Drowning New Definitions and Protocols

1. DrowningNew Definitions and Protocols Charles Stewart MD, EMDM Director of ResearchUniversity of Oklahoma Tulsa School of Community MedicineOklahoma Institute for Disaster and Emergency Medicine

2. Drowning Much of our experience with the resuscitation of patients is a direct result of man’s ventures into the water.

3. Drowning • Demographics • 6,000 - 8,000 deaths per year • The 3rd leading cause of accidental death in USA • The 2nd leading cause of death in children • 25,000 rescues each summer on California beaches

4. Drowning • Statistical Risk Factors • Age: Youth 40% under 4 years old • Location: Pools, bathtubs, lakes, rivers • Sex: Male 3:1 • Time of year: Warm months

5. Drowning • We really don’t know how many ‘near’ drownings occur each year. • Death statistics are readily available • >15% of school children have at least one submersion incident per year. • With 7.4 per 100,000 reported mortality, that means at least ½ million per year in South Carolina alone!.

6. Near Drowning • Statistical Risk Factors • Predisposing Illnesses: Epilepsy, seizures • Trauma: Diving and boating accidents, falls • Mental impairment: Drugs and alcohol

7. Near Drowning • Most common sites: • Fresh inland bodies of water • Lakes • Rivers • Quarries • Residential swimming pools

8. Predisposing Factors • Coma, seizures • Alcohol/Drugs • Exhaustion • Hyperventilation • Rapidly moving water

9. Predisposing Factors • Poor swimming ability • Exhaustion • Panic • Hypothermia • Trauma

10. Near Drowning Murder ??? Suicide ???

11. Near Drowning Definitions Definitions were revised at 2002 World congress on Drowning in Amsterdam, Netherlands. They are now internationally accepted and more uniform

12. Near Drowning Survival beyond 24 hours after immersion. This definition is no longer used…

13. Drowning Submersion in a fluid resulting in immediate death or death with 24 hours Respiratory impairment from submersion in a liquid. May have outcome of death, morbidity, or no morbidity

14. Drowning The fluid does not have to be water

15. Drowning • Unconsciousness • Due to : • Trauma • Seizure • Coma • Drug/Alcohol abuse

16. Drowning Pathophysiology • 3 Major metabolic abnormalities • Anoxia • Acidosis • Hypercapnia

17. Wet Drowning • Approximately 90% of drowning victims • aspirate water • vomit • cough • gasp • flood lungs with water

18. Pathophysiology withaspiration • Hypoxemia • Occurs whether or not patient aspirates • 85-90% aspirate • 10-15% DO NOT aspirate

19. Pathophysiology withoutaspiration • Severe, persistent laryngospasm • Anoxic seizures • Death

20. Pathophysiology withaspiration • Hypoxemia • Asphyxia starts the Hypoxia • Intrapulmonary shunting leads to further hypoxemia • Pulmonary damage continues the process

21. Does the type of aspirated water matter?

22. Pathophysiology • Consequences of Aspiration • Few survivors of drowning aspirate enough water to cause significant changes in either blood volume or serum electrolytes.

23. Pathophysiology • Consequences of Aspiration • 2.2 cc/kg Hypoxia • 11 cc/kg Blood volume changes • 22 cc/kg Electrolyte changes • Average aspiration is only 2-4 cc/kg

24. Pathophysiology withaspiration • Pulmonary Edema • Damage to Alveolar membrane • Damage to pulmonary microcirculation

25. Salt vs Fresh There are REAL differences

26. Near Drowning • Potential Fresh Water Damage • Hypoxia • Atelectasis Strips surfactant • Pulmonary Edema • Hypotonic • Hemolysis • Lowered Na, Cl, and K

27. Potential Fresh Water Damage • Hypoxia • Atelectasis • Pathogenic bacteria and impurities lethal • Produces greater long-term damage due to salt in pulmonary edema

28. Drowning • Potential Salt Water Damage • Hypovolemia if large amounts swallowed • Hypertonic Elevation of Na, Cl and K, decrease blood volume • Salt water is 2 times as lethal

29. Drowning Final Pathway • Pulmonary Edema • Hypoxia

30. COLD WATER and WARM WATER drownings are different

31. Warm Water • 20oC and above • 72oF and above • Lakes, ponds, quarries

32. Hot Water • Body temperature and above • Hot tubs, bath tubs, hot springs

33. Warm Water Drownings • 49 Warm Water Drownings in Children • 29 died 58% • 13 neurological cripples 27% • 7 survived intact 15%

34. Cold water has more survivors

35. Very Cold Water • The definition is not easy • It is usually below 21oC or (71oF)

36. 6 5 100% Lethal 50% unconscious 4 Hours 3 Probable Drowning 2 Safe 1 20 30 40 50 -8 -2 4 10 Water Temperature

37. Mammalian Diving Reflex • Circulatory system shunts blood to the brain and heart from extremities, GI tract and skin • Apnea and bradycardia follow, allowing prolonged submersion

38. Mammalian Diving Reflex • Found in all mammals • Heart Rate Slows • Airway closes • Circulatory system shunts blood to brain and heart from extremities, GI tract and skin • Apnea and bradycardia follow, allowing prolonged submersion

39. Mammalian Diving Reflex • Mammalian Diving Reflex in Humans • Not very active • Probably not the mechanism for survival in prolonged submersions in children

40. Immersion syndrome • Sudden exposure to very cold water. • Probably vagal dysrhythmia • Asystole • Ventricular fibrillation • Alcohol and intoxicants are predisposition

41. Immersion Hypothermia A special case….

42. Cold water immersion Survival Times - Persons of Average Build Water Temperature Survival Time 0 Deg C 45 minutes 9.5 deg C 2 to 3 hours 11 deg C 4 hours 14 deg C 6 hours 18 deg C 10 hours

43. Immersion hypothermia Huddle HELP

44. Submersion victims aren’t dead until they are WARM and DEAD

45. Field Management

46. Drown not thyself to save a drowning man Old Proverb

47. Rescue • Most people drown within 10 to 30 feet of safety. • Reach • Throw • Row • Go? American Red Cross

48. Scene Assessment • Type of incident? • Duration of submersion? • Type and temperature of water? • Duration of on scene CPR? • Prior health of patient? • Drug and Alcohol use?

49. Near Drowning • Watch for trauma in rapidly moving water

50. Resuscitation