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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)