Chapter 25 Submersion Incidents: Drowning & Diving Emergencies

GAS in body

gas contained in: -organs -dissolved i the blood -found in hollow spaces It is COMPRESSIBLE

Hypovolemia during and after CPR

increased capillary permeability can cause hypovolemia, then hypo BP. It is possible when the body is starting to rewarm, causing the blood vessels to dilate, causing hypovolemia, cardiac dysrhythmia, hypoxia, acid imbalance.

Most important factors to survive drowning?

- quick rescue from water - early CPR

Criteria to safely attempt a water rescue?

Unless a water emergency occurs in open, shallow water that has a stable, uniform bottom, never go out into the water to attempt a rescue unless you meet all of the following criteria: -You are a good swimmer. -You are specially trained in water rescue techniques. -You are wearing a personal flotation device. -You are accompanied by other rescuers.

If the patient is responsive and close to shore...

Use the "reach, throw, row, go strategy". Make sure you have firm, solid footing and can't slip into the water. Try to reach to the patient by holding out an object for him to grab. You can use an oar, branch, fishing pole, towel, shirt, or other strong object that won't break. Once the patient has grabbed the object, pull him to shore. If too far, you can also throw something at the person, like a rope.

Type II Decompression Sickness

- more serious than Type I - Signs & Symptoms are more severe -onset is immediate but can be delayed up to 36 hours. Signs and Symptoms would affect primarily: - the nervous system - the respiratory system - the circulation system

Drownings in Kids under 1 year of age.

- occurs in less than 5 min - #1 in bathtubs Check for potential child abuse.

PRIMARY HYPOTHERMIA

- occurs in water below 41°F/ 5°C. - because it is a quick process, it may actually protect tissues against hypoxia.

How to treat Severe Gastric Distention

- place patient on his side -be ready to suction -place your hand over the epigastric area and apply firm pressure to release the distention. -this will cause regurgitation, suction immediately Use this technique ONLY if the gastric distention is interfering with your ability to ventilate properly the patient with PPV.

#3 / Cardiac Arrest

- pulseless -Apnea -Approximately half of drowning patients are in asystole (absence of rhythm, which appears as a flat line on the monitor), requiring CPR. -Approximately one-third are in ventricular tachycardia or fibrillation and in need of CPR and defibrillation.

The drowning patient can be placed into one of the following four categories:

- Asymptomatic -Symptomatic -Cardiac Arrest -Obviously dead

4 Laws of Physics playing a major role in diving emergencies.

- Boyle Law - Dalton Law - Henry Law - Charles Law

NERVOUS SYSTEM

- Low back pain that progresses to paresis (weakness), paralysis, numbness or tingling, loss of sphincter control, and girdle pain to the lower abdomen from spinal cord effects—the most common site for type II DCS Headache, visual disturbances, dizziness, tunnel vision Altered mental status Nausea, vomiting, vertigo, tinnitus, partial deafness

Drownings in teenagers.

- Occurs mostly in ponds, lakes, rivers, ocean. - Possible trauma, especially cervical spine injuries from diving into shallow waters or area with rocks. - Alcohol involved - recreational drugs

Advices to prevent drowning accidents...

- fence your pool -kids around water should be supervised -no alcohol around water -PFD when boating - no diving into shallow waters - if you have seizure, be more careful around water.

PRIMARY ASSESSMENT

- general impression -responsive or not -reaction to painful stimuli in all 4 extremities because of potential spinal injuries. - manual in-line stabilization -assess airway -suction water - insert oral or nasal airway adjunct if needed -check if breathing is adeq - give O2 if res distress, hypoxia, hypothermia via nasal cannula - severe hypoxia, O2 via non-rebreather mask 15l - inadequate breathing, PPV with sup O2 - check circulation -check pulse-assess for internal or external wounds, or shock. -control bleeding -make decision on priority status

EMS CARE for: - air embolism - decompression sickness - barotrauma

- in-line stabilization if spinal injury is suspected. - If altered mental status, place patient in lateral position. - open airway - assess breathing - ADMINISTER OXYGEN even if SpO2 is greater than 95% !!!! non-rebreather mask at 15l - If inadequate breathing, administer PPV with sup O2 - CPR & AED if needed - IMMEDIATE TRANSPORT - obtain the patient's diving log - call Medical Direction to consider transport to a facility with a decompression chamber/ Hyperbaric chamber. - Continue O2 therapy during transport.

How to treat drowning patient

- monitor breathing - PPV if inadequate - auscultate lungs - search to crackles/ rales - consider CPAP if patient can breathe on his own or if not CPAP available, do early PPV + high O2 - if adequate breathing, give non-rebreather 15l

EMS Care for Drowning Patients

- splint head & neck with arms -roll patient over -ensure airway and breathing Patient not breathing: -begin rescue breathing using a pocket mask, and rescue from water ASAP Patient breathing: -slide backboard under patient -Apply a rigid extrication collar -float board to poolside -remove patient from water No spine injury: -place patient on his left side -be ready to suction If in respiratory arrest: -check airway for obstruction - airway adjunct + PPV with sup O2 Pulseless & apneic: - CPR + AED - manage other injuries -transport ASAP

When you are drowning

- very traumatic - you aspirate water - your larynx spasms and makes you suffocate - lack to ventilation - leads to severe Hypoxia - cumulation of CO2 in blood - acid buildup severe Hypoxia + Acidosis= - severe brain injury - cardiac arrest

How the Mammalian diving Reflex works?

- when face submerged in cold water - larynx spasms - breathing is inhibited - heart rate slows down - blood vessels constrict - but blood flow to heart and brain is maintained. The colder the water, the more oxygen is diverted to the heart and brain.

When performing an assessment on the patient, the following may be found in DCS:

-Fatigue -Signs and symptoms of shock -Pupillary changes -Pallor to the tongue -Bloody sputum -Nasal flaring, retraction of the chest, and accessory muscle use -Tachypnea -Crackles (rales) upon auscultation -SpO2 reading of <94% prior to oxygen administration -Vomiting -Urinary bladder distention -Seizure -Uncoordinated movement (ataxia), weakness, motor and sensory deficits -Joint pain, decreased range of motion -Edema -Cyanosis, pallor, itching, mottling, marbling

Predisposing FACTORS to Decompression Sickness

-Flying or going to a high altitude too soon after a dive (12-24 hours). -Failure to take the necessary safety stops while ascending from a dive. -Inadequate surface intervals (allows nitrogen to accumulate during a sequence of dives). -Inadequate decompression or passing the no-decompression limit. -Diving at depths for too long a period of time. -Repeated dives at depth on the same day.

Signs & Symptoms of Arterial Gas Embolism

-Itchy, blotchy, or mottled skin -Difficulty in breathing -Dizziness -Chest pain -Severe, deep aching pain in the muscles, joints, and tendons -Blurred or distorted vision -Partial deafness -Nausea and vomiting -Numbness or paralysis -Weakness or numbness on one side of the body -Staggering gait or lack of coordination -Frothy blood in the nose and mouth -Swelling and crepitus in the neck -Loss or distortion of memory -Coma -Cardiac or respiratory arrest -Behavioral changes (sometimes the only sign)

CIRCULATORY SYSTEM

-Signs of hypovolemic shock, primarily tachycardia and hypotension, resulting from fluid shifting from intravascular (inside the vessels) to extravascular (outside of the vessel). -Formation of a thrombus from activation of the blood coagulation system.

RESPIRATORY SYSTEM

-Substernal burning sensation on inhalation -Nonproductive cough -Respiratory distress The respiratory signs and symptoms are known as the "chokes." The symptoms can begin up to 12 hours following the dive and last for 12-48 hours.

3 categories for Decompression Sickness

-Type I decompression sickness (mild) -Type II decompression sickness (serious) -Arterial gas embolism (AGE)

Important questions to ask in the history of a suspected DCS patient are...

-Where did the patient dive (river, lake, ocean, cave)? -What was the lowest depth and for what period of time? -What were the other depths and for what periods of time? -What was the rate of ascent from the various depths? -What has the patient done since the dive? Did the patient fly on an airplane? -What did the patient do the 72 hours prior to the dive? number of dives? length of dives? time off between dives? surface intervals? water temperature? -Did the patient do any type of work during the dive? -What gases did the patient use during the dive? -Were there any problems experienced by the diver (e.g., entanglement, marine animal bites or stings, equipment problems)? -What physical condition was the patient in before, during, and after the dive (e.g., fatigue, drug or alcohol use, fever, dizziness, nausea)? -Was any first aid provided for the patient (e.g., oxygen, position, medications)?

Deep water complications are...

-coma -asphyxiation -head injury -heart attack -air-tank contamination -intoxication -aspiration -decompression sickness -arterial gas embolism -barotrauma

HIGH Priority Patient if

-high spinal injuries affecting respirations - found in respiratory distress -found unresponsive

Suspect a spine injury when...

-person was diving off a board etc... -water slide -struck by a boat -water skying accident -intoxicated -evidence of trauma

Scene SIZE-UP

-safety is your first and only priority - when within 10 feet of water's edge, wear PFD. - consider additional help / a dry and a wet team - # patients

How could we prevent deaths related to water?

-wear a PFD/ Personal Flotation Device -fences and adult supervision around pools -proper CPR techniques

DRY drowning

10-15% patients do NOT aspirate water into lungs during submersion because of: - the spasms and tight closing of larynx (laryngospasm). They last until all inspiratory efforts have ceased.

Patient may suffer from SEVERE GASTRIC DISTENTION

A condition in which the stomach is filled with water, enlarging the abdomen, lungs cannot inflate properly. Too forceful PPV can also cause this condition by filling up the stomach with air.

Type I Decompression Sickness

A milder form of DCS. Signs & Symptoms: -Pain -Pruritus (itching) and burning sensation of the skin (referred to as "skin bends") -Skin rash (mottling or marbling of skin) -Skin has orange-peel appearance (rare) -Painless pitting edema (uncommon) - The pain, "the Bend", is hallmark of Type I. -It occurs in 70-85% of cases - Pain is dull, aching and throbbing - Pain usually located in the joints & tendons, as in the shoulder. - Pain can also be in other tissue. - Pain starting mild then gradually intensifies to severe. Pain is often confused with a pulled muscle. - Decreased function of extremities can be a consequence of muscle splinting. It is most common in upper extremities.

When do we transport a drowning patient?

ALWAYS TRANSPORT, even if you think the patient has not suffered any serious effects. A drowning patient can develop complications that lead to death as long as 72 hours after the incident. Approximately 15 % of all drowning-related deaths result from secondary complications. During transport, you should keep the patient warm and continue to provide high-concentration oxygen.

Signs & Symptoms of water-related Emergencies

Airway obstruction Absent or inadequate breathing Pulselessness (cardiac arrest) Spinal injury or head injury Soft tissue injuries Musculoskeletal injuries External or internal bleeding Shock Hypothermia Alcohol or drug abuse Drowning or submersion

CHARLES Law

All gases will expand equally upon being heated. Thus, as a diver descends into colder water temperatures, the inhaled and dissolved gases will contract. As the diver ascends, the temperature increases and the gases will expand.

#2 / Symptomatic

Altered mental status (may be as slight as confusion) Altered vital signs (e.g., tachycardia, bradycardia, tachypnea, bradypnea, hypothermia) Respiratory distress or respiratory arrest (respirations may be agonal) Dyspnea (no matter how slight, patient is considered symptomatic) SpO2 reading that is <94% with or without oxygen support (An SpO2 reading may be difficult to obtain or may be very low if the patient is hypothermic.) Persistent cough Wheezing or crackles (rales) upon auscultation of breath sounds Decreased body core temperature (hypothermia) Cool skin or cyanosis Vomiting, diarrhea, or both Anxiety

HENRY Law

At a constant temperature, the amount of gas that dissolves in a liquid it is in contact with is proportionate to the pressure of the gas around it. As already noted, when a diver descends and pressure increases, the nitrogen inhaled will tend to dissolve into the body's liquids, mainly the blood plasma. It will then also begin to dissolve into and accumulate in the body fat and tissues. If the diver then ascends too quickly, the dissolved nitrogen is returned to a gaseous state while it is still dissolved, causing bubbles to form in the blood and tissues.

!!!!!! BOYLE Law !!!!!!!

At a constant temperature, the volume of a gas is inversely related to the pressure. If the pressure increases = the volume of the gas decreases. If the pressure decreases = the volume of the gas increases. If the diver breathes in compressed air at a depth where there is a higher pressure on the body and then suddenly ascends, the volume of air in the lungs will rapidly expand because of the decrease in pressure as the diver is ascending. This may lead to barotrauma, or rupture of the alveoli and other lung structures.

OXYGEN is essential in diving emergencies because...

Oxygen reduces the size of the nitrogen bubbles and improves circulation. Document the exact time of O2 delivery.

ENVIRONMENTAL FACTORS putting the diver at risk for decompression Sickness

Cold water (vasoconstriction decreases the ability of nitrogen to off-load) Rough sea conditions (increase workload and effort) Heated diving suits (lead to dehydration) Heavy work (gas pockets are created in tendons)

Atelectasis

Condition when the surfactant is being washed out.

Decompression Sickness / DCS

Decompression sickness (DCS) occurs as the result of the bubbles formed from the expansion of nitrogen in the blood and tissues as described in the Henry law. The bubbles can cause cell damage and lead to organ dysfunction. The bubbles have two primary effects on the body: (1) They act as emboli and cause obstruction in the circulation (2) they compress or stretch the blood vessels and nerves. Also, the bubbles may cause coagulation of blood to occur. In response, the vessels and surrounding tissues may release substances as they would in an allergic reaction. These substances may produce signs and symptoms similar to those of an allergic reaction.

3rd cause of accidental deaths

Drowning kills 4500 persons in USA each year. It is the 3rd most common cause of accidental death. 1st / 40% are kids under 5. 2nd/ teenagers 3rd/ elderly 85% of drownings are in males and alcohol is often involved.

Causes for water-related deaths?

Drownings are only a small part. Mainly caused by: -diving -deep water exploration -boating -water skiing -motor vehicle accidents

REASSESSMENT

During reassessment, be alert for signs the patient is deteriorating into respiratory or cardiac arrest, especially if you previously resuscitated this patient. Perform reassessment: -repeating the primary assessment -repeating the secondary assessment -repeating vital signs -checking interventions Every 5 minutes if the patient is unstable Every 15 minutes if the patient is stable.

Drownings in Adults

Hypoglycemia Myocardial infarction (heart attack) from exertion Cardiac dysrhythmia Syncope Seizure Depression or a suicide attempt Anxiety or a panic disorder Arthritis, Parkinson's disease, or other neuromuscular disorder that leads to poor body control Exhaustion Hypothermia Alcohol or drug use Trauma, especially head or spinal

What to do is the body core temperature is less than 86°F and the heart rhythm is shockable during resuscitation?

If the body core temperature (BCT) is less than 86°F, defibrillation and ALS medications are not effective. The patient must be rewarmed to a BCT above 86°F before proceeding with more than one defibrillation.

If suspected of being HYPOTHERMIC, you must...

If the drowning patient is suspected of being hypothermic: -assess the pulse for 10 seconds If no pulse is found: -assume it is not present -begin chest compressions -apply the AED.

SECONDARY ASSESSMENT

If unresponsive/ or Altered Mental Status: -do a rapid 2nd assessment - look for signs of injuries -collect history from friends, family ... If Patient is alert: - get history

The Mammalian Diving Reflex

In cold water below 70°F/ 21°C, the metabolism slows down drastically and increases the chances for the patient to be successfully resuscitated, even after a prolonged submersion. Although there is a controversy about the Mammalian Diving Reflex and its positive effects.

Water in the body

It is NOT compressible.

ARTERIAL GAS EMBOLISM

It is a blocking of blood vessels by an air bubble or clusters of air bubbles. The blockage interferes with perfusion of body tissues with oxygen and nutrients normally supplied by the blood. During a dive, pressure on the diver's body increases and the volume of a gas decreases as he descends. Conversely, that pressure is lessened as the diver ascends. If the diver ascends rapidly while holding his breath, the air in the lungs expands rapidly, rupturing the alveoli and damaging adjacent blood vessels. As a result, air bubbles enter the bloodstream. The signs and symptoms of air embolism have a rapid onset, often appearing within 15 minutes of a diver's surfacing.

DYSBARISM

It is a medical condition that results from the effects on the body of changes in ambient pressure. The pressure changes may occur when a person descends in water or ascends in altitude. Recreational and commercial divers, when descending into depths of water, experience a drastic increase of pressure on the body. The pressure affects only the compressible structures and substances within the body. The body is made up primarily of water, which is noncompressible, but the gas contained within the organs, dissolved in the blood, and found in hollow spaces is compressible and is affected by changes in pressure.

DROWNING/ Utstein Style reporting data

It is an incident in which someone is submerged or immersed in a liquid that results in a primary respiratory impairment. The person may live or die. It is called a drowning regardless of the outcome.

Acute Respiratory Distress Syndrome/ ARDS

It is the condition when the alveoli collapse. The damage to alveolar-capillary structures creates ventilation problems by decreasing functional lung volume and allowing fluid to leak around and into the alveoli, which creates pulmonary edema. The alveolar- capillary damage also interferes with gas exchange, impairing oxygenation of the blood and off-loading of carbon dioxide from the blood. This complication is known as acute respiratory distress syndrome (ARDS).

SECONDARY HYPOTHERMIA

It occurs after victims is removed from water. It is due to heat loss through evaporation. It does NOT protect patient against Hypoxia. It may cause additional damages to patient

The Orlowski Score

It predicts the likelihood a patient would survive neurologically intact. It is Best if patient scores 0, 1 or 2 max. If 3 or more, patient has only 5% chance of survival.

Signs & Symptoms of BAROTRAUMA

Mild to severe pain in the affected area Clear or bloody discharge from the nose or ears Extreme dizziness Nausea Disorientation

Hypothermia and Submersion

Moderate body core hypothermia associated with submersion is thought to provide a protective mechanism that reduces brain and other organ damage in children. However, most people do not become hypothermic quickly enough after submersion to reduce the severe cerebral injury from hypoxia and ischemia.

Drownings in Kids 1 to 5 years of age

Occurs mostly in swimming pools.

#1 / Asymptomatic

Patient displays no signs or symptoms of the drowning event.

Orlowski predictors of poor survival

Patient is 3 years of age or older. Patient was submerged for greater than 5 minutes. Resuscitation did not begin for more than 10 minutes after rescue. Patient is comatose on delivery to emergency department. Patient's arterial blood is very acidic (pH less than 7.10).

Immediate Medical Care needed for Barotrauma

Patients suffering from barotrauma must be cared for at a medical facility immediately to prevent permanent deafness, residual dizziness, or the inability to dive in the future.

Diving into a pool...

Patients who dive into water from a diving board, shore, poolside, boat, or dock often sustain injuries to the: -head and spine -fractures of the arms, legs, and ribs. You should always assume that a diver has sustained neck and spine injuries, even if the diver is still responsive.

PHYSICAL CHARACTERISTICS & CONDITIONS predisposing a diver to Decompression Sickness

Poor physical condition Obesity (nitrogen dissolves easily in fat) Age Dehydration Heart or lung diseases or conditions Preexisting musculoskeletal injury Fatigue

#4 / Obviously Dead

Rigor mortis Dependent lividity (purplish color caused by blood pooling in the lowest areas of the body).

How to determine the seriousness of a drowning?

Signs and symptoms to look for: Persistent cough Dyspnea (shortness of breath) or apnea (absence of breathing) Altered mental status or loss of consciousness at some point during the submersion Vomiting Drug or alcohol use Pertinent past medical history (e.g., seizures, diabetes mellitus, neuromuscular disorder) Hypothermia Duration of cardiac or respiratory arrest Age of the patient Preexisting disease or conditions

BAROTRAUMA

Sometimes called "the squeeze," barotrauma occurs during ascent or descent when air pressure in the body's air cavities (such as the sinuses or middle ear) becomes too great. As a result, tissues in the air cavities are injured; for example, the eardrum or sinus may rupture. Divers with upper respiratory infection or allergy are at increased risk of barotrauma.

SURFACTANT

Surfactant is a lipoprotein that lines the inner surface of the alveoli. It maintains a surface-wall tension that keeps the alveoli from completely collapsing.

The "BEND"

The pain has given this disorder its nickname, "the bends." It usually results from a diver ascending too rapidly from a deep, prolonged dive. Gases, typically nitrogen, form bubbles within the blood and tissues, causing obstruction of vessels and compression and stretching of tissue. The onset of DCS may occur up to 72 hours following the dive.

DALTON Law

The total pressure of a mixture of gases equals the sum of the partial pressures of the individual gases that make up the mixture. -For example, the air we breathe is about 78% nitrogen. -Since the air pressure at sea level is 760 mmHg, the pressure of nitrogen at sea level (78% of the total) is about 593 mmHg. -As a diver descends, the total pressure of the air that he is breathing increases, and the pressure of each component gas in the air increases proportionately. -As the diver goes deeper underwater and the pressure of the inhaled nitrogen increases, the nitrogen begins to dissolve into the blood. -Other gases in the mixture of inhaled air do not have this action. -Nitrogen in the blood will affect the electrical properties of the brain and produce a "nitrogen narcosis" with effects similar to an anesthetic. -As a result, every 50 feet of depth is equivalent to one alcoholic drink in its impairment of the diver's judgment.

Mammalian Diving Reflex in the younger.

Their skin surface is greater than their body mass. The Diving Reflex is more pronounced. The cooling is more rapid.

saltwater vs freshwater drowning

There is not real difference for the EMT's work. Both types have the tendency to wash out the surfactant.

Drowning with swallowed water

Usually only a small amount of water. The water is quickly absorbed by the respiratory tract and into the circulation. It does not pose a major problem with the airway obstruction.

Resuscitation efforts on hypothermic patients

You should attempt resuscitation on any pulseless, nonbreathing patient who has been submerged in cold water. Remember, hypothermic patients are not pronounced dead until after both rewarming and resuscitation have been performed.

How much water for an infant to drown?

a 5-gallon bucket bathtub toilets

Abdominal thrusts for a drowning patient during resuscitation efforts.

are not necessary, no real airway obstruction. Abdominal thrusts may lead to regurgitation & aspiration of gastric content. Instead, suction out water in airway. If patient vomits, roll to his side and suction. Abdominal thrusts are ONLY if you suspect an airway obstruction in patient.

A hypothermic patient...

body temperature of 95°F or less/ 35°C

Training EMS for water rescue

must carry a 100 feet of polypropylene rope. Have a solid firm grip, and stand on solid ground. Tie rope to an object that floats, inflatable ball, rescue ring, thermos jug, a picnic cooler, a capped empty plastic milk jug. Pull when victim has hold of object. If too far, use a boat or swim if you can follow the safety list only.

The secondary injury

ongoing hypoxia damaging organs, tissues

How much needs an adult to drown?

only a few inches

Primary injury

the initial drowning event

Body in water below 68°F

the body's metabolic requirements are only 50% of normal. The brain and heart remain oxygenated for some time, death is significantly delayed. Body in cardiac arrest for 30 minutes or longer can be resuscitated.

The greatest factor when drowning

the duration of submersion. Consequently, the severity of Hypoxia.