2.1 DROWNING AND NEAR- DROWNING EMERGENCIES
Drowning is defined as death that is the result of asphyxia due to airway obstruction secondary to laryngospasm and/or aspiration of liquid into the lungs after submersion and occurs within twenty-four (24) hours after submersion. Near-Drowning is defined as a submersion episode that results in survival (full or partial recovery) or temporary survival that ultimately leads to death after a period of twenty-four (24) hours.
Drowning begins with accidental or intentional submersion in any liquid, however, fresh and salt water drowning are the most common. Fresh-water drowning/near-drowning and salt-water drowning/near-drowning have different physiologic mechanisms leading to asphyxia, however, pre-hospital management of these patients is the same: treatment must be directed toward correcting severe hypoxia.
Factors affecting survival include the patient's age, length of time of submersion, general health of the victim, type and cleanliness of liquid medium and water temperature that may contribute to the effectiveness of the mammalian diving reflex. (decreased respirations, decreased heart rate and vasoconstriction with maintenance of blood flow to the brain, heart and kidneys).
SPECIAL CONSIDERATIONS:
a. The cold water drowning/near-drowning victim is not dead until he/she is warm and dead unless the patient has been submerged greater than one (1) hour. Near-drowning victims may exhibit delayed pulmonary complications up to 24- 36 hours after the submersion incident. This is especially true concerning salt-water exposure. Patients who have had a true near-drowning exposure should seek/receive medical attention and be informed as to the potential delayed complications.
b. All drowning/near-drowning victims with suspected barotrauma / decompression sickness should be transported in the left lateral Trendelenburg position to prevent any emboli in the ventricles from migrating to the arterial system. These patients also should be candidates for hyperbaric chamber therapy.
ASSESSMENT / TREATMENT PRIORITIES
1. Assure scene and rescuer safety. Call appropriate public service agencies: fire, rescue, or police teams, including scuba teams to properly stabilize the scene and safely rescue the victim(s) from the source of submersion.
2. Maintain universal blood and body fluid precautions.
3. Maintain an open airway immediately upon obtaining access to patient. Assure spinal stabilization and immobilization if indicated (i.e., unwitnessed event, unconscious patient, or mechanism of injury). Assist ventilations as needed.
4. Once the patient is rescued and is placed in a safe environment, rescuers may administer specific emergency care such as: suctioning the airway and use of airway adjuncts as indicated and the administration of high flow oxygen by non-rebreather mask or bag valve mask as determined by patient's condition.
5. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs. Treat all life threatening conditions as they become identified. Initiate CPR when appropriate.
6. Obtain appropriate history related to event (length of exposure, temperature of liquid medium, potential for injury), including Past Medical History, Medications, Drug Allergies, Substance abuse.
7. If suspected hypothermia: see Hypothermia / Cold Emergencies protocol.
8. If near drowning incident involves a scuba diver, suggesting barotrauma, consider utilization of hyperbaric treatment facility and follow regional point-of-entry protocol.
9. If the scene time and/or transport time will be prolonged, and a landing site is available, consider transport by air ambulance from the scene to an appropriate Trauma Center. See Air Ambulance protocol.
TREATMENT
BASIC PROCEDURES
1. Assure scene and rescuer safety. Call appropriate public service agencies: fire, rescue, or police teams, including scuba teams to properly stabilize the scene and safely rescue the victim(s) from the source of submersion.
2. Maintain universal blood and body fluid precautions.
3. Maintain an open airway and assist ventilations as needed, immediately upon obtaining access to patient. Assure spinal stabilization and immobilization if indicated (i.e., unwitnessed event, unconscious patient, or mechanism of injury).
4. Once the patient is rescued and is placed in a safe environment, rescuers may administer specific emergency care such as suctioning the airway and use of airway adjuncts as indicated and the administration of high flow oxygen by non-rebreather mask or bag valve mask as determined by patient's condition.
5. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs. Treat all life threatening conditions as they become identified. Initiate CPR when appropriate and follow AED/SAED protocol (if AED/SAED certified).
6. Obtain appropriate history related to event (length of exposure, temperature of liquid medium, potential for injury), including Past Medical History, Medications, Drug Allergies, Substance abuse.
7. If suspected hypothermia: see Hypothermia / Cold Emergencies protocol.
8. Activate ALS intercept, if deemed necessary and if available.
9. Initiate transport as soon as possible with or without ALS.
10. Notify receiving hospital.
Note: If near drowning incident involves a scuba diver, suggesting barotrauma, consider utilization of hyperbaric treatment facility and follow regional point-of-entry protocol
INTERMEDIATE PROCEDURES
1. Assure scene and rescuer safety. Call appropriate public service agencies: fire, rescue, or police teams, including scuba teams to properly stabilize the scene and safely rescue the victim(s) from the source of submersion.
2. Maintain universal blood and body fluid precautions.
3. Maintain an open airway and assist ventilations as needed, immediately upon obtaining access to patient. Assure spinal stabilization and immobilization if indicated (i.e., unwitnessed event, unconscious patient, or mechanism of injury).
4. Once the patient is rescued and is placed in a safe environment, rescuers may administer specific emergency care such as suctioning the airway and use of airway adjuncts as indicated and the administration of high flow oxygen by non-rebreather mask or bag valve mask as determined by patient's condition.
5. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs. Treat all life threatening conditions as they become identified. Initiate CPR when appropriate and follow AED/SAED protocol (if AED/SAED certified).
6. Obtain appropriate history related to event (length of exposure, temperature of liquid medium, potential for injury), including Past Medical History, Medications, Drug Allergies, Substance abuse.
7. ALS STANDING ORDERS
a. Provide advanced airway management if indicated.
b. Initiate IV Normal Saline (KVO) in non-traumatic drowning/near drowning. If suspected hypovolemia, (i.e., associated injury) titrate IV to patient's hemodynamic status.
8. Obtain appropriate history related to event (length of exposure, temperature of liquid medium, potential for injury), including Past Medical History, Medications, Drug Allergies, Substance abuse.
9. If suspected hypothermia: see Hypothermia / Cold Emergencies protocol.
10. Activate Paramedic intercept, if deemed necessary and if available.
11. Initiate transport as soon as possible with or without Paramedics.
12. Notify receiving hospital.
Note: If near drowning incident involves a scuba diver, suggesting barotrauma, consider utilization of hyperbaric treatment facility and follow regional point-of-entry protocol.
PARAMEDIC PROCEDURES
1. Assure scene and rescuer safety. Call appropriate public service agencies: fire, rescue, or police teams, including scuba teams to properly stabilize the scene and safely rescue the victim(s) from the source of submersion.
2. Maintain universal blood and body fluid precautions.
3. Maintain an open airway and assist ventilations as needed, immediately upon obtaining access to patient. Assure spinal stabilization and immobilization if indicated (i.e., unwitnessed event, unconscious patient, or mechanism of injury).
4. Once the patient is rescued and is placed in a safe environment, rescuers may administer specific emergency care such as suctioning the airway and use of airway adjuncts as indicated and the administration o f high flow oxygen by non-rebreather mask or bag valve mask as determined by patient's condition.
5. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs. Treat all life threatening conditions as they become identified. Initiate CPR when appropriate.
6. Obtain appropriate history related to event (length of exposure, temperature of liquid medium, potential for injury), including Past Medical History, Medications, Drug Allergies, Substance abuse.
7. ALS STANDING ORDERS
a. Provide advanced airway management if indicated.
b. Initiate IV Normal Saline (KVO) in non-traumatic drowning/near drowning. If suspected hypovolemia, (i.e., associated injury) titrate IV to patient's hemodynamic status.
c. Cardiac Monitor / dysrhythmia recognition: manage per protocols.
8. Obtain appropriate history related to event (length of exposure, temperature of liquid medium, potential for injury), including Past Medical History, Medications, Drug Allergies, Substance abuse.
9. If suspected hypothermia: see Hypothermia / Cold Emergencies protocol.
10. Contact MEDICAL CONTROL. Medical Control may order:
a. Additional 250 cc - 500 cc fluid bolus(es), wide open or titrate to patient's hemodynamic status.
11. Initiate transport as soon as possible.
12. Notify receiving hospital.
Note: If near drowning incident involves a scuba diver, suggesting barotrauma, consider utilization of hyperbaric treatment facility and follow regional point-of-entry protocol.
MoonDragon's EMS Index Page
HELPFUL PRODUCTS & FURTHER EDUCATION
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
-- by Phyllis A. Balch, James F. Balch - 4th Edition
-- by Phyllis A. Balch
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