1. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DOT National Standard EMT-Intermediate/85 Refresher DOT National Standard EMT-Intermediate/85 Refresher Welcome!

2. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease

3. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES Near Drowning Perspective Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment

4. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Near Drowning 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”

5. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training epidemiology In 2005, the WHO published a new policy defining drowning in a attempt to clarify documentation & better track submersion injuries worldwide

6. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training epidemiology Submersion injuries occur in –Domestic settings Swimming pools Hot tubs Large buckets* All forms of natural bodies of water Submersion injuries occur in –Domestic settings Swimming pools Hot tubs Large buckets* All forms of natural bodies of water

9. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology Unexpected submersion triggers breath- holding, panic an a struggle to surface Air hunger and hypoxia develop, & the victim begins to swallow water Unexpected submersion triggers breath- holding, panic an a struggle to surface Air hunger and hypoxia develop, & the victim begins to swallow water

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

19. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Management/Treatment Clinical presentation of severe hypothermia often mimic death –Case report exist of functional recovery for individuals submerged for 66 minutes! Clinical presentation of severe hypothermia often mimic death –Case report exist of functional recovery for individuals submerged for 66 minutes!

21. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Review Protocol Go to Near Drowning- Adult Go to ALOC-Adult Go to Call Matrix -General Go to Near Drowning- Adult Go to ALOC-Adult Go to Call Matrix -General

22. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Perspective Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment Perspective Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment

23. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Questions?

24. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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. 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.