DOT National Standard EMT-Intermediate/85 Refresher

1. Welcome! DOT National Standard EMT-Intermediate/85 Refresher

2. MEDICAL EMERGENCIES • Allergic reaction • Possible overdose • Near-drowning • ALOC • Diabetes • Seizures • Heat & cold emergencies • Behavioral emergencies • Suspected communicable disease

3. NearDrowning Perspective Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment MEDICAL EMERGENCIES

4. Submersion injuries that resulted in death in <24 hours were termed “near drowning” Submersion injuries that resulted in survival >24 hours were termed “near drowning” Near Drowning

5. epidemiology • In 2005, the WHO published a new policy defining drowning in a attempt to clarify documentation & better track submersion injuries worldwide

6. epidemiology • Drowning was defined as “the process of experiencing respiratory impairment from submersion/immersion in liquid.” • Furthermore, the WHO policy states that “drown outcomes should be classified as: death, morbidity, & no morbidity…” • The term near-drowning should not be used, & the association of the term drowning with a fatal outcome should be abandoned

7. epidemiology • Unintentional drowning accounted for 3308 deaths in the US in 2004 • Drowning is the 4th common cause of accidental death in the US • Boys account for almost 80% of victims older than 1 yr

8. epidemiology • Submersion injuries occur in • Domestic settings • Swimming pools • Hot tubs • Large buckets* • All forms of natural bodies of water

9. epidemiology • 1 study found • infants < 1yr • 55% drowned in bathtubs • 16% in large household buckets • 1 to 4 years • 56% artificial pools • Older children • 63% natural bodies of fresh water

10. epidemiology • Drowning in the US follows clear temporal patterns • 2/3 pediatric deaths occur between May & August • Most occurred on weekends • Noon - 8pm • Victims >20 yrs - most often participating in water sports or using watercraft

11. epidemiology • Ethanol consumption in proximity w/ water is a major risk factor for submersion injury or death • Acute alcohol intoxication may be a contributing factor in 30-50% of drowning among adolescents & adults

12. pathophysiology • Unexpected submersion triggers breath-holding, panic an a struggle to surface • Air hunger and hypoxia develop, & the victim begins to swallow water

13. pathophysiology • As breath-holding is overcome by the bodies desire for oxygen- involuntary gasping results in aspiration • The quantity of fluid aspirated, rather than the composition, determines subsequent pulmonary derangement

14. pathophysiology • Investigations have revealed that significant intravascular abnormalities do not occur until the amount of aspirated water exceeds 11mL/kg of body weight • And autopsy studies show that most drowning victims aspirate less than 4mL/kg

15. pathophysiology • Many factors may influence the pathophysiologic sequence of events in submersion injury & affect the chance of survival, including • Age • Water temperature • Duration & degree of hypothermia • Diving reflex • Effectiveness of diving of resuscitative effort

16. pathophysiology • Children- lower ratio of body mass to surface area = hypothermia more quickly & to a greater degree than adults • Hypothermia lowers cerebral metabolic rate & is neuroprotective to some extent

17. pathophysiology • Despite dramatic case reports of pts surviving prolonged submersion in cold water with full neurologic recovery, hypothermia is generally a poor prognostic finding • Speeds the development of exhaustion, ALOC, & cardiac dysrhythmias

18. s/s, physical exam & assessment, diagnotics, monitoring, management, pertinent positives • Most submersion injuries are witnessed • Signs of pulmonary injury: • Hypoxic, cyanotic, respiratory distress/arrest • aspiration of gastric contents greatly compounds the degree of pulmonary injury & increase likelihood of ARDS • victims swallow a significant amt of water • Aspiration & gastric distention PPV • 60% vomit after submersion • CNS injury • Mild lethargy to coma • >25min general unfavorable outcome

19. Differential Diagnosis Considerations • Pt found unconscious in water: • Ethanol or other drugs • Cardiac arrest • Hypoglycemia • Seizures • Attempted suicide of homicide • Pediatrics • Child abuse or neglect • Head or spinal injury • Although review of 2,244 cases Washington state • 0.5% cervical spine injury • Signs of serious trauma, MVC, fall from heights or diving into water

20. Management/Treatment • Clinical presentation of severe hypothermia often mimic death • Case report exist of functional recovery for individuals submerged for 66 minutes!

21. Review Protocol • Go to Near Drowning- Adult • Go to ALOC-Adult • Go to Call Matrix -General

22. Perspective • Pathophysiology • Epidemiology • Physical Exam Findings • Diagnostic Findings • Signs and Symptoms • Differential considerations • Treatment

23. Questions?

24. Questions? • References • Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. • Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. • Wolfson, Allan B. ed. , Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.