Pool Danger. Pediatric Drowning. Pediatric Drowning. Pediatric Drowning Objectives. Peter Antevy MD

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Baldric Terry
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Physician EMS Medical Director Pool Danger Objectives Drowning from a medical perspective Where

1 Pediatric Drowning Pediatric Drowning Disclosure Pediatric Emergency Standards, Inc. Founder and CMO Consulting Pediatric Resuscitation System Peter Antevy MD Pediatric Emergency Physician EMS Medical Director Pool Danger Objectives Drowning from a medical perspective Where we ve been.where are we going? The body during submersion Statistics Prevention The future and new ideas 3

2 A Day at the Beach Prevention Rescue Medical A Similar Story Allan s Story Pregnancy Delivery Life

3 Allan is down Allan is down Recognize - Understand - React Will you step in? Can you control your adrenaline surge? Will you do something wrong? Rescue arrives in 4 minutes Child found blue and asystolic CPR ensues Child transported rapidly to Joe DiMaggio Children s Hospital Do you know the physiology? He is unconscious ED Arrival Allan is down Copious amounts of emesis Moderate respiratory distress O2 Sat of 92% on 100% non-rebreather Minutes later he vomits a frothy pink fluid What is happening? ED Management Placed on a ventilator Labs suggest significant illness Oxygen starvation Elevated Acid levels IV medications & fluid Transferred to PICU

PICU Course A Mothers Reflection Severe lung swelling at 12 hours

Gastrostomy tubes Multiple specialists involved 3 month

didn t drown, so I thought he d be OK They asked if I want to

4 PICU Course A Mothers Reflection Severe lung swelling at 12 hours Significant brain swelling over 24 hours Tracheostomy and Gastrostomy tubes Multiple specialists involved 3 month hospitalization Initial explanation did not sink in I was told he didn t drown, so I thought he d be OK They asked if I want to disconnect the ventilator at 48 hours Things sunk in at 3 weeks Allan s Story A Recent Photo

History History Until the 18 th Century drowning was accepted as part of life Bystander rescue of the drowning victim was not considered until the late 1700 s Prevention efforts begun Posters in

5 History History Until the 18 th Century drowning was accepted as part of life Bystander rescue of the drowning victim was not considered until the late 1700 s Prevention efforts begun Posters in coffee shops Abraham Calcoen 1766 History History Baptist van Engelen 1767 Encouraged resuscitation Promoted knowledge of resuscitation Dutch Society to Rescue People from Drowning Do Something! World Congress on Drowning New definition of drowning 2. Preventative strategies / collaboration needed 3. Police officers and firefighters must learn to swim 4. Rescue techniques must be investigated 5. CPR must be learned by lay persons / rescuers 6. Hospital treatment should be concentrated

6 "Drowning Submersion Terminology Survival not included Near-drowning and Dry vs. Wet Respiratory impairment Epidemiology 500,000 deaths / year - Worldwide China and India (40% of total) Ranks higher than death through war! 4,000 deaths / year United States 3,000 are children Fatality rates highest in children < 5yrs 23 24

7 Broward County Florida Statistics 14 counties with at least 9 incidents in 2005 Broward, Miami- Dade, and Palm Beach Counties experienced the greatest number of drowning incidents to residents aged 0-4 years in To access your county s statistics visit Place of Occurence Data Source: DOH Vital Statistics

8 Epidemiology Epidemiology Males predominate in drownings in all age groups (peaks at 2 and 18 years) About 80% of submersion deaths are male Native Americans and African American Rope Swinging

9 Rope Swinging How Children Drown Pools Drain Danger Children < 5 at greatest risk Between noon and dinner 14 X greater than death from MVA in kids < % occur in residential pools Be wary of the drain Virginia Graeme Baker

Drain Danger Bathtubs 80% of these are accidental A review of 21 bathtub deaths revealed 67% had historical or physical exam findings suggestive of abuse Typical age 8-18 months Infants as young as

10 Drain Danger Bathtubs 80% of these are accidental A review of 21 bathtub deaths revealed 67% had historical or physical exam findings suggestive of abuse Typical age 8-18 months Infants as young as 10 months can climb into the bathtub Low socioeconomic homes Bathtubs Pathophysiology The usual series of events Family routine suddenly broken Acute illness Marital strife Stressed mother trying to cope with bathing and feeding several kids Telephone or doorbell rings Mother leaves infant in the care of older kids Older kids climb out à Infant drowns

11 Pathophysiology Pathophysiology Oxygen CO2 Reflex Aspiration Glottic Closure Panic Pathophysiology Pathophysiology Ingest large amount of Water With prolonged hypoxia the laryngospasm abates 1. Surfactant destroyed 2. Impaired gas exchange 3. Pulmonary edema 4. O2 CO2 5. Acidosis

Pathophysiology COld Case 1. Panic 2. Reflex aspiration (lungs) 3. Laryngospasm 4.

Pulmonary edema Fluid required =1ml/kg 10 & 7 year old brothers swimming in Lake

CO-LD Case Cold Case Both were excellent swimmers No evidence of trauma on

12 Pathophysiology COld Case 1. Panic 2. Reflex aspiration (lungs) 3. Laryngospasm 4. Water swallowed 5. Water aspirated 6. Surfactant destroyed 7. Pulmonary edema Fluid required =1ml/kg 10 & 7 year old brothers swimming in Lake Powell Both found submerged 30 minutes later Both Died! Cause of Death? CO-LD Case Cold Case Both were excellent swimmers No evidence of trauma on post-mortem Carbon Monoxide Poisoning Level of 59 & 52% after brief exposure One test revealed the diagnosis CO Level

13 CO Poisoning CO Poisoning CO Poisoning CO Poisoning

14 Teak Surfing Treatment On Scene Management Most significant aspect of resuscitation Most important maneuver is. Reinstitution of Effective Respiration Bondi Beach Rescue Rescue Video

Basic Principles Submersion Time OPEN THE

Chin lift Slow ventilatory delivery Smaller

ER Resuscitation Prolonged resuscitation

15 Basic Principles Submersion Time OPEN THE AIRWAY Positioning Oral airways Jaw thrust Chin lift Slow ventilatory delivery Smaller tidal volumes Cricoid pressure CPR Duration ER Resuscitation Prolonged resuscitation (ACLS >25 min) of warm water pediatric drowning victims is NOT indicated The longest ED CPR with a good neurologic outcome was 12 minutes

16 Bystander CPR Innovative Items Therapeutic Hypothermia Family members performed CPR in 20% of cases 65 received bystander CPR prior to paramedic arrival 41/63 breathing and with pulses when EMS arrived All 41 survived to hospital discharge Sirbaugh (Ann Emerg Med, 1999) 63 64

TTM Targeted Temperature Management Therapeutic Hypothermia 65 66 Resuscitation 2013 43 Arrests Hypothermia 35% n=14 Normothermia 65%

17 TTM Targeted Temperature Management Therapeutic Hypothermia Resuscitation Arrests Hypothermia 35% n=14 Normothermia 65% n=28 78% Survival 46% 9/14 Neuro Intact 6/28 Neuro Intact Predictors of Survival Short EMS Response Shockable Rhythm Non-Salt Water 68

18 In Water Resuscitation In Water Resuscitation Mouth to Mouth BVM The Future Portable ECMO Pediatric Drowning Portable ECMO 71 72

proof Approved floatation devices Boating safety Other ideas Pediatric

19 Prevention Prevention Swimming lessons early Self rescue techniques at all ages Do not allow a false sense of security No child is ever Drown proof Approved floatation devices Boating safety Other ideas Pediatric Drowning Peter Antevy MD Pediatric Emergency Physician EMS Medical Director

Canadian Red Cross Summary First Aid Technical Changes for 2011 Implementation

Canadian Red Cross Summary First Aid Technical Changes for 2011 Implementation Wound Care Second part of a SFA course On the first day and included in EFA To meet legislative requirements Assessment and