Submersion Emergencies

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Submersion Emergencies Water Rescues

• Amy Gutman MD EMS Medical Director
• prehospitalmd_at_gmail.com / www.TEAEMS.com

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Overview

• Drowning Near Drowning
• Epidemiology
• Pathophysiology
• Water Rescue Techniques
• Technical Rescue Incidents

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Drowning vs Near-Drowning

• Drowning
• Death within 24 hrs of water submersion
• Near Drowning
• Incident resulting in survival gt24 hrs after
  water submersion

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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 lt15yo
• 1st in FL, CA, AZ
• Water-related incidents 2 all fire department
  calls
• 1 fire service fatalities water related
•  

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Submersion Injuries

• Cold Water
• Water temp gt20C
• Warm Water
• Water temp lt20C
• Very Cold Water
• Water temp lt5C
• Swift vs Still Water
• Fresh vs Salt Water

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Pools Kids

• Kids lt4yo 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 lt4yo

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Personal Flotation Devices (PFDs)

• Type I (Ski Belt)
• lt15 lbs buoyancy
• Type II (Over The Head)
• gt15.5 lbs buoyancy
• Type III (Face Up in Water)
• gt34 lbs buoyancy
• Vest, float coat
• Type IV (Throwable)
• Type V (Special Use Devices)
• 30-40 lbs buoyancy

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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

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Vulnerable Populations

• Geography
• Southern States
• Gender
• Males gt 81 drownings
• Age
• Children lt15 yo

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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

• 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

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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 lt4 mL/kg
• Aspiration gt11 mL/kg alters blood volume
• Aspiration gt22 mL/kg causes electrolyte changes

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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

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Drowning Pulmonary Edema
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Causes

• Access
• Ethanol
• gt 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

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Dangerous TOOs

• TOO tired
• TOO cold
• TOO far away
• TOO much sun
• TOO much exercise
• TOO many drugs
• Diving face TOO water

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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

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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

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Water Body Temperature

• Body cant maintain temp in water lt92oF
• 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

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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

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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

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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)
• Dont be fooled by the near-drowning patient who
  looks well

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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

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Backboarding In Water

• Maintain airway in-line stabilization
• Submerge longboard under patients waist
• Allow board to float up to victim
• Secure victim with straps prior to securing head

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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

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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

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Factors Affecting Survival

• Water cleanliness
• Time submerged
• Victims age, general health, long volume PDF
  usage
• Water temperature
• Increased survival in children with hypothermic
  submersion (core lt32C)
• Most cold-water submersions dont develop
  hypothermia rapidly enough to lower brain
  metabolism before severe hypoxia occurs
• Position underwater

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Submersion Prognosis

• The most important factors to morbidity
  mortality from are hypoxemia decreased O2
  delivery to vital tissues
• gt90 survive initial submersion event

• Good Prognosis

• Poor Prognosis

• AOX3 breathing on ED arrival usually survive
  w/o deficits
• Submersion lt10 mins
• Early response to resuscitation

• Submersion gt25 mins
• Prolonged time to initial resuscitation
• Acidosis at ED presentation

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• Orlowski Score of Submersion Survivability

• Conn Cerebral Hypoxia Classification

• 1 point for each item
• lt2 90 full recovery
• gt3 5 chance of survival
• Items
• Age gt3 yo
• Submersion gt5 mins
• No resuscitation gt10 mins after rescue
• Comatose on ED arrival
• pH lt7.10

• Category A - Alert
• Category B ALOC
• Lung injury may result in hypoxemia CNS injury
• Category C - Comatose
• C1 Decorticate
• C2 Decerebrate
• C3 Flaccid

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Water Technical Rescue Incidents (TRIs)
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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

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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

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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

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Scene PPE

• PFD, helmet throw bag / flotation device if
  within 10 feet of water
• No turnout gear
• No fire helmets

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• Swift Water

• Still Water

Ice Water
Dive
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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

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Specialized Equipment?
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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

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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

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Water PPE

• Gloves, Shoes
• Fins
• Accessories
• Helmets
• Wet Dry Suits
• PFD

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Rescue Methods

• Use fastest, lowest risk least complex methods
• Talk
• Reach
• Throw
• Wade
• Row
• Go
• Helo

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Talk

• Direct victim to safety who can walk, float or
  swim to shore
• Victim must be able to understand you cooperate

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Reach
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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

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Throw
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Wade

• Never wade unless you have proper training, PPE
  have considered unseen hazards potentials
• High foot entrapment risks

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Foot / Extremity Pins

• When swimming or walking in swift water gt knee
  depth never put feet on bottom
• Leg may become trapped pinning you below surface
  by waters force / weight
• Foot entrapments worsened by hydraulic forces

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Row
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Go (Into Water)
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Helo(copter)
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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

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Company Assignments

• Establish ICS
• Request SR, 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

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Swift Water Safety

• PFD throw bag but dont tie rope to yourself
• Upstream spotters downstream safeties
• Dont 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

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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

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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
  waters 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

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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

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Flow Terminology
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Recirculating Currents

• Develop as water moves over uniform obstructions
• Hydraulic forms, moves against flow
• Recirculating water traps people against object

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Strainers

• Obstructions that filter water
• Downed trees, gratings, mesh
• Creates unequal forces
• People pinned under waters force
• Height no indication of danger
• All dams have recirculating currents
• Intake grates serve as strainers

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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

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Rescue vs. Recovery

• Time submerged
• Age
• Physical condition
• Known/suspected trauma
• Water temperature
• Estimated time for rescue/removal

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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 table-top
  live drills at least once seasonally

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References

• NFPA 1670
• Bledsoe B. Paramedic Care Principles Practice
  3rd Ed. 2008
• Sanders M. Mosbys Paramedic Textbook 3rd Ed.
  2007
• www.pubmed.com, www.wikipedia.com,www.emsc.org
• PALS, PEPP course materials

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Conclusionsprehospitalmd_at_gmail.com /
www.TEAEMS.com

• Drowning is preventable
• Education is the key in prevention
• Treatment outcomes relies on skilled
  performance of basic ABCs spinal injury
  management