropharyngeal airway, and begin positive pressure ventilation with supplemental oxygen. Immediately begin CPR. After five cycles of CPR, apply the AED and follow the AED protocol for hypothermic patients. Watch for (and treat) severe gastric distention and transport without delay while continuing resuscitative efforts. Yes, you should apply the AED, but because the cardiac arrest was not witnessed or it may have been greater than four to five minutes since the cardiac arrest, perform five cycles of CPR prior to activating the AED. Because of the probability of hypothermia, only deliver one shock. If it is not successful, continue CPR and the immediately transport the patient. Numerous special considerations are related to managing this patient, but the following should all be included: the ambient temperature, the patient’s core temperature, the patient’s age, the temperature of the water (and its effect on resuscitation), and the AED protocol for hypothermic patients. 63

Reinforce and Review Please visit www.bradybooks.com
and follow the myBradykit links to access content for the text. Please visit and follow the MyBradyKit links to access content for this text. Under instructor resources, you will find curriculum information, lessons plans, PowerPoint slides, TestGen, and an electronic version of the instructor’s edition. Under student resources, you will find quizzes, critical thinking scenarios, weblinks, animations, and videos related to this chapter—and much more.

Submersion Incidents: Drowning and Diving Emergencies

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