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
5 Pond Depths Swim Area
6 Drowning / Near-Drowning Definition and Classification Drowning: submersion resulting in immediate death or death within 24 hours 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
7 Near-Drowning Pathophysiology 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
8 Near-Drowning BLS 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
9 Near-Drowning Victim On 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?
10 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% O 2 via BVM D: Defibrillation Dry victim’s chest Apply “FAST” patches = asystole
11 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
12 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 Secondary ABCD Survey
13 Third Quadrad O 2 –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)
14 Case Progression Response 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
15 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?
16 Summary: ACLS Management of 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)