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Advocacy Project : Drowning Prevention

Advocacy Project : Drowning Prevention. Lindsay M. Stewart, MD July 26, 2012 University of Nevada School of Medicine. Disclosures. No current research No financial investments. Objectives. MEDICAL KNOWLEDGE PATIENT CARE INTERPERSONAL & COMMUNICATION SKILLS

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Advocacy Project : Drowning Prevention

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  1. Advocacy Project:Drowning Prevention Lindsay M. Stewart, MD July 26, 2012 University of Nevada School of Medicine

  2. Disclosures • No current research • No financial investments

  3. Objectives • MEDICAL KNOWLEDGE • PATIENT CARE • INTERPERSONAL & COMMUNICATION SKILLS • PRACTICE-BASED LEARNING & IMPROVEMENT • SYSTEMS-BASED PRACTICE • PROFESSIONALISM

  4. In the Community July 11, 2012

  5. 1. MEDICAL KNOWLEDGE • Learn what constitutes a drowning • Understand the pathophysiology • Review findings at autopsy

  6. “… the process of experiencing respiratory impairment from submersion/immersion in liquid” Can be any kind of fluid Drowning Peden M, McGee K, Sharma K. The injury chart book: a graphical overview of the global health burden of injuries. Geneva: World Health Organization, 2002.

  7. Terminology • Nonfatal drowning- if the person is rescued at any time; the process of drowning is interrupted • Fatal drowning- if the person dies at any time as a result of drowning • Water rescue- any submersion or immersion without evidence of respiratory impairment Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

  8. Phases of Drowning • Submersion • Struggle • Exhaustion • Drowning • Loss of consciousness • Death

  9. Pathophysiology (0.6% NaCl) • Fresh water - water passes from lungs to blood- hemodilution; denaturation of surfactant -> alveolar collapse -> decr lung compliance -> severe V-Q mismatch -> hypoxia -> neuro damage • Electrolyte shifts -> Cardiac arrhythmias Blood Lung Tissue Blood Lung Tissue

  10. Pathophysiology (3% NaCl) • Sea water - water passes from blood into lung tissue- hemoconcentration • Na incr -> severe pulm edema Blood Lung Tissue

  11. Pulmonary edema Plant material in bronchus Histology

  12. Findings on Autopsy • Fine white froth in the mouth, nose, lungs and air passages • Water-logged lungs • Venous congestion and fluid blood • Water in the stomach and intestines

  13. Findings on Autopsy Middle ear hemorrhages

  14. 2. PATIENT CARE • Identify patients at risk • Perform accurate H&P • Develop appropriate treatment plan

  15. More at Risk? OR Males: ~80% Females: ~20% Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2011 Apr 6]. Available from URL: http://www.cdc.gov/injury/wisqars

  16. More at Risk? 1-4 yo 5-8 yo OR Children ages 1 to 4 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2011 Apr 6]. Available from: URL: http://www.cdc.gov/injury/wisqars

  17. More at Risk? OR OR Minorities: AA 1.3x W; NA & Alaskan 1.7x W Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2011 Apr 6]. Available from: URL: http://www.cdc.gov/injury/wisqars

  18. More at Risk? OR

  19. Others at Risk Low income, neglected Poor education Aquatic exposure Alcohol use, risky behavior Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

  20. Also at Risk Epilepsy pts Risk of drowning is 15-19 times higher than those without epilepsy!!! Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

  21. Also at Risk Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

  22. H&P for Well Child Check • What questions should you ask? • When should you ask them? • What should you look for on physical exam?

  23. Initial Resuscitation • CPR • Resp? -> rescue breathing only • Cardiac? -> ABC • 5 rescue breaths • 30 compressions • 2 rescue breaths • 30 compressions • Aspiration risk Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

  24. Pre-Hospital Care • BLS until PALS available • O2 by face mask at 15L • Early intubation & mech ventilation • Peripheral IV or IO • Correct hypotension with crystalloids • If CPR does not result in cardiac activity, epi or norepi may be considered Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

  25. ED • Secure airway • Insert NG tube • Thermal insulation • Find out if precipitated by injury or medical condition • Phys exam, CXR, ABG Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

  26. PICU • Follow guidelines for ARDS • Keep on vent at least 24 hrs even if gas exchange appears to be adequate • Little evidence supporting glucocorticoid use • Pneumonia often misdiagnosed • No evidence supporting use of specific fluid therapy, diuretics or water restrictions • Induced hypothermia (32-34°C) for 24 hrs may be neuroprotective Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

  27. Complications • SIRS • Sepsis & DIC possible in first 72 hrs after resuscitation • Renal insufficiency or failure (rare) Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

  28. 3. INTERPERSONAL & COMMUNICATION SKILLS • Apply skills to different cultural backgrounds, SES, developmental levels • Develop rapport • Use a team approach

  29. Counseling • Don’t lecture • Don’t talk down to or belittle • Do ask questions • Do offer suggestions • Do assess for understanding

  30. How do you develop rapport?

  31. Formal swimming lessons Designated supervision Buddy system Seizure disorder safety Learn CPR Use personal flotation devices Barriers such as fences Lock up pool toys No “holding breath” contests Obey beach warnings Watch for signs of rip currents Avoid alcohol Drowning Prevention

  32. 4. PRACTICE-BASED LEARNING & IMPROVEMENT • Acknowledge barriers • Analyze your skills & practice them • Evaluate the effectiveness of your encounter • Identify ways to improve compliance

  33. Possible Barriers?

  34. Evaluate Your Encounter • Did you have good rapport? • What did you do well? • What can you improve on?

  35. Ways to Improve Compliance • Handouts • Videos • Make it relevant • Repetition • Follow up on it

  36. 5. SYSTEMS-BASED PRACTICE • Review incidence rates • Understand cultural norms & health beliefs • Invest in the health literacy & awareness in your community

  37. Incidence • In 2007 there were ~4,000 fatal unintentional drownings in the U.S. • ~3,500 non-boating related • ~500 boating-related incidents • > 1 in 5 people who die from drowning are children 14 and younger • 2nd leading cause of unintentional injury-related death for children ages 1 to 14 years Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2012 July 23]. Available from URL: http://www.cdc.gov/injury/wisqars

  38. Statistics • 19% of drowning deaths in children occur in public pools with certified lifeguards present • Of all preschoolers who drown, 70% are in the care of one or both parents at the time of the drowning and 75% are missing from sight for 5 min or less • 92% of children who survive are discovered within 2 min following submersion, and 86% of children who die are found after 10 min Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2012 July 23]. Available from URL: http://www.cdc.gov/injury/wisqars

  39. Statistics • Among children 1-4 yo, most drownings occur in residential swimming pools, and 11% occur in portable pools • >50% of drownings among infants occur in bathtubs, buckets or toilets Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2012 July 23]. Available from URL: http://www.cdc.gov/injury/wisqars

  40. Southern NV Health District Southern Nevada Health District [online]. Drowning and Near Drowning Statistics. [cited 2012 July 20]. Available from URL: http://www.southernnevadahealthdistrict.org/stats-reports/drowning-statistics.php

  41. Myths About Swimming • You shouldn’t swim right after eating. • Clear pool water means clean pool water. • I only need to take a shower before swimming if I haven’t bathed that day. • As long as a child is wearing a diaper in the pool, there’s no chance for contamination of the water. • When I smell the strong odor of pool chemicals, it means the water is very clean. Water Quality and Health Council [online]. [cited 2012 July 20]. Available from URL: http://www.healthypools.org/resources/swimming-pools-myths-facts/

  42. Support In Our Community • Swim Lessons: • Clark County Parks & Recreation- Free • Swim Squad- 1st Assessment $20 • YMCA- 4 lessons $50 • Bubble Swim School- $15, one day/wk x5 • Private lessons- $22.50 • Group swim- $15

  43. Support In Our Community • CPR Lessons: • UMC- Free ($10 deposit required & refunded) • UNLV & Amer Red Cross- Free • Safe Sitter Courses (ages 11-13): • UMC- Free, monthly

  44. Support In Our Community • Life Jackets: • Walmart: $6.96 $13.96 $16.00 • Recommend checking local Goodwill etc. • Amazon: ~$5 -Ebay: ~$12

  45. 6. PROFESSIONALISM • Demonstrate cultural competency • Emphasize medical ethics • Reflect on professional impact

  46. Professional Impact

  47. References • Peden M, McGee K, Sharma K. The injury chart book: a graphical overview of the global health burden of injuries. Geneva: World Health Organization, 2002. • Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2012 July 23]. Available from: http://www.cdc.gov/injury/wisqars • Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10. • Southern Nevada Health District [online]. Drowning and Near Drowning Statistics. [cited 2012 July 20]. Available from URL: http://www.southernnevadahealthdistrict.org/stats-reports/drowning-statistics.php • Water Quality and Health Council [online]. [cited 2012 July 20]. Available from URL: http://www.healthypools.org/resources/ swimming-pools-myths-facts/

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