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)
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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)
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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
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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
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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
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Utilities
Haz Mat
Engulfment hazard
Environmental conditions
 Operate only to training
level & equipment available
 Size-up includes:
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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
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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
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Gloves, Shoes
Fins
Accessories
Helmets
Wet & Dry Suits
PFD
Rescue Methods
 Use fastest, lowest risk & least
complex methods
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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
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120+ persons killed annually in US
by driving their vehicles into water
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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
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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:
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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