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Drowning
David Slocum MD
Albany Medical Center
Miracles
Matthew Granger



14 month old
20-40 minutes
Vocabulary
Drowning – death within 24 hours
Near-drowning – survival past 24 hours
Who?
Usually young, healthy individuals
2006 Drowning
U.S.A. – 5000 died
Worldwide – over 100,000 died
Epidemiology
500,000 submersion events annually
2nd cause of death – children under 15
Injury ranges



Transient
Profou...
Three Peaks
Toddlers
Adolescents
Elderly
Toddlers
Toilets
Bathtubs
Buckets
Coastal Areas
Swimming pools more likely
Adolescents
Stupidity
Young Adults
Alcohol



40% adult drownings
75% boat drownings
Elderly
Complicating Factors
Spinal cord injury
Hypothermia
Panicking
Syncope
Seizures
Pathophysiology
Central Nervous System Injury
Pulmonary Injury
Dry-drowning
10-20% of submersions
Laryngospasm
Hypoxia
Loss of consciousness
Wet-drowning
Aspiration of water
Dilution of surfactant
Diminished gas transfer
Atelectasis
Ventilation perfusion mismatch
Pulmonary Injury
Contaminated foreign material
Particulate matter
Bacteria
Vomitus
Chemical irritants
Prognosis
Submersion time
Physiological scoring systems
Two extremes
Fair cardiovascular and neurological
function


Minimal disability

Unstable cardiovascular function and
com...
End Organ Damage
Renal injury




Hypoxia
Myoglobinuria
Hemoglobinuria

Hematologic



Hemolysis
DIC
Treatment
Prehospital Care
Resuscitation


Time optimizes outcome

Removal from water


C-spine protection

CPR ASAP
Airway
Breathing


High flow oxygen by facemask

Not Breathing



Bag valve mask
Endotracheal tube
Unconscious
Protect ...
Who to transport?
Amnesia
Loss or depressed consciousness
Period of apnea
Period of artificial respirations
Even if asympt...
Don’t Forget
Warm patient


Hypothermia

Monitor
IV access


Warm isotonic fluids
Summary
Rapid, cautious rescue
Spine precautions
Cardiopulmonary resuscitation
Supplemental Oxygen
Transport
ED Treatment
Continue EMS care







Airway
Oxygen
Ventilation
Warmed fluids
Warming adjunts
Treat associated injur...
GCS > 12
Oxygen to keep sat > 95%
Observe 4-6 hours
Pulmonary exam normal
Saturation normal
Discharge home
No xray or labs...
GCS > 12
Oxygen to keep sat > 95%
Observe 4-6 hours
Pulmonary exam abnormal
Requires oxygen
Deteriorates
Admit to Monitore...
GCS < 13
High flow oxygen
Intubation for low PaO2
CXR, Labs
Continuous cardiac monitoring
Frequent reassessments
Seizure
Dilutional hyponatremia
Control seizures
Correct electrolytes
Residual disorder uncommon
ED Arrest
Warm water drowning
Recovery doubtful
Consider early discontinuation of efforts
Risk profound neurological handi...
Hospital Management
Supportive
Avoid ARDS
Pneumonia rare
Dopamine, epinephrine drips
48 hour window
No benefit
Mannitol
Loop diuretics
Hypertonic saline
Fluid restriction
Hyperventilation
Controlled hypothermia
Barbiturate...
Prognosis
No CPR



Full recovery within 48 hours
May develop ARDS

Bystander CPR



Steady recovery
Steady decline

E...
Pediatric Warm Water Drowning
500 victims
100% received ED CPR
84% died
16% severe hypoxic encephalopathy
Diving Reflex
Mammals
Bradycardia
Peripheral Vasoconstriction
Greatest in cold water
Preserves oxygen
ICE water submersion
Asystole
Children and Adults
Complete Recovery
Rare
Resuscitate until normothermic
Prevention
Infants


Parental vigilance

Toddler


Pool fencing

Adolescent/Young Adult



Control Alcohol/Drug Use
Sw...
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Drowning

  1. 1. Drowning David Slocum MD Albany Medical Center
  2. 2. Miracles Matthew Granger   14 month old 20-40 minutes
  3. 3. Vocabulary Drowning – death within 24 hours Near-drowning – survival past 24 hours
  4. 4. Who? Usually young, healthy individuals
  5. 5. 2006 Drowning U.S.A. – 5000 died Worldwide – over 100,000 died
  6. 6. Epidemiology 500,000 submersion events annually 2nd cause of death – children under 15 Injury ranges   Transient Profound neurological deficit
  7. 7. Three Peaks Toddlers Adolescents Elderly
  8. 8. Toddlers Toilets Bathtubs Buckets
  9. 9. Coastal Areas Swimming pools more likely
  10. 10. Adolescents Stupidity
  11. 11. Young Adults Alcohol   40% adult drownings 75% boat drownings
  12. 12. Elderly
  13. 13. Complicating Factors Spinal cord injury Hypothermia Panicking Syncope Seizures
  14. 14. Pathophysiology Central Nervous System Injury Pulmonary Injury
  15. 15. Dry-drowning 10-20% of submersions Laryngospasm Hypoxia Loss of consciousness
  16. 16. Wet-drowning Aspiration of water Dilution of surfactant Diminished gas transfer Atelectasis Ventilation perfusion mismatch
  17. 17. Pulmonary Injury Contaminated foreign material Particulate matter Bacteria Vomitus Chemical irritants
  18. 18. Prognosis Submersion time Physiological scoring systems
  19. 19. Two extremes Fair cardiovascular and neurological function  Minimal disability Unstable cardiovascular function and coma   Poorly Hypoxic CNS injury
  20. 20. End Organ Damage Renal injury    Hypoxia Myoglobinuria Hemoglobinuria Hematologic   Hemolysis DIC
  21. 21. Treatment
  22. 22. Prehospital Care Resuscitation  Time optimizes outcome Removal from water  C-spine protection CPR ASAP
  23. 23. Airway Breathing  High flow oxygen by facemask Not Breathing   Bag valve mask Endotracheal tube Unconscious Protect from aspiration
  24. 24. Who to transport? Amnesia Loss or depressed consciousness Period of apnea Period of artificial respirations Even if asymptomatic
  25. 25. Don’t Forget Warm patient  Hypothermia Monitor IV access  Warm isotonic fluids
  26. 26. Summary Rapid, cautious rescue Spine precautions Cardiopulmonary resuscitation Supplemental Oxygen Transport
  27. 27. ED Treatment Continue EMS care       Airway Oxygen Ventilation Warmed fluids Warming adjunts Treat associated injuries
  28. 28. GCS > 12 Oxygen to keep sat > 95% Observe 4-6 hours Pulmonary exam normal Saturation normal Discharge home No xray or labs needed
  29. 29. GCS > 12 Oxygen to keep sat > 95% Observe 4-6 hours Pulmonary exam abnormal Requires oxygen Deteriorates Admit to Monitored bed
  30. 30. GCS < 13 High flow oxygen Intubation for low PaO2 CXR, Labs Continuous cardiac monitoring Frequent reassessments
  31. 31. Seizure Dilutional hyponatremia Control seizures Correct electrolytes Residual disorder uncommon
  32. 32. ED Arrest Warm water drowning Recovery doubtful Consider early discontinuation of efforts Risk profound neurological handicaps
  33. 33. Hospital Management Supportive Avoid ARDS Pneumonia rare Dopamine, epinephrine drips 48 hour window
  34. 34. No benefit Mannitol Loop diuretics Hypertonic saline Fluid restriction Hyperventilation Controlled hypothermia Barbiturate coma
  35. 35. Prognosis No CPR   Full recovery within 48 hours May develop ARDS Bystander CPR   Steady recovery Steady decline ED CPR  Very poor prognosis
  36. 36. Pediatric Warm Water Drowning 500 victims 100% received ED CPR 84% died 16% severe hypoxic encephalopathy
  37. 37. Diving Reflex Mammals Bradycardia Peripheral Vasoconstriction Greatest in cold water Preserves oxygen
  38. 38. ICE water submersion Asystole Children and Adults Complete Recovery Rare Resuscitate until normothermic
  39. 39. Prevention Infants  Parental vigilance Toddler  Pool fencing Adolescent/Young Adult   Control Alcohol/Drug Use Swimming lessons Elderly  Same as infant/toddler
  • arjunharidas007

    Dec. 20, 2018

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