Submersion Emergencies & Water Rescues Amy Gutman MD ~ EMS Medical Director
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Transcript Submersion Emergencies & Water Rescues Amy Gutman MD ~ EMS Medical Director
Submersion
Emergencies &
Water Rescues
Amy Gutman MD ~ EMS Medical Director
[email protected] /
www.TEAEMS.com
Overview
Drowning & Near Drowning
Epidemiology
Pathophysiology
Water Rescue Techniques
Technical Rescue Incidents
Drowning vs Near-Drowning
Drowning
Death within 24 hrs of
water submersion
Near Drowning
Incident resulting in
survival >24 hrs after water
submersion
Epidemiology
4000 US drownings annually
9 drowning deaths daily
15,000 – 70,000 near-drowning annually
For every death, 4 hospitalizations & 14 ED visits
1/3 survivors have moderate-severe neurologic sequelae
Drowning 2nd cause traumatic deaths in <15yo
1st in FL, CA, AZ
Water-related incidents 2% all fire department calls
1% fire service fatalities water related
Submersion Injuries
Cold Water:
Water temp >20°C
Warm Water:
Water temp <20°C
Very Cold Water:
Water temp <5°C
Swift vs Still Water
Fresh vs Salt Water
Pools & Kids
Kids <4yo = 50% pool drownings
20% deaths in guarded public pools
60% deaths in home pools
70% toddlers who drown in the care
of a parent at the time of the event
Pool 14 X more likely than motor
vehicle to be involved in the death of
a child <4yo
Personal Flotation Devices (PFDs)
Type I (Ski Belt)
<15 lbs buoyancy
Type II (Over The Head)
>15.5 lbs buoyancy
Type III (Face Up in Water)
>34 lbs buoyancy
Vest, float coat
Type IV (Throwable)
Type V (Special Use Devices)
30-40 lbs buoyancy
Boats & PFDs
89% boating fatalities related to
lack of a PFD
PFDs should be worn when
working in, on or near water
Of 481 boating-related drownings
in 2003, 416 preventable if PFDs
had been used
Vulnerable Populations
Geography:
Southern States
Gender:
Males > 81% drownings
Age:
Children <15 yo
Type of water
Drownings (%)
Swimming
pools
53%
Bath tubs
15%
Buckets
4%
In US there are 50,867,840 acres
of lakes, 633,109 miles of rivers
& 88,633 miles coastal shoreline
Fish ponds,
tanks
4%
Toilets
4%
75% diving injuries in natural
bodies of water
Washing
machines
1%
Ocean
1-2%
TOTAL
~83%
Flat / Still Water
Submersion Injury
Pathophysiology
Aspiration 1-3 mL/kg results in impaired gas
exchange from altered surfactant function
Water aspiration (wet drowning) vs dry
drowning (laryngospasm w/o aspiration)
10-15% asphyxiate w/o aspiration
Most aspirations <4 mL/kg
Aspiration >11 mL/kg alters blood volume
Aspiration >22 mL/kg causes electrolyte changes
Fresh Water vs Salt Water
Freshwater (Hypotonic / Hyposmolar)
Hypotonic relative to plasma disrupting alveolar surfactant
Pulled into pulmonary circulation by osmosis
Blood dilution leads to hemolysis, hyperkalemia, hyponatremia
Leads to VT/ VF within 2-3 mins
Sea water (Hypertonic / Hyperosmolar)
High osmotic gradient draws fluid into alveoli washing out surfactant
Osmosis pulls water from blood into lungs, thickening blood into
“sludge”, causing arrest from high cardiac work-load
Drowning & Pulmonary Edema
Causes
Access
Ethanol
> 50% for teens & adults
Lack of Adult Supervision
Lack of Education
Weak swimmers, deep water
Boating, Surfing, Jet ski
Secondary to an event
Heart attack, CNS injury
“Dangerous TOOs”
TOO tired
TOO cold
TOO far away
TOO much sun
TOO much exercise
TOO many drugs
Diving face “TOO” water
Submersion Injury Classifications
Distressed Swimmer
Too tired to reach safety but able to stay afloat, breathe & call for help
Active “Vertical” Drowning
Vertical in water but unable to swim, tread water & struggling to keep
their head above water
Passive “Horizontal” Drowning:
Not moving, floating face-down on bottom or surface
Near Drowning: SSX
Respiratory distress
Coughing / frothy sputum
Hypoxia / cyanosis
Tachypnea / apnea
AMS
If conscious: confused, lethargic, irritable
CNS damage from hypoxemia (primary injury) or secondary injury (lung,
reperfusion, multi-organ dysfunction)
Cardiac Arrest
Water & Body Temperature
Body can’t maintain temp in water <92oF
Heat loss 25x faster than in air rapidly causing
hypothermia
Hypothermia leads to inability to self-rescue,
follow commands, grasp lines & floatation
devices
Sudden immersion leads to laryngospasm &
drowning
Mammalian Dive Reflex
Submerging face in water colder 68 °F triggers MDR putting body into
energy saving mode
HR & circulation slows by 50%
Peripheral vasoconstriction increases blood & O2 supply to vital organs
Blood shifts to thoracic cavity to avoid lungs collapsing under high
pressures
May result in brain cooling similar to hypothermia
Maintaining Body Temperature
Personal Flotation Devices
Slow heat loss
Less energy expended for flotation
Heat Escape Lessening Position (HELP)
Head out of water
Body floating in fetal position
60% heat loss reduction
Huddle together in groups
General Management
Principles
Attempt rescue only if trained & equipped
All patients treated as if a spinal & head injury present
If necessary, start ventilations while patient in water followed by
aggressive airway management
Limit heat loss & utilize hypothermic protocols if indicated
Constant re-evalution of ABCs
Begin ACLS / CPR if indicated once on dry land / boat
Dry patient prior to defibrillation (limits arcing)
Don’t be fooled by the near-drowning patient who looks “well”
In-Water Management
Splint victim head, neck with arms
Roll victim to face-up position &
protect airway
Adjuncts prn
Rescue breathing prn
Primary rescuer maintains airway,
immobilization until c-collar applied
Second rescuer sizes, applies collar
Backboarding In Water
Maintain airway & in-line
stabilization
Submerge longboard under
patient’s waist
Allow board to float up to
victim
Secure victim with straps
prior to securing head
Removal From Water
Move to extraction point with
patient in head-first position
Pass from water to rescuers on
land
Use bystanders who can swim as
a breakwater behind patient
Prehospital Decompensation
Potential for rapid decompensation
Pulmonary parenchymal injury
Surfactant destruction
Aspiration pneumonitis
Pneumonia
Hypoxia / hypercarbia
Mixed metabolic & respiratory acidosis
Cerebral hypoxia
Ventricular arrhythmias
Cardiac arrest
Factors Affecting Survival
Water cleanliness
Time submerged
Victim’s age, general health, long volume & PDF usage
Water temperature
Increased survival in children with hypothermic submersion (core <32°C)
Most cold-water submersions don’t develop hypothermia rapidly
enough to lower brain metabolism before severe hypoxia occurs
Position underwater
Submersion Prognosis
• The most important factors to morbidity & mortality from are hypoxemia
& decreased O2 delivery to vital tissues
• >90% survive initial submersion event
Good Prognosis
A&OX3 & breathing on ED arrival
usually survive w/o deficits
Submersion <10 mins
Early response to resuscitation
Poor Prognosis
Submersion >25 mins
Prolonged time to initial
resuscitation
Acidosis at ED presentation
Orlowski Score of
Submersion Survivability
1 point for each item
<2 = 90% full recovery
>3 = 5% chance of survival
Items:
Age >3 yo
Submersion >5 mins
No resuscitation >10 mins
after rescue
Comatose on ED arrival
pH <7.10
Conn Cerebral Hypoxia
Classification
Category A - Alert
Category B – ALOC
Lung injury may result in
hypoxemia & CNS injury
Category C - Comatose
C1 Decorticate
C2 Decerebrate
C3 Flaccid
Water Technical
Rescue Incidents
(TRIs)
NFPA 1670 Standard for Technical Search &
Rescue Incidents Operations & Training
Implement assessment
Size-up of existing & potential conditions
Identification of resources to conduct safe & effective water operations
Implement emergency response system for water incidents
Implement site control & scene management
Recognition of hazards associated with water incidents & procedures
necessary to mitigate these hazards
Determine rescue versus body recovery
Incident Management
Size-up & hazard assessment
Isolate entry
Assess resource & equipment needs
Provide safety for rescuers & victims
Utilize ICS
Incident Commander (IC)
Technical Safety Officer (TSO)
Rescue Group Supervisor (RGS)
Rescue Group or Rescuer(s)
Spotters
Support Group
Medical Group
Rescue F-A-I-L-U-R-E
Failure to understand environment
Additional medical problems not considered
Inadequate rescue skills
Lack of teamwork or experience
Underestimating incident logistics
Rescue vs recovery mode
Equipment not mastered
Scene PPE
PFD, helmet & throw bag /
flotation device if within 10 feet
of water
No turnout gear
No fire helmets
Swift Water
Still Water
Ice Water
Dive
Scene Size-Up
Identify potential hazards
Utilities
Haz Mat
Engulfment hazard
Environmental conditions
Operate only to training
level & equipment available
Size-up includes:
Scope & magnitude
Risk-benefit analysis
# Patients & condition(s)
Access / Egress
Environmental factors
Available / required resource &
rescue methods
Control perimeter
establishment
Specialized Equipment?
Water Forces
Normal summer river &
creek flow = 2 mph
OW
The flow of the same waters
in winter = 15+ mph
3 mph = 33.6 lbs/ft
6 mph = 134 lbs/ft
9 mph = 302 lbs/ft
12 mph = 538 lbs/ft
LA
MI
NA
R
FL
Force (lb/ft)
FAST
SLOW
SLOWEST
Rescue Equipment
Boards
120 lbs. +/- flotation
Simple backboards do not have “intrinsic”
floatation capabilities
Throw Bags
75' 3/8" polypropylene rope
1,200 lb tensile strength
Water PPE
Gloves, Shoes
Fins
Accessories
Helmets
Wet & Dry Suits
PFD
Rescue Methods
Use fastest, lowest risk & least
complex methods
Talk
Reach
Throw
Wade
Row
Go
Helo
Talk
Direct victim to safety who can
walk, float or swim to shore
Victim must be able to
understand you & cooperate
Reach
Throw
• Two shots
• Consider water speed
• Aim directly on top or
upstream of victim
• Brace yourself
• Pendulum victim to shore
• Do not directly attach rope to
your body
Throw
Second throw 45
degrees down
river, In front of
the victim
First throw 45
degrees up river,
In front of the
victim
Wade
• Never wade unless you have
proper training, PPE & have
considered unseen hazards
potentials
• High foot entrapment risks
Foot / Extremity
Pins
When swimming or walking in
swift water > knee depth never
put feet on bottom
Leg may become trapped
pinning you below surface by
water’s force / weight
Foot entrapments worsened by
hydraulic forces
Row
Go (Into Water)
Helo(copter)
Vehicle Rescue
•
120+ persons killed annually in US
by driving their vehicles into water
•
Adds level of technical difficulty as
the vehicle is inherently unstable
Company Assignments
Establish ICS
Request S&R, water &/or dive teams
Gather & relay information
Point / time last seen
Number & age of patients
Type/color of clothing, PFD?
Search immediate area
Downstream/water containment
Upstream/water spotters
Swift Water Safety
PFD & throw bag but don’t tie rope to yourself
Upstream spotters & downstream safeties
Don’t put feet down in water
Never count on victim to help in their own rescue
Never tie a rope at a right angle to the current
Given choice between fire helmet & no helmet, NO HELMET
Be ready for self-rescue
Swift Water Rescues
Most dangerous water rescue
If water speed doubles, force quadruples
Cars can float in 12 inches of water
Swift water rescue requires proficiency in:
Technical rope rescue skills
Crossing moving water
Defensive swimming
Use of throw bags
Shore-based and boat-based rescues
Ability to package patient in water
Self-Rescue
Avoid entering water except as last resort
Protect head, mouth & nose, keep face out of water
Do not stand up (until egress)
Eddies may flow upstream, moving you toward water’s edge
Water moves slower on inside of bends
More obstructions closer to shore
To traverse current put your head in direction you want to travel toward
near shore at 45o angle & swim on your back with your feet downstream
Locating Victims
In flat water, victim under
average conditions is 1.5 x water
depth of where went down
In moving water, victims usually
w/i 100-150 yards downstream
Common locations:
Deep holes
Eddies
Strainers
Boil Line
Flow
Terminology
Pillow
Eddy
Hydraulic
LOW HEAD DAM
Recirculating Currents
Develop as water moves over uniform obstructions
“Hydraulic” forms, moves against flow
Recirculating water traps people against object
Strainers
Obstructions that filter water
Downed trees, gratings, mesh
Creates unequal forces
People pinned under water’s force
Height no indication of danger
All dams have recirculating currents
Intake grates serve as strainers
Eddies
Eddies caused by objects in river or
by a bank in any moving current
Backflow traveling slowly upstream
Areas are relatively calm & get
rescuer out of main current
Rescue vs. Recovery
Time submerged
Age
Physical condition
Known/suspected trauma
Water temperature
Estimated time for rescue/removal
Prevention
PFD-wearing children must be attended at
all times around water
Rules for safer swimming & boating
Water safety education classes
Practice local ICS & water rescue via tabletop & live drills at least once seasonally
References
NFPA 1670
Bledsoe B. Paramedic Care: Principles
& Practice 3rd Ed. 2008
Sanders M. Mosby’s
Textbook 3rd Ed. 2007
Paramedic
www.pubmed.com,
www.wikipedia.com,www.emsc.org
PALS, PEPP course materials
Conclusions
[email protected] / www.TEAEMS.com
Drowning is preventable
Education is the key in prevention
Treatment & outcomes relies on
skilled performance of basic ABCs &
spinal injury management