Drowning & Dive Rescue Emergencies

Graig Temple, NREMT-P

Dive Rescue Specialist

ObjectivesObjectives

Students shall be able to differentiate between an Active and Passive Drowning.

Students shall be able to explain the difference between a Near Drowning verses an actual Drowning including signs and symptoms.

Students will be able to compare and contrast a fresh water drowning verses a salt water drowning.

ObjectivesObjectives

Students shall be able to identify a Rip-Currents in typical surf conditions

Students will obtain a basic knowledge of Yell - Reach – Throw – Row – GO

ObjectivesObjectives

Students shall be able to identify various types of dive related emergencies along with their associated signs, symptoms and immediate treatments.

Students will be able to describe basic scene management of a dive emergency

Students will be able to identify basic components of SCUBA gear including

DrowningDrowning

Definition - Die by immersion in water: to die by immersion and usually suffocation in water or other liquid, or kill a person or animal in this way. Death occurs either from lack of oxygen or as a result of cardiac arrest from the lowered body temperature.

Active DrowningActive Drowning

Conscious Victim Thrashing Vertical in water Unable to call for help Body may be low in

the water

Passive DrowningPassive Drowning

Unable to stay afloat Unable to fight on the

surface Submerges Becomes apneic Body floats on surface

or could sink Cardiac Arrest

imminent

Near DrowningNear Drowning

Definition – a person who nearly drowns from suffocation in a liquid: Injury occurs as of a direct result of the suffocation but does not result in death.

Near DrowningNear DrowningSigns and SymptomsSigns and Symptoms

Abdominal distention Bluish skin of the face,

especially around the lips Chest pain Cold skin and pale

appearance Confusion Cough with pink, frothy

sputum

Irritability Lethargy No breathing Restlessness Shallow or gasping

respirations Unconsciousness Vomiting

Fresh Water DrowningFresh Water Drowning

A type of drowning in which hypo-osmolar water compromises the surface tension of alveolar surfactant, causing an imbalance in the ventilation-perfusion–V/Q ratio, with a collapse of some alveoli, and both true–absolute, and relative–intrapulmonary shunting

Fresh Water cont.Fresh Water cont.

If the drowning or near drowning occurs in fresh water and water enters the lungs, that water is quickly absorbed into the blood stream. Fresh water has a lower solute concentration than the plasma in the pulmonary capillaries; therefore, the fresh water is absorbed across the alveolar membrane into the bloodstream.

Fresh Water cont.Fresh Water cont.

Once in the bloodstream, this fresh water dilutes the blood and changes the blood chemistry. Fresh water also affects blood cells and tissue membranes causing hemolysis which is destruction of the blood cells. The chemical change in the blood can result in cardiac dysrhythmias

Salt Water DrowningSalt Water Drowning

Sea water aspiration results in fluid-filled but perfused alveoli, accompanied by a V/Q abnormality due to pulmonary edema; the shifts of fluids and electrolytes in salt water drowning result in hemoconcentration, CHF, and hypernatremia

Rip CurrentsRip Currents

A strong, narrow surface current that flows rapidly away from the shore, returning the water carried landward by waves.

Occurs when waves break heavily in one area and weaker in others.

Current in the Rip is “jet like” and will carry the victim typically from several feet to a 100 yards before the current stops.

Majority of Near Drownings occur as a result of being caught in Rip Currents

How to Escape the RipHow to Escape the Rip

Surface RescueSurface Rescue

YELL – Reach – Throw – Row – GO Yell for Help Reach for the victim (with an object if possible) Throw a Life ring, Rope bag or Floatation Device to

the victim Row or Paddle to the victim if possible GO yourself by swimming to their aid.

KNOW YOUR LIMITATIONS!!

Useful ToolsUseful Tools

Public Safety DiversPublic Safety Divers

ResponsesResponses

DrowningMVC’s with submersionBoating and PWC accidentsOff Shore SCUBA accidentsIce RescuesMutual Aid

TrainingTraining

Due to the various types of incidents that public safety divers respond to, it is necessary to be trained in multiple disciplines including;– Basic and Advanced Open Water– Rescue, Dry Suit, Wreck and Night Diving– Public Safety Diving– CPR/AED/EMT/Paramedic

Dive EmergenciesDive Emergencies

Heat Exposure– Hyperthermia– Heat Exhaustion– Heat Stroke

Cold Exposure– Hypothermia– Frostbite

Dehydration

Soft Tissue Injuries– Lacerations– Abrasions– Contusions

Stress– Increased Heart Rate– Elevated B/P– Elevated R/R– Psychological

Medical MonitoringMedical Monitoring

BLS/ALS Crew equipped to assess– Vitals Pre and Post dive– SpO2 and EtCO2– Cardiac Monitoring and 12 Lead EKG– Mental Status and Neuro Exam– Secondary physical exam

Dive EmergenciesDive Emergencies

Oxygen ToxicityNitrogen NarcosisFree Diving and Shallow water blackoutCarbon Dioxide RetentionDecompression Sickness and Illness

Oxygen ToxicityOxygen Toxicity

Works off of Daltons Law on Partial Pressures.– The result is an elevated pO2 and convulsions.

This is the direct cause of Nitrogen Narcosis which eventually leads to DCS.

SIGNS and SYMPTOMSSIGNS and SYMPTOMS

Muscle spasms Nausea/Vomiting Dizziness Tunnel vision Tinnitus

Irritability Anxiety Trouble Breathing Unusual fatigue Loss of coordination Convulsions

Nitrogen NarcosisNitrogen Narcosis

Often referred to as the “Raptures of the Deep” occurs when divers dive below 100 feet.

This condition happens due to two laws. Dalton’s law states that the total pressure exerted by a mixture of gases is equal to the sum of the total pressure of each gas in the mixture as if it were occupying the same space.

Narcosis cont.Narcosis cont.

Boyle’s Law states that it is these same gases when rapidly reduced that causes decompression sickness. That is why Nitrogen is the gas that determines decompression schedules.

Suffering from Nitrogen NarcosisSuffering from Nitrogen Narcosis

Contributing factors– Cold– Stress– Heavy work and

fatigue– CO2 retention.

Signs and Symptoms– Complex reasoning

decreases by 33%.– Manual dexterity

decreases 7.3%.– Diver appears “drunk”.– Example; diver appears

to have drank 1 Martinis per every 50 feet.

TreatmentsTreatments

Immediate CONTROLLED ascent with constant monitoring by buddy/dive master or Dive-medic.

100% O2Cessation of diving, no further 100ft plus

dives.Monitor and transport.

Free Diving/Shallow Water Free Diving/Shallow Water BlackoutBlackout

Shallow water blackout (SWB) is a sudden loss of consciousness caused by oxygen starvation following a breath holding dive.

About 7000 drownings a year occur as a result of this occurrence.

Free divers use hyperventilation to reduce CO2 build up to extend the breath holding time.

Shallow Water Blackout cont..Shallow Water Blackout cont..

Effects divers that use “closed circuit” breathing apparatus.

Occurs commonly within 15 feet of the surface.

Loss of oxygen to the starved lungs causes rapid loss of consciousness.

Occurs insidiously without warning.Victims don’t know what hit them.

Signs and SymptomsSigns and Symptoms

Altered Mental Status secondary to hypoxiaSudden onset of unconsciousnessRespiratory Arrest – Near DrowningCardiac Arrest

CO2 RetentionCO2 Retention

Primary concern due to skipped breathing. Breath holdingClosed system divingDiving with contaminated air.

Signs and SymptomsSigns and Symptoms

TachycardiaTachypneaShortness of BreathSeizures/ConvulsionsAMS/UnconsciousnessHeadacheSweating

TreatmentTreatment

100% O2 via Non-RebreatherMonitor Vital Signs, SpO2, EtCO2ALS Assessment – Cardiac Monitor, 12

Lead EKG, Stroke AssessmentTransport if needed

Decompression SicknessDecompression Sickness““the bendsthe bends””

Discovered in 1841 by sport divers.Caused by the production of Nitrogen that

leaks into blood circulation and accumulates in the joints.

Severity is determined by the depth and time of a dive, along with the rate in which the diver ascends.

Types of DCSTypes of DCS

Type I-– Cutaneous manifestations and minor joint pain.

Referred to as “pain only”.– Caused by bubbles, intravascular and

extravascular with large gas stores in the fatty bone marrow.

– Cause of Dysbaric Osteonecrosis.

Types of DCS cont.Types of DCS cont.

Type II– Includes severe symptoms related to

cardiopulmonary and neurological systems.– Usually involves extensive damage to the

spinal cord.

Types of DCS cont.Types of DCS cont.

Type III– Commonly a combination of an Arterial gas

embolism and Decompression Sickness.– Involves neurological symptoms.– Generally termed the worse form of

Decompression Sickness.

Signs and SymptomsSigns and Symptoms

Signs-– Blotchy Rash– Paralysis or weakness– Coughing Spasms– Staggering gate or instability– Unconsciousness

Signs and Symptoms cont.Signs and Symptoms cont.

Symptoms-– Tired feeling– Itching– Pain in arms, legs or thorax– Dizziness– Numbness, tingling or paralysis– Chest compression or Shortness of Breath

TreatmentsTreatments

Immediate 100% oxygen breathing even if a marked improvement is noted.

Stabilize the same as you would for an Air Embolism.

RecompressionRapid Air Transport to a medical facility

with re-compression abilities.

Accident ManagementAccident Management

Rescue -– Removal from the water as quickly as possible.– Diver must be made positively buoyant by

removing their weight belt.– Wait until the diver is aboard a vessel (diving

bell, platform, boat) before resuscitation is preformed.

TreatmentsTreatments

Cardiopulmonary Resuscitation should not be altered for the patient who is involved in a diving accident.

Keep in mind that water temperatures are colder at depth than on the surface. The chances that the diver may be hypothermic are high. “They are not dead until they are warm and dead”

PositioningPositioning

If any form of Decompression Sickness is suspected the diver must be kept in a supine position and not allowed to sit up or stand.

Sitting up or standing may cause bubbles to distribute from the left ventricle and aorta to the brain.

Trendelenburg is NOT recommended.

BLS TreatmentBLS Treatment

Baseline Assessment, Vitals and Injury Management

Oxygen - is the definitive treatment of patients with salt water aspiration syndrome and most pulmonary barotrauma.

Consider CPAP for near-drowningsReassessment every 5 minutes

ALS TreatmentsALS Treatments

Aggressive IV rehydration is a benefit to divers.

Use an Isotonic fluid with large bore catheter if possible.

DO NOT use any solutions which are composed of glucose. It has been shown that these solutions may increase neurological trauma.

ALS Treatments cont.ALS Treatments cont.

No drugs have been shown to be a benefit in the treatment of Decompression Illnesses.

Aspirin may be ordered by a physician to lessen the chances of blood clots.

Diazepam or Versed to control and prevent convulsions.

Analgesics as needed (Morphine/Fentanyl)

TransportTransport

Stabilization of the diver must precede transportation. Resuscitation, O2 administration, IV access, hemorrhage control and passive re-warming of the hypothermic patient.

Transport should be rapid and to an appropriate Trauma Center with the capability of recompression.

Transport cont.Transport cont.

Special transport considerations -– Must stay below 1000 feet.– Road transportation may be inappropriate

depending on the roads altitude, contour and surface. (Mountains, Valleys etc.)

HYPERBARICSHYPERBARICSHow does it work?How does it work?

When the body is pressurized free gases that are in the body decrease as the pressure increases.

Gas Wash Out- If the body has been flooded by large amounts of one type of gas, the pressurization causes the gas to wash out.

MonoplaceMonoplace

Local Chambers for DiversLocal Chambers for Divers

Maryland– GBMC, Baltimore– MIEMSS (Shock Trauma),

Baltimore Delaware, none New Jersey

– Ocean County Med. Ctr, Atlantic City

– Comprehensive Wound Treatment Ctr., Hackensack

– Morristown Memorial, Morristown

– Seachrist Clinical Services, Kearny

Virginia– Mount Vernon Hospital,

Alexandria – US Army, Fort Eustis – Metropolitan Hospital,

Richmond – DePaul Medical Center,

Norfolk – Sentara Leigh Hospital,

Norfolk– Naval Medical Center,

Portsmouth

Important Phone NumbersImportant Phone Numbers

USCG, Ocean City (410) 289-7457USCG, Indian River (302) 227-2121Divers Alert Network 1-919-684-4DAN

LODDLODD