Submersion Incidents: Drowning and Diving Emergencies

Chapter 25Chapter 25

Objectives

• Water-Related EmergenciesWater-Related Emergencies• Incidence in DrowningIncidence in Drowning• Prognostic PredictorsPrognostic Predictors• Pathophysiology of DrowningPathophysiology of Drowning• Diving EmergenciesDiving Emergencies• Safety Measures in Water-Related EmergenciesSafety Measures in Water-Related Emergencies• Spine InjurySpine Injury• ResuscitationResuscitation• Assessment-based Approach to Water-Related Assessment-based Approach to Water-Related

Emergencies and DrowningEmergencies and Drowning• Scuba or Deep-Water Diving EmergenciesScuba or Deep-Water Diving Emergencies• Decompression SicknessDecompression Sickness

Definitions• Common sense precautions;Common sense precautions;

– All pools should be fencedAll pools should be fenced– Children should be supervisedChildren should be supervised– Water activities and alcohol don’t mixWater activities and alcohol don’t mix– Life preservers or PFD must always be wornLife preservers or PFD must always be worn– Avoid diving in shallow waterAvoid diving in shallow water– People with seizure disorders must be careful People with seizure disorders must be careful

• Drowning – recommended term for submersion Drowning – recommended term for submersion events (not near-drowning)events (not near-drowning)

• Drowning – incident in which someone is Drowning – incident in which someone is submersed or immersed in a liquid that results in submersed or immersed in a liquid that results in primary respiratory impairmentprimary respiratory impairment

Incidence of Drowning• Approximately 4,500 Approximately 4,500

death per year in US death per year in US (40% children under 5)(40% children under 5)

• 85% are males85% are males• Most common location Most common location

is bathtubs for children is bathtubs for children less than 1, swimming less than 1, swimming pools for children 1-5 pools for children 1-5 years oldyears old

Incidence of Drowning• Adults, consider following conditions that may lead to Adults, consider following conditions that may lead to

submersion;submersion;– HypoglycemiaHypoglycemia– Myocardial infarction from exertionMyocardial infarction from exertion– Cardiac dysrhythmiaCardiac dysrhythmia– SyncopeSyncope– SeizureSeizure– Depression or suicide attemptDepression or suicide attempt– Anxiety or panic disorderAnxiety or panic disorder– Arthritis, Parkinson’s, other neuromuscular disorderArthritis, Parkinson’s, other neuromuscular disorder– ExhaustionExhaustion– HypothermiaHypothermia– Alcohol/Drug useAlcohol/Drug use

• Water sports (mixed with alcohol/drugs) also poses a Water sports (mixed with alcohol/drugs) also poses a hazardhazard

Prognostic Predictors• Quick rescue and early resuscitation are most Quick rescue and early resuscitation are most

critical factors associated with better outcomescritical factors associated with better outcomes• Best chance of survival, patient who has 2 or fewer Best chance of survival, patient who has 2 or fewer

characteristics on the Orlowski predictors;characteristics on the Orlowski predictors;– 3 years of age or older3 years of age or older– Submersed greater than 5 minutesSubmersed greater than 5 minutes– Resuscitation began over 10 minutes after rescueResuscitation began over 10 minutes after rescue– Comatose patient upon delivery at EDComatose patient upon delivery at ED– Acidic arterial blood (pH < 7.10)Acidic arterial blood (pH < 7.10)– Moderate body core hypothermia is thought to provide a Moderate body core hypothermia is thought to provide a

protective mechanism that reduces brain and organ protective mechanism that reduces brain and organ damage in childrendamage in children

Pathophysiology of Drowning• Most significant consequence – lack of ventilation Most significant consequence – lack of ventilation

while submerged, leading to severe and prolonged while submerged, leading to severe and prolonged hypoxia and accumulation of carbon dioxide in hypoxia and accumulation of carbon dioxide in blood, leads to severe acid build-upblood, leads to severe acid build-up

• Combined hypoxia and acidosis may lead to Combined hypoxia and acidosis may lead to severe brain injury and cardiac arrestsevere brain injury and cardiac arrest

• Severe hypoxia associated with initial drowning Severe hypoxia associated with initial drowning could produce prolonged effects that continue to could produce prolonged effects that continue to damage tissues and organs, creating an ongoing damage tissues and organs, creating an ongoing hypoxiahypoxia

Pathophysiology of Drowning

• 10 – 15% of drowning victims are prevented 10 – 15% of drowning victims are prevented from aspirating water during submersion due from aspirating water during submersion due to the spasm and tight closing of the larynx to the spasm and tight closing of the larynx that last until all inspiratory efforts have that last until all inspiratory efforts have ceased (dry drowning)ceased (dry drowning)

• Abdominal thrusts are not helpful or Abdominal thrusts are not helpful or necessarynecessary

Pathophysiology of Drowning

• Surfactant – substance that maintains Surfactant – substance that maintains surface tension in the alveoli to keep them surface tension in the alveoli to keep them from collapsing. from collapsing.

• If surfactant is washed out, alveoli tend to If surfactant is washed out, alveoli tend to collapse (atelectasis)collapse (atelectasis)– Collapse creates ventilation problems, leads to Collapse creates ventilation problems, leads to

pulmonary edemapulmonary edema– Collapse interferes with gas exchange and leads Collapse interferes with gas exchange and leads

to acute respiratory distress (ARDS)to acute respiratory distress (ARDS)

Pathophysiology of Drowning

• Hypothermia – another problem as a result Hypothermia – another problem as a result of extremely cold water (<41of extremely cold water (<41°F or < 5°C)°F or < 5°C)

• Hypovolemia can occur during and after Hypovolemia can occur during and after initial resuscitation period from an increase initial resuscitation period from an increase in capillary permeability, producing in capillary permeability, producing hypotensionhypotension

Signs/Symptoms/factors for determining seriousness of event

• Persistent cough, Dyspnea or apneaPersistent cough, Dyspnea or apnea• Altered mental status, loss of consciousness at some Altered mental status, loss of consciousness at some

point during the submersionpoint during the submersion• VomitingVomiting• Drug/alcohol useDrug/alcohol use• Pertinent past medical historyPertinent past medical history• HypothermiaHypothermia• Duration of cardiac or respiratory arrestDuration of cardiac or respiratory arrest• Age Age • Pre-existing disease or conditionsPre-existing disease or conditions

Diving Emergencies

• Diving in water from diving board, shore, Diving in water from diving board, shore, poolside, boat, or dock often sustain injuries poolside, boat, or dock often sustain injuries to head and spine, fractures of the arms, to head and spine, fractures of the arms, legs, and ribslegs, and ribs

• Always assume that a diver has sustained Always assume that a diver has sustained neck and spine injuries, even if responsive neck and spine injuries, even if responsive and out of the waterand out of the water

• If patient still in water, provide care for a If patient still in water, provide care for a submersion patientsubmersion patient

Safety Measures in Water-Related Emergencies

• Certain deep-water accidents Certain deep-water accidents require special equipmentrequire special equipment

• Unless water emergency occurs in Unless water emergency occurs in open, shallow water that has a open, shallow water that has a stable, uniform bottom, never go stable, uniform bottom, never go out to attempt rescue unless you out to attempt rescue unless you meet the following criteria;meet the following criteria;– You are a good swimmer, You are a good swimmer, andand – You are specially trained in water You are specially trained in water

rescue rescue andand– You are wearing a PDF You are wearing a PDF andand– You are accompanied by other You are accompanied by other

rescuersrescuers

Guidelines• Responsive patient, close to Responsive patient, close to

shore, use the reach, throw, shore, use the reach, throw, row, go strategyrow, go strategy

• Responsive, but too far Responsive, but too far away, throw something away, throw something (rope tied to a floating (rope tied to a floating object)object)

• Unresponsive, out of reach Unresponsive, out of reach with a line, need to row or with a line, need to row or go by wading or swimming go by wading or swimming or using float boardor using float board Don’t become a fatality yourself!

Possible Spine Injury

• Cases to suspect spinal injury;Cases to suspect spinal injury;– Involved in a diving accidentInvolved in a diving accident– Struck by boat, water skier, surfboard, otherStruck by boat, water skier, surfboard, other– Had been divingHad been diving– Had used a waterslideHad used a waterslide– Suspected of intoxicationSuspected of intoxication– Has evidence of traumatic injuryHas evidence of traumatic injury

• Support back, and stabilize head/neckSupport back, and stabilize head/neck• Stabilize properly before removing from Stabilize properly before removing from

water (backboard)water (backboard)

Resuscitation

• Water < 70Water < 70° F or 21°C, mammalian dive reflex ° F or 21°C, mammalian dive reflex may drastically slow down metabolism and make may drastically slow down metabolism and make patient more likely to be resuscitated even after patient more likely to be resuscitated even after long submersionlong submersion

• Diving reflex more pronounced and cooling more Diving reflex more pronounced and cooling more rapid in youngrapid in young

• Attempt resuscitation on any pulseless, non-Attempt resuscitation on any pulseless, non-breathing patient who has been submerged in cold breathing patient who has been submerged in cold water (Not dead, until warm & dead)water (Not dead, until warm & dead)

• Some experts advise resuscitation to every Some experts advise resuscitation to every drowning victim, regardless of water temperaturedrowning victim, regardless of water temperature

Assessment-based Approach:Drowning and Water-Related Emergencies

Scene Size-upScene Size-up

• Ensure own safety and crewEnsure own safety and crew

• Consider PDF within 10’ of water edgeConsider PDF within 10’ of water edge

• Take BSI and MOITake BSI and MOI

• Survey scene for number of patientsSurvey scene for number of patients

• Decide if additional resources are needed or Decide if additional resources are needed or special teamsspecial teams

Primary Assessment

• Form general impressionForm general impression• Assess level of consciousness, record itAssess level of consciousness, record it• Assess airway, potential spine injury, and Assess airway, potential spine injury, and

suction, oral or nasal airwaysuction, oral or nasal airway• Check breathing, administer oxygen via Check breathing, administer oxygen via

NRB @ 15 lpm or PPV if neededNRB @ 15 lpm or PPV if needed• Check circulation, pulse and life-Check circulation, pulse and life-

threatening bleeding needs to be controlledthreatening bleeding needs to be controlled• Make a priority transport decisionMake a priority transport decision

Secondary Assessment Signs/Symptoms

• Perform rapid secondary assessmentPerform rapid secondary assessment– Airway obstructionAirway obstruction– Absent/inadequate breathingAbsent/inadequate breathing– Pulselessness (cardiac arrest)Pulselessness (cardiac arrest)– Spine or head injurySpine or head injury– Soft-tissue injuriesSoft-tissue injuries– Musculoskeletal injuriesMusculoskeletal injuries– External/internal bleedingExternal/internal bleeding– ShockShock– HypothermiaHypothermia– Alcohol/drug useAlcohol/drug use– Drowning or submersionDrowning or submersion

Categories• Asymptomatic – no signs/symptoms of drowning eventAsymptomatic – no signs/symptoms of drowning event• SymptomaticSymptomatic

– Altered mental statusAltered mental status– Altered vital signsAltered vital signs– Respiratory distress/arrestRespiratory distress/arrest– DyspneaDyspnea– Low SpO2 readingLow SpO2 reading– Persistent cough, wheezing, cracklesPersistent cough, wheezing, crackles– Decreased core temperatureDecreased core temperature– Cool skin or cyanosisCool skin or cyanosis– Vomiting/diarrheaVomiting/diarrhea– AnxietyAnxiety

• Cardiac Arrest: Pulseless, Apnea (Asystole or V-Fib, V-Tach)Cardiac Arrest: Pulseless, Apnea (Asystole or V-Fib, V-Tach)• Obviously dead – Rigor mortis or lividityObviously dead – Rigor mortis or lividity

Emergency Care

• Do not assume patient is deadDo not assume patient is dead• Remove patient from water quickly and safelyRemove patient from water quickly and safely• Stabilize head/neckStabilize head/neck• Keeping head/neck in-line with spinal column, Keeping head/neck in-line with spinal column,

slide long backboard under patient; secure torso slide long backboard under patient; secure torso and legs to backboardand legs to backboard

• Apply C-collar and head immobilization deviceApply C-collar and head immobilization device• Float board to shore, lift patient out of waterFloat board to shore, lift patient out of water

Emergency Care• No spinal injury suspected, place patient on No spinal injury suspected, place patient on

left side so water, vomitus, and secretions left side so water, vomitus, and secretions draindrain

• Be prepared to suctionBe prepared to suction

• Establish airway, begin PPV with Establish airway, begin PPV with supplemental oxygensupplemental oxygen

• If pulseless/apneic, begin CPR, 1 shock If pulseless/apneic, begin CPR, 1 shock from AED (if patient hypothermic)from AED (if patient hypothermic)

Emergency Care

• With patient on side, apply pressure to abdomen in With patient on side, apply pressure to abdomen in cases of severe gastric distension onlycases of severe gastric distension only

• Manage any other medical/trauma conditions Manage any other medical/trauma conditions associated with drowning eventassociated with drowning event

• Transport quickly – always transport drowning Transport quickly – always transport drowning patientpatient

• Reassessment: Be alert for deterioration into Reassessment: Be alert for deterioration into respiratory or cardiac arrest. Reassess every 5 respiratory or cardiac arrest. Reassess every 5 minutes if unstable, every 15 minutes if stableminutes if unstable, every 15 minutes if stable

Scuba or Deep-Water Diving Emergencies

PathophysiologyPathophysiology

• Bubbles that form from the expansion of Bubbles that form from the expansion of nitrogen in blood and tissues act as an nitrogen in blood and tissues act as an emboli, cause obstruction in the circulation emboli, cause obstruction in the circulation and compress or stretch blood vessels and and compress or stretch blood vessels and nerves, and may cause coagulation of bloodnerves, and may cause coagulation of blood

Predisposing Factors • Flying or going to high altitude too soon after a dive (12-Flying or going to high altitude too soon after a dive (12-

24 hours)24 hours)• Failure to take necessary safety stops while ascending Failure to take necessary safety stops while ascending

from a divefrom a dive• Inadequate surface intervalsInadequate surface intervals• Inadequate decompression/passing decompression limitInadequate decompression/passing decompression limit• Diving at depths for too longDiving at depths for too long• Repeated dives at depth on same dayRepeated dives at depth on same day• Poor physical condition, obesity, age, dehydration, Poor physical condition, obesity, age, dehydration,

heart/lung diseases, Pre-existing musculoskeletal injuryheart/lung diseases, Pre-existing musculoskeletal injury• Fatigue, cold water, rough sea conditions, heated diving Fatigue, cold water, rough sea conditions, heated diving

suits, heavy worksuits, heavy work

Basic Laws of Physics

Decompression SicknessCategories

• Type 1 (mild)Type 1 (mild)– Pain – common, dull, aching, throbbing in Pain – common, dull, aching, throbbing in

joints or tendonsjoints or tendons– Pruritus (itching) and burning sensationPruritus (itching) and burning sensation– Skin rash- mottling or marblingSkin rash- mottling or marbling– Skin with orange-peel appearance (rare)Skin with orange-peel appearance (rare)– Painless pitting edema (uncommon)Painless pitting edema (uncommon)

Categories

• Type 2 – seriousType 2 – serious– Nervous System – low back pain that Nervous System – low back pain that

progresses into paresis, paralysis, progresses into paresis, paralysis, numbness/tingling, loss of sphincter control, numbness/tingling, loss of sphincter control, girdle pain to lower abdomen, Headache, visual girdle pain to lower abdomen, Headache, visual disturbances, dizziness, tunnel vision, altered disturbances, dizziness, tunnel vision, altered mental status, nausea, vomiting, vertigo, mental status, nausea, vomiting, vertigo, tinnitus, partial deafnesstinnitus, partial deafness

Categories

• Type 2Type 2– Respiratory System (chokes) – substernal Respiratory System (chokes) – substernal

burning sensation on inhalation, non-productive burning sensation on inhalation, non-productive cough, respiratory distresscough, respiratory distress

– Circulatory System – signs of hypovolemic Circulatory System – signs of hypovolemic shock, formation of thrombusshock, formation of thrombus

Common Signs/Symptoms

• Fatigue, uncoordinated movement, weakness, Fatigue, uncoordinated movement, weakness, motor/sensory deficitsmotor/sensory deficits

• Signs/symptoms of shockSigns/symptoms of shock• Pupillary changes, pallor to tongue, bloody Pupillary changes, pallor to tongue, bloody

sputum, nasal flaring, retraction of chest, sputum, nasal flaring, retraction of chest, accessory muscle useaccessory muscle use

• Tachypnea, crackles, SpO2 < 95% prior Tachypnea, crackles, SpO2 < 95% prior oxygen, cyanosis, pallor, itchingoxygen, cyanosis, pallor, itching

• Vomiting, urinary bladder distention, seizure, Vomiting, urinary bladder distention, seizure, joint pain, decreased range of motion, edemajoint pain, decreased range of motion, edema

Questions to ask DCS patients

• Where was the dive? (lake, river, ocean, cave)Where was the dive? (lake, river, ocean, cave)• What was the lowest depth, for how long?What was the lowest depth, for how long?• What were the other depths, for how long?What were the other depths, for how long?• What was the rate of ascent?What was the rate of ascent?• What has patient done since dive? Flying?What has patient done since dive? Flying?• What did patient do 72 hours prior to dive?What did patient do 72 hours prior to dive?• Did patient do work during dive?Did patient do work during dive?• What gases did patient use?What gases did patient use?• Were there any problems experienced?Were there any problems experienced?• What physical condition was patient in before, during, and after What physical condition was patient in before, during, and after

dive?dive?• Was any first aid provided for patient?Was any first aid provided for patient?

Arterial Gas Embolism (AGE)

• Blockage of blood vessels by air bubble or Blockage of blood vessels by air bubble or clusters of air bubblesclusters of air bubbles

• Interferes with perfusion of body tissues Interferes with perfusion of body tissues with oxygen and nutrientswith oxygen and nutrients

• Results from air in lungs rapidly expanding, Results from air in lungs rapidly expanding, rupturing alveoli, damaging adjacent blood rupturing alveoli, damaging adjacent blood vessels, leading to air bubbles in the blood vessels, leading to air bubbles in the blood streamstream

Signs/Symptoms – rapid onset• Itchy, blotchy, mottled skinItchy, blotchy, mottled skin• Difficulty breathing, frothy blood in nose/mouthDifficulty breathing, frothy blood in nose/mouth• Dizziness, nausea/vomitingDizziness, nausea/vomiting• Chest pain, cardiac/respiratory arrestChest pain, cardiac/respiratory arrest• Severe, deep aching pain in muscles, joints, tendonsSevere, deep aching pain in muscles, joints, tendons• Blurred or distorted visionBlurred or distorted vision• Partial deafness, distortion of sensesPartial deafness, distortion of senses• Numbness or paralysisNumbness or paralysis• Staggering gait or lack of coordinationStaggering gait or lack of coordination• Weakness/numbness on one side of bodyWeakness/numbness on one side of body• Swelling and crepitus in neckSwelling and crepitus in neck• Loss or distortion of memory, behavioral changes Loss or distortion of memory, behavioral changes

(sometimes only sign)(sometimes only sign)• ComaComa

Barotrauma – the Squeeze• Occurs during ascent or descent when air Occurs during ascent or descent when air

pressure in body’s air cavities becomes too pressure in body’s air cavities becomes too greatgreat

• Signs/SymptomsSigns/Symptoms– Mild-severe pain in affected areas, clear or Mild-severe pain in affected areas, clear or

bloody discharge form nose/earsbloody discharge form nose/ears– Extreme dizziness, Nausea, disorientationExtreme dizziness, Nausea, disorientation

• Patients must be cased for a medical facility Patients must be cased for a medical facility immediately to prevent permanent deafness, immediately to prevent permanent deafness, residual dizziness, inability to dive in futureresidual dizziness, inability to dive in future

Emergency Care

• Spine injury suspected: in-line stabilizationSpine injury suspected: in-line stabilization• No spine injury: place in lateral recumbent No spine injury: place in lateral recumbent

positionposition• Oxygen via NRB if breathing and/or tidal Oxygen via NRB if breathing and/or tidal

volume are adequatevolume are adequate• PPV with supplemental oxygen if PPV with supplemental oxygen if

inadequateinadequate• Initiate CPR/AED if neededInitiate CPR/AED if needed• Transport immediately (possibly Transport immediately (possibly

recompression chamber)recompression chamber)

Questions ????