Post on 02-Apr-2018
transcript
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Learning Station 3
Environmental Emergency 1
A Swimmer Disappears1999 American Heart Association
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Acknowledgments
Cindy Goodrich, RN, supplied the first drafts
of the slides and instructors notes for near-
drowning. We acknowledge her generosityin donating this work to the AHA. Mary
Fran Hazinski, RN, MSN, wrote the
instructors notes and reviewed the patho-physiology of drowning.
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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 learning station you should
be able to
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Case 1. 24-year-old victim
24-year-old man disappeared after diving into
water to swim to a platform in the middle of a lake
He was submerged for several minutes beforebeing found by friends and pulled to shore
At the scene he was unresponsive, without
respiratory effort, and pulseless
Bystander CPR begun, EMS activated
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Drowning/Near-DrowningDefinition and Classif ication
Drowning: submersion resulting in immediate
death or death within 24hours
Near-drowning: submersion, no immediate deathor 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
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Near-DrowningPathophysiology
Hypoxemia is the major insult; duration
determines outcome
Rule out associated conditions: trauma, alcoholintoxication, hypothermia
Potential neurologic insults: hypoxia, trauma
Potential pulmonary insults:pulmonary edema,intrapulmonary shunting, surfactant inactivation,
ARDS, aspiration
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Near-DrowningBLS at Scene
Treat as traumatic event; immobilize cervicalspine
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
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Near-Drowning VictimOn Medic Arr ival
Call-to-scene interval: 8 minutes
On EMS arrival: victim unresponsive,
apneic, and pulseless
CPR is producing chest rise, good pulse
What should ACLS providers do fi rst?
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Primary ABCD Survey
A:Open the airway
Always use c-spine precautions
B: Breathing
Not breathing (CPR continues) Ventilate with 100% O2 via BVM
Use the Sellick maneuver
C: CirculationContinue chest compressions
(check for pulse)D: Defibrillation
Remove victim from water, dry victims chest
Apply AED: no shock advised (asystole)
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Secondary ABCD Survey
I s 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: I s advanced support needed?
I s support effective? Verify tube placement Monitor chest expansion, breath sounds,
oxygenation
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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
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Third QuadradO2I VMonitorFluids
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)
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Case ProgressionResponse to EMS Treatment
Airway and breathing: 8-mm ETT in place,bilateral chest expansion, lungs compliant
Circulation: epinephrine and atropineadministered, pulses return (sinus rhythmobserved on AED screen)
Vital signs: HR = 139 bpm, BP = 94/74 mm Hg,
RR = 14/min (hand ventilation),temp = 35C axillary
Transport: Spine immobilized with cervicalcollar
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Case ProgressionArr ival 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?
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Summary: ACLS Managementof 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)