10/1/2015 Describe the need for a universal drowning definition - PDF document

10/1/2015  Describe the need for a universal drowning definition  Name two of the organs that may be impacted from a submersion injury  Describe at least three appropriate prehospital care interventions in caring for the submersion injury patient  Identify three possible current nursing management strategies for managing the submersion patient  Incidence/recent data  Males 5 times more than females  2005-2009 mean 3880 deaths/year  Estimated 5789 people treated for nonfatal drowning ▪ Difficult to know???  Preventable measures  Fence (self closing gate)  Unattended children ▪ Lifeguard distracted (socializing, other duties or chores)  Poor pool maintenance ▪ Murky waters make it difficult to see 1

10/1/2015  2005 Data  Most prevalent from May to August  After 1 year of age males account for 75% of drowning deaths (riskier behavior?)  Age distribution (peaks) ▪ <5 years: pools, bath tubs, liquid filled containers ▪ 1-4 years 50% die in swimming pools ▪ 15 – 25 years: natural bodies of water ▪ Beaches-rip currents account for 80%  Boating drownings: 50% R/T ETOH ▪ >50% adult drownings believed to be R/T ETOH  Epilepsy (tub)  LQT Syndrome/Heart issues ▪ Cold water and exercise arrhythmias in LQT Syndrome? ▪ Long QT syndrome difficult to prove but mutations have been identified on some drowning victims ▪ Catecholaminergic polymorphic VT?  Suicide/homicide  Infants < 1 year of age  About 50% drownings occurred in bathtub  Medical eval, search for other injuries, get social work involved  Abuse, neglect? 2

10/1/2015  Various, ambiguous, terminology (at least 20)  Near drowning, silent drowning, passive drowning, wet/dry drowning etc. etc. etc.  No uniformity has caused confusion  Amongst clinicians  Amongst data interpreters ▪ Studies inconsistent ▪ Enhance future reporting and enable greater analysis for better treatment options  2002 World Congress of Drowning  “Drowning is a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium.”  Term drowning used no matter the outcome  Outcomes should be classified as death, morbidity, or no morbidity  Discourages use of other terms ie wet/dry drowning, near drowning etc.  Def accepted by WHO, CDC, ILCOR, AHA  Head above water  Child struggles 20 seconds  Adult struggles 60 seconds  Head below water = panic and hold breath  H2O in oropharynx/larynx may trigger involuntary laryngospasm (7-10%) 3

10/1/2015  No gas exchange (hypoxia/hypercarbia)=acidosis  Water is swallowed  Prolonged hypoxia ceases laryngeal spasm/obstruction (if occurred)  Victim inhales liquid  Victim’s O2 levels quickly dwindle  Not enough O2 to the brain  Loss of consciousness  Apnea  Changes in lungs, body fluids, pulm edema, pulm hypertension  Death results from prolonged submersion R/T hypoxia  Dry drownings happen about 2%  Fresh vs. saltwater Floating in Dead Sea  Not much difference as earlier thought (canine studies)  Aspiration of 22ml/kg for electrolyte change  Aspiration of 11 ml/kg for blood vol change  Avg. aspiration 2-4 ml/kg  Aspiration of fluid content may be clinically relevant ▪ Silt, mud, sewage, bacteria , seaweed, sand, etc.  Salt water  Impurities and bacteria  Pseudomonas putrefactions, Staph. aureus 4

10/1/2015 Cascade of events leading to secondary drowning  Lung changes (variable length of submersion)  Sig. impairment to gas exchange aspiration (1-3 ml/kg)  Surfactant washed out ▪ Alveolar instability ▪ Atelectasis ▪ Dec. lung compliance ▪ V/Q mismatch  Damage to alveolar-capillary membrane leads to pulmonary edema  Asp. Fluid causes vagal reflexes which causes pulmon. vasoconstriction and pulmon HTN  Aspirate vomit further complicate acute lung injury  Bronchospasm  Fluid in airways  ARDS (evidence usually occurs promptly)  Noncardiogenic Pulmonary Edema  Impaired oxygenation  Bilat. Pulm infiltrates 5

10/1/2015  Cardiovascular Effects  Hypovolemia R/T increased capillary permeability  Rewarming (surface)associated with vasodilatation  Pulmonary HTN ▪ Difficult to pump blood to lungs ▪ Less blood returns from lungs ▪ Decreased cardiac output  Decreased cardiac output R/T hypoxemia, acidosis  Myocardial dysfunction R/T arrythmias  CNS effects  Initial injury R/T tissue hypoxia and ischemia  Secondary injury ▪ Reperfusion, Cerebral edema, Excitory transmitters ▪ Impaired cerebral autoregulation ▪ Hypotension ▪ Sustained acidosis ▪ Hyperglycemia, hypoglycemia ▪ Seizures  Hypothermia  Hypotension, bradycardia, conduction abnormalities ▪ Hypotension from cold water diuresis  Antiarrythmics, insulin may be ineffective and accumulate to toxic levels R/T slowed metabolism and excretion  Neuro protective if rapid hypothermia prior to cardiac arrest ▪ Icy water submersion (<10-20 C) ▪ Mammalian diving reflex? ▪ Not happening here? 6

10/1/2015  Drowning  Factors (anything that can precipitate syncope) ▪ Seizures, hypoglycemia, hyperventilation (divers 87 vs 146 sec), hypothermia, ETOH, drugs, trauma ▪ Epileptics (15-19 times more likely to drown) ▪ LQTS (exertion, cool water, swimming) ▪ Stroke, heart attack (older pop)  What caused the drowning??  Most want to breathe so don’t cry for help  Treatment of drowning patients  Minimally asymptomatic ▪ Small cough, no foam at mouth or nose ▪ Usually released with instructions to watch for signs  All patients with respiratory symptoms ▪ Dyspnea, foam, rales ▪ Transport with O2  BLS at scene (biggest factor influencing survival)  ABC not CAB ▪ IF in water pulse check unnecessary ▪ If not in full arrest should respond with few breaths Credit Wellcome Library ▪ IF out of water ▪ Prior to compressions  AHA – 2 breaths  ERC-5 breaths ▪ Pulse may be hard to feel  Bradycardia, hypoxemia,  Hypothermia, vasoconstriction 7

10/1/2015  Cervical spine injury  Very uncommon  11 out of 2244 victims (0.5%) ▪ All had signs of trauma ▪ Diving, motor vehicle crash  Use caution but don’t delay resuscitation  Remove from water  Maintaining airway  Jaw thrust  Obstructed with foam or water  Rescue breathing in water useful  Ventilation and O2 most important initially  Chest compressions in water?  Heimlich maneuver? 8

10/1/2015  100% oxygen  Until pt is able to keep sats >mid 90’s  Intubate? ▪ Supraglottic airway (LMA)?  PPV use cricoid pressure ▪ Full stomach  Suction  Vomit ▪ Lateral decubitus ▪ Suction equipment (soft tipped, yankauers, etc)  Pulmonary edema (copious secretions)?  Remove wet clothing if possible  Cover with blankets  Monitor VS  Monitor for further vomiting  Monitor for deterioration  Pulmonary edema  Shock  History  Fluid pt was submerged in  Temperature of solution  Duration of submersion  Resuscitative efforts at scene  Response to efforts  ETOH/drugs suspected (Narcan??)  Pre-existing conditions or diseases 9

10/1/2015  Crucial in management (full neurologic recovery)  60 minutes in icy water?  20 minutes in cool water (5-10 mins by other source)?  Hot springs or hot tubs much shorter times  Submersions (non icy) greater than 25 mins likelihood for poor outcome approaches 100%  Inaccurate (rough estimate)  Emotional excitement  Time of call to rescue arrival  Hence, attempt to resuscitate all victims  Drowning scope can range from asymptomatic patient (dunked) to pulseless arrest  Asymptomatic (observe for approx 4-8 hours then discharge if physician decides with instructions to responsible parent/adult about symptoms) ▪ Awake, alert ▪ No adventitious breath sounds ▪ No required rescue breathing or supp O2 ▪ Normal pulse ox ▪ Normal x ray  Resuscitation  PALS guidelines but ABC  Usually tachycardia then bradycardia then PEA the asystole  Hypothermic (<35 C core temp) patient (effects include arrythmias, coagulopathy, impaired immune function, acidosis) ▪ May appear dead d/t profound bradycardia, intense vasoconstriction, marked depression of brain and cardiovascular patient, dilated pupils — begin CPR if unsure 10

10/1/2015  AHA unsure of what temp to start defib  Try at least once — may keep trying? (says to follow PALS/ACLS protocols)  Medications ▪ “may be reasonable to consider administration of a vasopressor during arrest” AHA 2010 Part 12 Drowning ▪ Ice water drowning rewarm core to minimum of 30 C before stopping CPR — others experts say higher  European Resuscitation Council  Suggest 3 defibrillations performed  Hold Epi until core temp > 30 C, then double time to next dose until temp >35 C  Resuscitation  Hypothermia (never allow hyperthermia) ▪ Aggressive attempts to restore normal body temp and establish safe steady warming rate while maintaining cardiac stability ▪ Rewarm pt 1-2 C/hour to 33-36 C ▪ Passive rewarming  Remove wet cold clothing  Warm blankets to insulate patients  Resuscitation  Hypothermia ▪ Rewarming techniques ▪ Active external rewarming  Hot packs  Heat lamps  Forced air external rewarmers 11