Submersion Submersion Emergencies &Emergencies &Water RescuesWater Rescues

Amy Gutman MD ~ EMS Amy Gutman MD ~ EMS Medical DirectorMedical Director

prehospitalmd@gmail.com / prehospitalmd@gmail.com / www.TEAEMS.comwww.TEAEMS.com

Overview

Drowning & Near Drowning Epidemiology Pathophysiology

Water Rescue Techniques Technical Rescue

Incidents

Drowning Death within 24 hrs

of water submersion

Near Drowning Incident resulting in

survival >24 hrs after water submersion

Drowning vs Near-Drowning vs Near-DrowningDrowning

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 

Epidemiology

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

Submersion Injuries

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

Pools & Kids

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 PopulationsVulnerable Populations

Geography: Southern States

Gender: Males > 81%

drownings

Age: Children <15 yo

In US there are 50,867,840 acres of lakes, 633,109 miles of rivers & 88,633 miles coastal shoreline

75% diving injuries in natural bodies of water

Flat / Still Water

Type of water

Drownings (%)

Swimming pools

53%

Bath tubs 15%

Buckets 4%

Fish ponds, tanks

4%

Toilets 4%

Washing machines

1%

Ocean 1-2%

TOTAL ~83%

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

Submersion Injury Pathophysiology

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

Fresh Water vs Salt Water

Drowning & Pulmonary Drowning & Pulmonary EdemaEdema

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

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

Submersion Injury Submersion Injury ClassificationsClassifications

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

Near Drowning: SSXNear Drowning: SSX

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

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

Mammalian Dive Reflex

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 General Management Management

PrinciplesPrinciples 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

Potential for rapid decompensation Pulmonary parenchymal injury Surfactant destruction Aspiration pneumonitis Pneumonia Hypoxia / hypercarbia Mixed metabolic & respiratory

acidosis Cerebral hypoxia Ventricular arrhythmias Cardiac arrest

Prehospital Prehospital DecompensationDecompensation

Factors Affecting SurvivalFactors 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

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

• The most important factors to morbidity & mortality from are hypoxemia & decreased O2 delivery to vital tissues

• >90% survive initial submersion event

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

PFD, helmet & throw bag / flotation device if within 10 feet of water

No turnout gear

No fire helmets

Scene PPE

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

The flow of the same waters in winter = 15+ mph

Force (lb/ft) 3 mph = 33.6 lbs/ft 6 mph = 134 lbs/ft 9 mph = 302 lbs/ft 12 mph = 538 lbs/ft

FAST

SLO W

SLO W EST

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

First throw 45degrees up river,

In front of thevictim

Second throw 45degrees dow n

river, In front ofthe 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

Flow Terminolo

gy

Boil L ine

PillowEddy

LO W HEAD DAM

Hydraulic

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

PreventionPrevention

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 table-top & live drills at least once seasonally

NFPA 1670

Bledsoe B. Paramedic Care: Principles & Practice 3rd Ed. 2008

Sanders M. Mosby’s Paramedic Textbook 3rd Ed. 2007

www.pubmed.com, www.wikipedia.com,www.emsc.org

PALS, PEPP course materials

ReferencesReferences

Drowning is preventable

Education is the key in prevention

Treatment & outcomes relies on skilled performance of basic ABCs & spinal injury management

Conclusionsprehospitalmd@gmail.com /

www.TEAEMS.com