2. DROWNING CLASSIFICATION SYSTEM FOR RESCUERS International Lifesaving Federation Medical Committee International Lifesaving Federation Medical Committee Primary author: Dr David Szpilman (Brazil) Member Approved: Dr. Steve Beerman (Canada), Chair Dr. Peter Wernicki (USA), Vice Chair Dr. Tony Handley (UK), Secretary Dr. Joost Bierens (Netherlands), Member Dr. John Pearn (Australia), Member Dr. Lorenzo Marugo (Italy), Associate Members Dr. Zaid Chelvaraj Abdullah (Malaysia), Associate Members Primary author: Dr David Szpilman (Brazil) Member Approved: Dr. Steve Beerman (Canada), Chair Dr. Peter Wernicki (USA), Vice Chair Dr. Tony Handley (UK), Secretary Dr. Joost Bierens (Netherlands), Member Dr. John Pearn (Australia), Member Dr. Lorenzo Marugo (Italy), Associate Members Dr. Zaid Chelvaraj Abdullah (Malaysia), Associate Members 26, Gemeenteplein, Leuven 3010 Belgium Tel:32-16-35-35-00 Fax: 32-16-35-01-02, Email: ils.hq@pandora.be 26, Gemeenteplein, Leuven 3010 Belgium Tel:32-16-35-35-00 Fax: 32-16-35-01-02, Email: ils.hq@pandora.be

3. ESTABLISHED FOR ALL LIFEGUARDS: These cases compose 0.5% of all cases rescued by lifeguards at the beach Respiratory arrest = Start artificial ventilation immediately. Cardiopulmonary arrest = Start CPR immediately. Basic Life Support (BLS) - Drowning - Szpilman 2004

4. What about 99.5% of all cases rescued at the beach, what should be done? What about 99.5% of all cases rescued at the beach, what should be done? How are we to know which cases need an EMT or an MD? ? Should we give oxygen in all cases?, if so, how much? Should we call an ambulance? Should we transport all of them to a hospital? Should we release or keep them a while in observation? How are we to know the prioritization on a busy day?, and Basic Life Support (BLS) - Drowning - Szpilman 2004

5. Do you need to know how to act appropriately and confidently in those cases? Do you need to know how to act appropriately and confidently in those cases? On a busy day, as a lifeguard, would you get medical support as quickly as you needed? On a busy day, as a lifeguard, would you get medical support as quickly as you needed? or Basic Life Support (BLS) - Drowning - Szpilman 2004

6. That´s why rescuers need a DROWNING CLASSIFICATION SYSTEM That´s why rescuers need a DROWNING CLASSIFICATION SYSTEM It allows Lifeguards and MD teams to speak the same language It gives the exact severity of the case It gives exactly what approach should be taken It advises when to call an ambulance It advises when to call an EMT or a MD It reassures lifeguard’s in front of the population, and Basic Life Support (BLS) - Drowning - Szpilman 2004

7. DROWNING CLASSIFICATION SYSTEM How it was created and applied DROWNING CLASSIFICATION SYSTEM How it was created and applied It was recently (2001) validated by a 10 year study with 46,060 rescues, of which 930 (2%) were drownings attended at the Drowning Resuscitation center (DRC) It was recently (2001) validated by a 10 year study with 46,060 rescues, of which 930 (2%) were drownings attended at the Drowning Resuscitation center (DRC) It was updated in 1997 to a new medical perspective It was based on the evaluation of 41,279 rescues The final group evaluated came from 1,831 medical reports It was based on beach and hospital attendance Only clinical parameters were considered to facilitate the use It was adapted to be understood by lifeguards It’s been used since 1973 by more than 3,000 lifeguards in Rio de Janeiro It was created in 1972 by MD and lifeguards working together

8. Lifeguard Rescue Begins Victim in Danger -- Resquest ACLS help PWCPWC Lifeguard Beach support HelicopterHelicopter BoatBoat Szpilman 2000 The lifeguard system ACLS Basic Life Support (BLS) - Drowning - Szpilman 2004 Call for Back up

9. Yes Check COUGH and FOAM in mouth & nose SMALL AMOUNT OF FOAM Yes Give 2 mouth-to-mouth ventilations and check signs of circulation Signs of Circulation ? Check victim’s response - Can you hear me? Absent Open airways - look, listen, and feel respiration COUGH WITHOUT FOAM NoYes No RADIAL PULSE ? No BREATHING PRESENT? CSI ? GREAT AMOUNT OF FOAM yes No Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 On shoreline or Pool Deck Call for Help Basic Life Support (BLS) - Drowning - Szpilman 2004 Click on numbers to see treatment

10. Yes Check COUGH and FOAM in mouth & nose SMALL AMOUNT OF FOAM Yes Give 2 mouth-to-mouth ventilations and check signs of circulation Signs of Circulation ? Check victim’s response - Can you hear me? Absent Open airways - look, listen, and feel respiration COUGH WITHOUT FOAM NoYes No RADIAL PULSE ? No BREATHING PRESENT? CSI ? GREAT AMOUNT OF FOAM yes No Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 On shoreline or Pool Deck Call for Help Basic Life Support (BLS) - Drowning - Szpilman 2004 Click on numbers to see treatment

11. NO COUGH or FOAM IN MOUTH or NOSE Mortality - 0% NO COUGH or FOAM IN MOUTH or NOSE Mortality - 0% Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 Evaluate and release from the accident site without further medical care Basic Life Support (BLS) - Drowning - Szpilman 2004

12. COUGH, WITHOUT FOAM in MOUTH or NOSE MORTALITY - 0% COUGH, WITHOUT FOAM in MOUTH or NOSE MORTALITY - 0% Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 1. Warm and calm the victim. 2. Advanced medical attention or oxygen not usually required 1. Warm and calm the victim. 2. Advanced medical attention or oxygen not usually required Basic Life Support (BLS) - Drowning - Szpilman 2004

13. 1. Oxygen - 5 liter / min by nasal cannula. 2. Warm and calm the victim. 3. Hospital observation from 6 to 48 hours. 1. Oxygen - 5 liter / min by nasal cannula. 2. Warm and calm the victim. 3. Hospital observation from 6 to 48 hours. Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 SMALL AMOUNT of FOAM in MOUTH or NOSE MORTALITY - 0.6% SMALL AMOUNT of FOAM in MOUTH or NOSE MORTALITY - 0.6% Basic Life Support (BLS) - Drowning - Szpilman 2004

14. Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 LARGE AMOUNT of FOAM in MOUTH & NOSE RADIAL PULSE PALPABLE (normal blood pressure) MORTALITY - 5.2% LARGE AMOUNT of FOAM in MOUTH & NOSE RADIAL PULSE PALPABLE (normal blood pressure) MORTALITY - 5.2% 1. 15 liters / min of oxygen by face mask at the accident site. 2. Right side recovery position. 3. ACLS and hospitalization in ICU required. 1. 15 liters / min of oxygen by face mask at the accident site. 2. Right side recovery position. 3. ACLS and hospitalization in ICU required. Basic Life Support (BLS) - Drowning - Szpilman 2004

15. 1. 15 liters/min of oxygen by face mask. 2. Monitor breathing with care (may stop breathing). 3. Right side recovery position. 4. ACLS immediate with mechanical ventilation and I.V fluids. 5. Urgent hospitalization in ICU required 1. 15 liters/min of oxygen by face mask. 2. Monitor breathing with care (may stop breathing). 3. Right side recovery position. 4. ACLS immediate with mechanical ventilation and I.V fluids. 5. Urgent hospitalization in ICU required Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 LARGE AMOUT of FOAM in MOUTH & NOSE NO RADIAL PULSE (low blood pressure) MORTALITY – 19.4% LARGE AMOUT of FOAM in MOUTH & NOSE NO RADIAL PULSE (low blood pressure) MORTALITY – 19.4% Basic Life Support (BLS) - Drowning - Szpilman 2004

16. 1. Start artificial ventilation immediately and keep it at a rate of 12 to 20 per min. Check signs of circulation regularly. 2. If possible use 15 liters/min of oxygen 3. After restoring ventilation, follow guideline for grade 4grade 4 Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 ISOLATED RESPIRATORY ARREST MORTALITY - 44% ISOLATED RESPIRATORY ARREST MORTALITY - 44% Basic Life Support (BLS) - Drowning - Szpilman 2004

17. 1. Start and continue CPR. 2. Use External Automatic Defibrilator if possible. 3. No one is considered dead if hypothermic 4. Do not resuscitate if submersion time over 1 hour or obvious physical evidence of death. 5. After successful CPR, victim should be followed as closely as possible and treat as grade 4.grade 4 Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 CARDIOPULMONARY ARREST MORTALITY - 93% CARDIOPULMONARY ARREST MORTALITY - 93% Basic Life Support (BLS) - Drowning - Szpilman 2004

18. Basic Life Support - DROWNING CLASSIFICATION and TREATMENT Based on evaluation of 1,831 cases - CHEST - Sep 1997 Grade 4 (19.4%) Grade 3 (5.2%) Reaction to ventilation or any movement? Yes No Grade 6 (93%) Grade 5 (44%) Yes Check for cough and/or foam in mouth/nose Grade 1 (0.0%) SMALL AMOUNT OF FOAM IN MOUTH/NOSE Grade 2 (0.6%) LARGE AMOUT OF FOAM IN MOUTH/NOSE RADIAL PULSE PALPABLE ? Yes COUGH, WITHOUT FOAM IN MOUTH/NOSE No Algorithm BLS: Near each grade the general mortality (%) is shown. Heimlich maneuver is only indicated with strong suspicion of foreign body obstruction; There is no difference in basic life support between different types of water drowning. (*)If the victim is grade 5, ventilation in-water can reduce mortality by almost 50%. CPA (Cardiopulmonary Arrest). References with the author Give 2 mouth to mouth breaths and check for signs of circulation Start complete CPR with 15 external chest compressions and alternate with 2 breaths until normal cardiopulmonary function is restored, ambulance arrives or lifeguard exhaustion. After successful CPR, the victim should be followed as close as possible because another CPA may occur. Continue mouth to mouth at 12 to 20 p/min until restore normal breath Check the victim response NoYes BREATH PRESENT? Absent Rescue (0.0%) Evaluate and release from the accident site without further medical care 1. Warm and calm the victim. 2. Advanced medical attention or oxygen not normally required 1. Oxygen - 5 L/min by nasal cannula. 2. Warm and calm the victim. 3. Hospital observation from 6 to 48 hours. No 1.15 liters/min of oxygen by face mask at the accident site. 2. Right side recovery position. 3. ACLS and hospitalization in ICU required. 1. 15 liters/min of oxygen by face mask. 2. Monitor breathing with care (may still stop breathing). 3. Right side recovery position. 4. ACLS immediately with mechanical ventilation and I.V fluids. 5. Hospitalization in ICU required After restoring spontaneous breathing and pulse, treat as grade 4 Warning: if any suspicion of cervical spine injury(0,5%), be careful while open airways - use special techniques to do so. Hospitalization Check for breathing - Open airways - look, listen and feel for respiration Check the victim in-water Conscious victim: bring back to shore/pool deck.; Unconscious victim - Shallow water: open victim’s airway, evaluate breathing, and begin mouth to mouth if necessary. Deep water: place the victim face up and open airway. If no spontaneous breathing, start mouth-to-mouth ventilation immediately at a rate of 12 to 20/min until reaching shore/swimming pool deck*. Mouth-to-mouth is possible in the water with 2 lifeguards or 1 lifeguard with lifesaving equipment. Do not check victim’s pulse while in the water. If no signs of circulation, don’t start chest compressions in-water, urgently bring the victim back to shore without further procedures. On shore/pool deck - victim’s trunk and head should be at same level, even in sloping sites Do not spend time trying to drain water from the lungs. Victim position of head lower than trunk will increase the occurrence of vomit or regurgitation. On sloping beaches all the victims should be put initially parallel to the waterline, in dorsal position. Lifeguard with his back to the sea with the victim’s head turned to lifeguard´s left side. This facilitates the rescuers CPR maneuvers so that he does not fall over the victim and makes placing the victim in right lateral decubitus easier. Victim transport to shore/pool deck should be with head up (except for hypothermic victim) Submersion time over 1 hour or obvious physical evidence of death (rigor mortis, putrefaction or dependent lividity). NoYes Dead Do not resuscitate MORGUE Szpilman 2001 - Published in: Circulation 2000, 102 (suppl I):I-233-36 & Pediatric Clinics of North America, June 2001

19. ONE TEAM, ONE GOAL LIFEGUARDS and MEDICAL STAFF

20. ONE WORLD, ONE DROWNING LANGUAGE ONE WORLD, ONE DROWNING LANGUAGE WE CARE ABOUT Ils Medical Comission

21. The End? BIBLIOGRAPHICAL REFERENCIES 1. Orlowski JP, Szpilman D, “Drowning - Rescue, Resuscitation, and Reanimation” Pediatric Critical Care: A New Millennium, W. B. Saunders Company Pediatric Clinics Of North America - V48, N3, June 2001. Review. 2. Cummins RO, Szpilman D. Submersion. In: Cummins RO, Field JM, Hazinski MF, Editors. ACLS - The Reference Textbook. Volume II: ACLS for Experienced Providers. Dallas, Tx: American Heart Association; 2003:97-107. 3. Szpilman D. Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1831 cases. Chest. 1997 Sep;112(3):660-5. 4. Adult Basic Life Support. Guidelines for cardiopulmonary resuscitation and emergency cardiac care (ECC). Circulation 2000;102:I22–59. The End? BIBLIOGRAPHICAL REFERENCIES 1. Orlowski JP, Szpilman D, “Drowning - Rescue, Resuscitation, and Reanimation” Pediatric Critical Care: A New Millennium, W. B. Saunders Company Pediatric Clinics Of North America - V48, N3, June 2001. Review. 2. Cummins RO, Szpilman D. Submersion. In: Cummins RO, Field JM, Hazinski MF, Editors. ACLS - The Reference Textbook. Volume II: ACLS for Experienced Providers. Dallas, Tx: American Heart Association; 2003:97-107. 3. Szpilman D. Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1831 cases. Chest. 1997 Sep;112(3):660-5. 4. Adult Basic Life Support. Guidelines for cardiopulmonary resuscitation and emergency cardiac care (ECC). Circulation 2000;102:I22–59.