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Environmental Emergency “A Swimmer Disappears ”

Environmental Emergency “A Swimmer Disappears ”. 1. Learning Objectives. Discuss potential complications of near-drowning, which may cause cardiopulmonary arrest or a prearrest condition

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Environmental Emergency “A Swimmer Disappears ”

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  1. Environmental Emergency “A Swimmer Disappears” • 1

  2. Learning Objectives • 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 After completing this discussion we should be able to:

  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

  4. Pond Depths Swim Area

  5. Drowning/Near-Drowning Definition and Classification • Drowning: submersion resulting in immediate death or death within 24hours • 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

  6. Near-DrowningPathophysiology • 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

  7. Near-DrowningBLS 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

  8. Near-Drowning VictimOn 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?

  9. 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

  10. 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

  11. 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

  12. 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)

  13. Case ProgressionResponse 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

  14. 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 What actual or potential problems may exist?

  15. Summary: ACLS Managementof 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)

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