2 Learning ObjectivesAfter completing this discussion we should be able to:Discuss potential complications of near-drowning, which may cause cardiopulmonary arrest or a prearrest conditionManage a case scenario describing the resuscitation and stabilization (ACLS) appropriate for a near-drowning victimCaptains:Use this Powerpoint to discuss with your crew a unfortunate casualty of summer, drowning or near-drowning. You can use this as a table top discussion for either BLS or ALS participants. If a medic is in attendance, ask him/her to help lead the discussions and answer some questions that may arise.
3 The case: 24-year-old victim 24-year-old man disappeared after diving into water from a platform near the edge of Klineline PondHe was submerged for several minutes before being found by friends and pulled to shoreAt the scene he was unresponsive, without respiratory effort, and pulselessBystander CPR begun, 911 activatedYou are responding to the above incident. Reports come in that the subject may be out of the water. If not, discuss what an engine company or squad crew can do without entering the water. What resources do you have readily available? Can you enter the water? Do you need to don PFD’s?
4 Klineline park, located off NE 117th Street is a county park frequented by the young and old, either as fishermen or to swim in the shallow waters near the shore line. NO LIFE GUARDS ARE ON DUTY.
6 Drowning / Near-Drowning Definition and Classification Drowning: submersion resulting in immediate death or death within 24 hoursNear-drowning: submersion, no immediate death or death within 24 hoursSubmersion liquid: contamination and chemical irritants more relevant than salt vs fresh waterNote: Duration of hypoxia, rather than submersion liquid, affects outcomeRead the slide for the definitions of drowning versus near-drowningSubmersion liquid: contamination and chemical irritants more relevant than salt vs fresh water ( relates to what they drowned in if the liquids are contaminated with pollutants or chemicals rather than if the liquid is saltwater versus fresh water. No saltwater exists near Clark county.
7 Near-Drowning Pathophysiology Hypoxemia is the major insult; duration determines outcomeRule out associated conditions: trauma, alcohol intoxication, hypothermiaPotential neurologic insults: hypoxia, traumaPotential pulmonary insults: pulmonary edema, intrapulmonary shunting, surfactant inactivation, ARDS, aspirationRead bullet points.Be sure to be a detective and try to determine the associated conditions possible with drowningARDS = Adult Respiratory Distress SyndromeOccurs when fluid builds up in the alveoli in the lungs. More fluid in the lungs means less oxygen can reach the bloodstream. This deprives the organs of the oxygen they need to function.
8 Near-Drowning BLS at Scene Treat as traumatic event; immobilize cervical spineImmediate BLS requiredHypoxia 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 recommendedHere’s what the AHA has to say about resuscitation of a drowning victim:“Attempts to remove water from the breathing passages by any means other than suction (e.g. abdominal thrusts or the Heimlich maneuver) are unnecessary and potentially dangerous. The routine use of abdominal thrusts or the Heimlich maneuver for drowning victims is not recommended.”“There is no evidence that water acts as an obstructive foreign body. Maneuvers to relieve FBAO [Foreign Body Airway Obstructions] are not recommended for drowning victims because such maneuvers are not necessary and they can cause injury, vomiting and aspiration and delay CPR.”
9 Near-Drowning Victim On Medic Arrival Call-to-scene interval: 8 minutesOn Fire arrival: victim out of water; unresponsive, apneic, and pulselessCPR is producing chest rise, good pulseWhat should ACLS providers do first?
10 Primary ABCD SurveyC: Circulation — Assess breathing as you approach. Check for pulse, if no pulse, turn “on” LP12 and begin chest compressionsA: Open the airwayAlways use c-spine precautionsB: BreathingNot breathing (CPR continues)Ventilate with 100% O2 via BVMD: DefibrillationDry victim’s chestApply “FAST” patches = asystoleIf an all BLS crew, attach AED and allow to analyze. AED says “ NO SHOCK ADVISED”Does this patient meet ALPS inclusion criteria?? Non-traumatic cardiac death …. yes
11 Is advanced support needed? Secondary ABCD SurveyIs advanced support needed?A = Airway: intubate at once if indicatedIntubation indicated to protect airway (8.0-mm tube successfully placed)Vomiting occurs frequently: prepare suctionB = Breathing: Is advanced support needed? Is support effective?Verify tube placementMonitor chest expansion, breath sounds,oxygenation
12 Secondary ABCD Survey C = Circulation, advanced support Check pulse frequently; continue CPR if neededInsert two 14- to 16-gauge IVs; infuse 500 mL 0.9% NaCl or normal salineCheck rhythm: follow ACLS asystole protocolD = Differential DiagnosisAsphyxia (including cerebral ischemia)Trauma to cervical spine, headSeizure or other cause of fall into waterAspiration pneumoniaHypothermia from submersion and heat loss
13 Third Quadrad O2 –IV–Monitor–Fluids OxygenContinue to deliver oxygenEnsure effective oxygenation and ventilationVerify proper tube placement and patencyIVInsert 2 large-bore cathetersMonitorDetermine rhythm (asystole)Verify ETT placement, evaluate temperatureFluidsInfuse NS (warm if the patient is cold)Until ROSC occurs, use high flow oxygen during resuscitation. However, once pulses restore, maintain oxygen saturation >94% but less than 100%
14 Case Progression Response to EMS Treatment Airway and breathing: 8-mm ETT in place, bilateral chest expansion, lungs compliantCirculation: epinephrine administered, pulses returnVital signs: HR = 139 bpm, BP = 94/74 mm Hg, RR = 14/min (hand ventilation), temp = 35°C (95°F) axillariesTransport: Spine immobilized with cervical collar
15 Case Progression Arrival in ED Airway and breathing: spontaneous respiratory efforts detectedCirculation: normal sinus rhythm (88/min), good perfusion, BP = 110/68 mm HgNeurologic evaluation: pupils equal and reactive, no spontaneous movementSee next slide for answerWhat actual or potential problems may exist?
16 Summary: ACLS Management of Near-Drowning Near-drowning creates severe hypoxic insultMust restore oxygenation and ventilationKey: drowning is trauma; immobilize cervical spinePerform Primary and Secondary ABCD Surveys (consider factors that may complicate submersion)