Assessment and Treatment of Submersion Injuries Greg Friese, MS, NREMT-P Randal F. Wojciehoski, DPM, DO No part of this presentation may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying or recording, or by any information storage and retrieval method without express written permission from CentreLearn Solutions, LLC. Case Study Water Rescue US Coast Guard Digital South Carolina/FEMA News Photo 1
Drowning Terminology Drowning 2
Drowning Outcomes Death Morbidity No Morbidity Drowning Process Begins to voluntarily hold breath Continuum of events begins Gas exchange interrupted Will most likely breathe in liquid Drowning Outcomes 3
Cough Reflex Drowning is respiratory impairment from submersion Objectives 1. Discuss submersion injury statistics 2. Explain causes of submersion injuries 3. Understand submersion injury patterns 4. Explore rescue and extrication considerations for submersion injury patients 5. Describe assessment and treatment of a submersion injury patient Objective 1: Submersion Injury Statistics 4
Submersion Injury Statistics 6,500 deaths per year Children 2 nd leading cause of injury related death < 1 year old bathtub, bucket, or toilet Bimodal death distribution Lack of supervision Lack of skill Risk-taking behavior and intoxication Submersion Injury Statistics While many children survive with little adverse effect, permanent damage can result Submersion Injury Statistics Large disparities exist in occurrence of drowning 5
Seasonal Distribution Geographic Distribution 90% of drownings occur in freshwater > 50% are in home swimming pools Submersion Fatalities and Alcohol Alcohol intoxication is involved in 25-50% of adolescent and adult water Click to Continue recreation fatalities 6
Objective 2: Submersion Injury Causes Drowning Pathophysiology Submersion Exhaustion Poor swimming skills Seizure Intoxication Trauma Drowning Pathophysiology Submersion Attempt to Breathe Laryngospasm 7
Drowning Pathophysiology Submersion Attempt to Breathe Influx of water collapses alveoli Reduces surface for gas exchange Aspiration Drowning Pathophysiology Submersion Dry Attempt to Breathe Wet Suffocation Hypoxia Brain Damage Drowning Pathophysiology Submersion Attempt to Breathe Laryngospasm Aspiration Suffocation Hypoxia Brain Damage 8
Drowning Pathophysiology Water flows to the lowest spot No action is required to remove inhaled or ingested water Cause of Submersion Trauma Seizures Cardiac disease Hypoglycemia Syncope Exhaustion Intoxication Hypothermia Length of Submersion U.S. COAST GUARD SLIDE < 1 hour begin resuscitation > 1 hour body recovery 9
Cold Water Drowning Water temp < 70 o F (21 o C) Fresh Water vs. Salt Water Both cause alveolar damages and disrupt gas exchange Treatment is the same U.S. COAST GUARD DIGITAL Water Purity 10
Time to Treatment Immediate BLS from bystanders is better than delaying treatment until EMS arrives Patient Age Generally, young healthy kids, submerged for a short duration, in very cold water that receive immediate BLS treatment after extrication have a better chance of survival Click to Continue Objective 3: Submersion Injury Patterns U.S. COAST GUARD DIGITAL 11
Identify and Treat Life Threats On-scene BLS that leads to a spontaneous return of pulse has the greatest impact on patient survival U.S. COAST GUARD DIGITAL Spinal Cord Injuries Cervical spine or head injuries, if present, are typically the cause of submersion Respiratory Complications Unsuccessful Resuscitation Pulmonary Edema Pneumonia 12
Hypothermia Focus treatment on the cardiopulmonary arrest Altered Mental Status Rocco Altobelli Collection Hypoglycemia Hypothermia Hypoxia Traumatic brain injury Seizure Intoxication Click to Continue Objective 4: Rescue and Extrication Considerations 13
Rescue and Extrication Keep patient s head above water Move patient along their vertical axis Float a backboard under the patient Reach! U.S. COAST GUARD DIGITAL Victim: awake and active Offer a reach or throw assist Throw! Aim for just beyond and upstream Let current wash the rope into the patient A strong rescue team may be needed Rocco Altobelli Collection 14
Go! If patient is silent, still, or not able to keep their head above water, they can not assist in their own rescue Swimming Rescue U.S. COAST GUARD DIGITAL Submerged Patient Clear water and known depth enter water feet first and swim patient to surface Begin spinal immobilization in the water Conditions of unknown depth, poor visibility, current, or hazardous bottom conditions consider probing for patient Prolonged search becomes a body recovery Click to Continue 15
Objective 5: Assessment and Treatment 1.5. Describe assessment and treatment of a submersion injury patient US Coast Guard Digital Scene Size-up Team Safety Use incident command system Appoint a safety officer Consider a rehab station Mixed MOI Trauma Medical Environment 16
MOI/NOI Cause of submersion MOI for spinal cord injury Patient s AVPU at time of extrication How patient was rescued Bystander treatments applied before your arrival Any changes in the patient s condition Spinal Immobilization Mechanism of Injury Positive Uncertain Negative Manage spine stable with full body immobilization Spine immobilization not needed Additional Resources U.S. COAST GUARD SLIDE Is there a swiftwater rescue team in your area? Does your service have a rescue boat and water rescue equipment? When was the last time you practiced using water rescue equipment? 17
Initial Assessment In the water Open airway Rescue breathing U.S. COAST GUARD SLIDE Chest compressions Only effective when patient is on a hard surface Airway Management Normal Methods Suction Positioning Finger sweep Abdominal thrusts are only indicated if patient has an airway obstruction. They are ineffective at removing aspirated water and waste valuable resuscitation time. Airway Management Expect the patient to vomit Remove with: Finger sweep Suction Recovery position U.S. COAST GUARD SLIDE 18
Breathing Check Breathing Check Pulse No breathing, pulse present Maintain open airway BVM ventilation with high flow O 2 Circulation Check Breathing Check Pulse No breathing, no pulse No breathing, Pulse present Maintain open airway CPR with BVM ventilation with high flow O 2 Maintain open airway BVM ventilation with high flow O 2 Spontaneous Breathing Present Check Breathing Check Pulse No breathing, No breathing, Breathing and No pulse Pulse present pulse present Maintain open airway CPR with BVM ventilation with high flow O 2 Maintain open airway BVM ventilation with high flow O 2 Maintain open airway high flow O 2 by BVM or nonrebreather 19
Wet Clothing Removal Prevent additional heat loss A wet patient will loose heat quickly through evaporation, radiation, convection, and conduction If no pulse Apply AED ASAP Follow prompts to deliver shocks, reassess patient, and resume CPR Treatment: BLS Transport Priority Any submersion injury patient with any ABC problems is a high priority patient U.S. COAST GUARD DIGITAL 20
Focused History and Physical Exam Complete as time allows Reassess for breath sounds U.S. COAST GUARD DIGITAL SAMPLE Frame by frame movie of what happened before, during, and after submersion U.S. COAST GUARD DIGITAL Reassess Vital Signs Three One sets Two sets starts starts merely interesting a to trend tell a story 21
ED Evaluation U.S. COAST GUARD DIGITAL Survival Prognosis Good if awake upon hospital arrival Poor if CPR still in progress 35-60% of patients die 60-100% of survivors have long term neurological side effects Suspected Child Abuse During your scene size-up and history questions to the parent, be aware of clues of child abuse 22
Injury Prevention Ideas Controlling access to swimming pools Adequate adult supervision anytime children are in or near the water, including a bathtub or buckets of water Encouraging use of US Coast Guard approved personal flotation devices Discouraging i alcohol l and drug use during recreational water activities like swimming and boating Check the water depth before diving Offer community CPR and first aid course for new parents and babysitters Swimming lessons Lifeguard supervision at pools and beaches Summary: Drowning/ Near Drowning Standard BLS and ALS interventions are indicated for submersion injuries, regardless of the mechanism Begin rescue breathing and high flow supplemental oxygen as soon as possible The prognosis is better if there is an early return of spontaneous circulation If a submersion injury patient is resuscitated, before or after EMS arrival, a hospital evaluation is still indicated Every submersion injury is preventable Rescuer safety is number one do not become a second victim Other Environmental Emergency CE Courses Hypothermia: Assessment and Treatment Heat Emergencies Lightning Injury Prevention and Treatment Avalanche: Rescue, Injury, and Treatment US COAST GUARD DIGITAL 23
Credits Lesson Authors Greg Friese, MS, NREMT-P Randal F. Wojciehoski, DPM, DO Design and Production Images United States Coast Guard Visual Imagery FEMA Image Library Rocco Altobelli Photo Collection Emergency Preparedness Systems LLC Photo Collection Narrator John A. Chamberlain Jr. References Cheng D. 2003. Drowning. emedicine.com, Inc. [retrieved May 25, 2005 from http://www.emedicinehealth.com/articles/6120-1.asp#] Shepherd S, Martin, J. 2005. Submersion Injury, Near Drowning. March 22, 2005. [retrieved May 25, 2005 from http://www.emedicine.com/emerg/topic744.htm.] Fiore M, Heidemann S. 2004. Near Drowning. September 20, 2004. [retrieved May 25, 2005 from http://www.emedicine.com/emerg/topic2570.htm.] National Center for Injury Prevention and Control. 2004. Water Related Injuries: Fact Sheet. August 5, 2004. [retrieved May 25, 2004 from http://www.cdc.gov/ncipc/factsheets/drown.htm] Brenner RA. 2003. Prevention of Drowning in Infants, Children, and Adolescents. Committee on Injury, Violence, and Poison Prevention, 2002 2003. Pediatrics. August 2003. 112(2) Stratbucker WB, Green CM. 2005. Injury Prevention. emedicine.com, Inc. January 10, 2005. [retrieved May 25, 2005 from http://www.emedicine.com/ped/topic3046.htm] State t of Alaska: Cold Injuries Guidelines: Alaska Multilevel l 2003 Version. Section of Community Health and EMS. Division of Public Health. Department of Health and Social Services. Juneau, AK. Revised January, 2005. Modell JH, Idris AH, Pineda JA, Silverstein JH. 2004. Survival After Prolonged Submersion in Freshwater in Florida. May 2004. Chest. 125(5). [retrieved May 25, 2004 from /das/journal/view/47514487-2/n/14712821?ja=418019&page=1.html&anchor=top&source=mi] Olshaker JS. 2004. Submersion. Emergency Medicine Clinics of North America. 22(2004):357-367. Hwang V, Shofer FS, Durbin DR. 2004. Prevalence of Traumatic Injuries in Drowning and Near Drowning in Children and Adolescents. Archive of Pediatric Adolescent Medicine 2003;157:50-53. Abstract reported in Annals of Emergency Medicine. 43:4. April 2004. The American Heart Association. Part 12: Cardiac Arrest in Special Situations. Circulation. 2010;122:S829-S86. Van Beek EF. A new definition of drowning: towards documentation and prevention of a global public health problem, 2005. Bulletin of the World Health Organization. 2005;83:853-856 World Health Organization. 2010. Facts about injuries: Drowning. [retrieved May 29, 2011 from http://www.who.int/mediacentre/factsheets/fs347/en/index.html] World Congress on Drowning. 2002. Final Recommendation of the World Congress on Drowning. 2002. [retrieved May 29, 2011 from http://www.cslsa.org/events/archiveattachments/spr03minutes/attachmentg2.pdf] 24