Drowning

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• Drowning Dive Rescue Emergencies
• Graig Temple, NREMT-P
• Dive Rescue Specialist

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Objectives

• Students shall be able to differentiate between
  an Active and Passive Drowning.
• Students shall be able to explain the difference
  between a Near Drowning verses an actual Drowning
  including signs and symptoms.
• Students will be able to compare and contrast a
  fresh water drowning verses a salt water drowning.

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Objectives

• Students shall be able to identify a Rip-Currents
  in typical surf conditions
• Students will obtain a basic knowledge of Yell -
  Reach Throw Row GO

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Objectives

• Students shall be able to identify various types
  of dive related emergencies along with their
  associated signs, symptoms and immediate
  treatments.
• Students will be able to describe basic scene
  management of a dive emergency
• Students will be able to identify basic
  components of SCUBA gear including

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Drowning

• Definition - Die by immersion in water to die by
  immersion and usually suffocation in water or
  other liquid, or kill a person or animal in this
  way. Death occurs either from lack of oxygen or
  as a result of cardiac arrest from the lowered
  body temperature.

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Active Drowning

• Conscious Victim
• Thrashing
• Vertical in water
• Unable to call for help
• Body may be low in the water

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Passive Drowning

• Unable to stay afloat
• Unable to fight on the surface
• Submerges
• Becomes apneic
• Body floats on surface or could sink
• Cardiac Arrest imminent

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Near Drowning

• Definition a person who nearly drowns from
  suffocation in a liquid Injury occurs as of a
  direct result of the suffocation but does not
  result in death.

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Near DrowningSigns and Symptoms

• Abdominal distention
• Bluish skin of the face, especially around the
  lips
• Chest pain
• Cold skin and pale appearance
• Confusion
• Cough with pink, frothy sputum

• Irritability
• Lethargy
• No breathing
• Restlessness
• Shallow or gasping respirations
• Unconsciousness
• Vomiting

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Fresh Water Drowning

• A type of drowning in which hypo-osmolar water
  compromises the surface tension of alveolar
  surfactant, causing an imbalance in the
  ventilation-perfusionV/Q ratio, with a collapse
  of some alveoli, and both trueabsolute, and
  relativeintrapulmonary shunting

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Fresh Water cont.

• If the drowning or near drowning occurs in fresh
  water and water enters the lungs, that water is
  quickly absorbed into the blood stream. Fresh
  water has a lower solute concentration than the
  plasma in the pulmonary capillaries therefore,
  the fresh water is absorbed across the alveolar
  membrane into the bloodstream.

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Fresh Water cont.

• Once in the bloodstream, this fresh water dilutes
  the blood and changes the blood chemistry. Fresh
  water also affects blood cells and tissue
  membranes causing hemolysis which is destruction
  of the blood cells. The chemical change in the
  blood can result in cardiac dysrhythmias

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Salt Water Drowning

• Sea water aspiration results in fluid-filled but
  perfused alveoli, accompanied by a V/Q
  abnormality due to pulmonary edema the shifts of
  fluids and electrolytes in salt water drowning
  result in hemoconcentration, CHF, and
  hypernatremia

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Rip Currents

• A strong, narrow surface current that flows
  rapidly away from the shore, returning the water
  carried landward by waves.
• Occurs when waves break heavily in one area and
  weaker in others.
• Current in the Rip is jet like and will carry
  the victim typically from several feet to a 100
  yards before the current stops.
• Majority of Near Drownings occur as a result of
  being caught in Rip Currents

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How to Escape the Rip
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Surface Rescue

• YELL Reach Throw Row GO
• Yell for Help
• Reach for the victim (with an object if possible)
• Throw a Life ring, Rope bag or Floatation Device
  to the victim
• Row or Paddle to the victim if possible
• GO yourself by swimming to their aid.
• KNOW YOUR LIMITATIONS!!

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Useful Tools
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Public Safety Divers
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Responses

• Drowning
• MVCs with submersion
• Boating and PWC accidents
• Off Shore SCUBA accidents
• Ice Rescues
• Mutual Aid

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Training

• Due to the various types of incidents that public
  safety divers respond to, it is necessary to be
  trained in multiple disciplines including
• Basic and Advanced Open Water
• Rescue, Dry Suit, Wreck and Night Diving
• Public Safety Diving
• CPR/AED/EMT/Paramedic

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Dive Emergencies

• Heat Exposure
• Hyperthermia
• Heat Exhaustion
• Heat Stroke
• Cold Exposure
• Hypothermia
• Frostbite
• Dehydration

• Soft Tissue Injuries
• Lacerations
• Abrasions
• Contusions
• Stress
• Increased Heart Rate
• Elevated B/P
• Elevated R/R
• Psychological

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Medical Monitoring

• BLS/ALS Crew equipped to assess
• Vitals Pre and Post dive
• SpO2 and EtCO2
• Cardiac Monitoring and 12 Lead EKG
• Mental Status and Neuro Exam
• Secondary physical exam

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Dive Emergencies

• Oxygen Toxicity
• Nitrogen Narcosis
• Free Diving and Shallow water blackout
• Carbon Dioxide Retention
• Decompression Sickness and Illness

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Oxygen Toxicity

• Works off of Daltons Law on Partial Pressures.
• The result is an elevated pO2 and convulsions.
  This is the direct cause of Nitrogen Narcosis
  which eventually leads to DCS.

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SIGNS and SYMPTOMS

• Muscle spasms
• Nausea/Vomiting
• Dizziness
• Tunnel vision
• Tinnitus

• Irritability
• Anxiety
• Trouble Breathing
• Unusual fatigue
• Loss of coordination
• Convulsions

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Nitrogen Narcosis

• Often referred to as the Raptures of the Deep
  occurs when divers dive below 100 feet.
• This condition happens due to two laws. Daltons
  law states that the total pressure exerted by a
  mixture of gases is equal to the sum of the total
  pressure of each gas in the mixture as if it were
  occupying the same space.

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Narcosis cont.

• Boyles Law states that it is these same gases
  when rapidly reduced that causes decompression
  sickness. That is why Nitrogen is the gas that
  determines decompression schedules.

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Suffering from Nitrogen Narcosis

• Contributing factors
• Cold
• Stress
• Heavy work and fatigue
• CO2 retention.

• Signs and Symptoms
• Complex reasoning decreases by 33.
• Manual dexterity decreases 7.3.
• Diver appears drunk.
• Example diver appears to have drank 1 Martinis
  per every 50 feet.

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Treatments

• Immediate CONTROLLED ascent with constant
  monitoring by buddy/dive master or Dive-medic.
• 100 O2
• Cessation of diving, no further 100ft plus dives.
• Monitor and transport.

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Free Diving/Shallow Water Blackout

• Shallow water blackout (SWB) is a sudden loss of
  consciousness caused by oxygen starvation
  following a breath holding dive.
• About 7000 drownings a year occur as a result of
  this occurrence.
• Free divers use hyperventilation to reduce CO2
  build up to extend the breath holding time.

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Shallow Water Blackout cont..

• Effects divers that use closed circuit
  breathing apparatus.
• Occurs commonly within 15 feet of the surface.
• Loss of oxygen to the starved lungs causes rapid
  loss of consciousness.
• Occurs insidiously without warning.
• Victims dont know what hit them.

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Signs and Symptoms

• Altered Mental Status secondary to hypoxia
• Sudden onset of unconsciousness
• Respiratory Arrest Near Drowning
• Cardiac Arrest

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CO2 Retention

• Primary concern due to skipped breathing.
• Breath holding
• Closed system diving
• Diving with contaminated air.

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Signs and Symptoms

• Tachycardia
• Tachypnea
• Shortness of Breath
• Seizures/Convulsions
• AMS/Unconsciousness
• Headache
• Sweating

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Treatment

• 100 O2 via Non-Rebreather
• Monitor Vital Signs, SpO2, EtCO2
• ALS Assessment Cardiac Monitor, 12 Lead EKG,
  Stroke Assessment
• Transport if needed

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Decompression Sicknessthe bends

• Discovered in 1841 by sport divers.
• Caused by the production of Nitrogen that leaks
  into blood circulation and accumulates in the
  joints.
• Severity is determined by the depth and time of a
  dive, along with the rate in which the diver
  ascends.

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Types of DCS

• Type I-
• Cutaneous manifestations and minor joint pain.
  Referred to as pain only.
• Caused by bubbles, intravascular and
  extravascular with large gas stores in the fatty
  bone marrow.
• Cause of Dysbaric Osteonecrosis.

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Types of DCS cont.

• Type II
• Includes severe symptoms related to
  cardiopulmonary and neurological systems.
• Usually involves extensive damage to the spinal
  cord.

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Types of DCS cont.

• Type III
• Commonly a combination of an Arterial gas
  embolism and Decompression Sickness.
• Involves neurological symptoms.
• Generally termed the worse form of Decompression
  Sickness.

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Signs and Symptoms

• Signs-
• Blotchy Rash
• Paralysis or weakness
• Coughing Spasms
• Staggering gate or instability
• Unconsciousness

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Signs and Symptoms cont.

• Symptoms-
• Tired feeling
• Itching
• Pain in arms, legs or thorax
• Dizziness
• Numbness, tingling or paralysis
• Chest compression or Shortness of Breath

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Treatments

• Immediate 100 oxygen breathing even if a marked
  improvement is noted.
• Stabilize the same as you would for an Air
  Embolism.
• Recompression
• Rapid Air Transport to a medical facility with
  re-compression abilities.

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Accident Management

• Rescue -
• Removal from the water as quickly as possible.
• Diver must be made positively buoyant by removing
  their weight belt.
• Wait until the diver is aboard a vessel (diving
  bell, platform, boat) before resuscitation is
  preformed.

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Treatments

• Cardiopulmonary Resuscitation should not be
  altered for the patient who is involved in a
  diving accident.
• Keep in mind that water temperatures are colder
  at depth than on the surface. The chances that
  the diver may be hypothermic are high. They are
  not dead until they are warm and dead

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Positioning

• If any form of Decompression Sickness is
  suspected the diver must be kept in a supine
  position and not allowed to sit up or stand.
• Sitting up or standing may cause bubbles to
  distribute from the left ventricle and aorta to
  the brain.
• Trendelenburg is NOT recommended.

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BLS Treatment

• Baseline Assessment, Vitals and Injury Management
• Oxygen - is the definitive treatment of patients
  with salt water aspiration syndrome and most
  pulmonary barotrauma.
• Consider CPAP for near-drownings
• Reassessment every 5 minutes

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ALS Treatments

• Aggressive IV rehydration is a benefit to divers.
• Use an Isotonic fluid with large bore catheter if
  possible.
• DO NOT use any solutions which are composed of
  glucose. It has been shown that these solutions
  may increase neurological trauma.

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ALS Treatments cont.

• No drugs have been shown to be a benefit in the
  treatment of Decompression Illnesses.
• Aspirin may be ordered by a physician to lessen
  the chances of blood clots.
• Diazepam or Versed to control and prevent
  convulsions.
• Analgesics as needed (Morphine/Fentanyl)

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Transport

• Stabilization of the diver must precede
  transportation. Resuscitation, O2 administration,
  IV access, hemorrhage control and passive
  re-warming of the hypothermic patient.
• Transport should be rapid and to an appropriate
  Trauma Center with the capability of
  recompression.

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Transport cont.

• Special transport considerations -
• Must stay below 1000 feet.
• Road transportation may be inappropriate
  depending on the roads altitude, contour and
  surface. (Mountains, Valleys etc.)

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HYPERBARICSHow does it work?

• When the body is pressurized free gases that are
  in the body decrease as the pressure increases.
• Gas Wash Out- If the body has been flooded by
  large amounts of one type of gas, the
  pressurization causes the gas to wash out.

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Monoplace
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Local Chambers for Divers

• Maryland
• GBMC, Baltimore
• MIEMSS (Shock Trauma), Baltimore
• Delaware, none
• New Jersey
• Ocean County Med. Ctr, Atlantic City
• Comprehensive Wound Treatment Ctr., Hackensack
• Morristown Memorial, Morristown
• Seachrist Clinical Services, Kearny

• Virginia
• Mount Vernon Hospital, Alexandria
• US Army, Fort Eustis
• Metropolitan Hospital, Richmond
• DePaul Medical Center, Norfolk
• Sentara Leigh Hospital, Norfolk
• Naval Medical Center, Portsmouth

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Important Phone Numbers

• USCG, Ocean City [phone]
• USCG, Indian River [phone]
• Divers Alert Network 1-919-684-4DAN

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LODD