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DROWNING (15-20 Pages) AHA ACEP ECC Textbook - Lippincott Williams and Wilkins edition Dr John M. Field M.D. <[email protected]> CHAPTER - DROWNING (15-20 pages) Authors: Dr. David Szpilman – Brazil Fire Department of Rio de Janeiro, Maritime Groupment, Head of Drowning Resuscitation Center in Barra da Tijuca; Hospital Municipal Miguel Couto – Head of Adult Intensive Care Unit; Founder and Ex- President of Brazilian Life Saving Society – SOBRASA; Member of Board of Director and Medical Committee of International Life-saving Federation, and Brazilian Resuscitation Council Associate. Dr. Anthony J Handley – United Kingdom Honorary Consultant Physician & Cardiologist, Colchester, UK; Chief Medical Adviser, Royal Life Saving Society UK; Honorary Medical Officer, Irish Water Safety; Honorary Medical Adviser, International Life Saving Federation of Europe; Chairman, BLS/AED Subcomittee Resuscitation Council (UK). Dr. Joost Bierens - Netherlands Department of anesthesiology, VU University Medical Center Amsterdam, the Netherlands; Professor in Emergency Medicine; Member of Medical Committee of International Life-saving Federation; Advisory Board Member Maatschappij tot Reding van Drenkelingen; (The Society to Rescue People from Drowning; founded in 1767); Medical Advisor The Royal Netherlands Sea Rescue Institution. Dr. Linda Quan - USA Attending physician-Emergency Services, Children’s Hospital Regional Medical Center, Seattle Washington, USA; Professor, Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA; Member of American Red Cross Advisory Council on First Aid and Safety. Dr. Rafael Vasconcellos - Brazil Fire Department of Rio de Janeiro, Medical Pre-Hospital Care, Teaching Department; Medical Rescue Team – Amil Resgate; Intervention Cardiologist. Corresponding Address: David Szpilman - Av. das Américas 3555, bloco 2, sala 302, Barra da Tijuca - Rio de Janeiro – RJ - Brazil 22793-004. Phone: 055 021 99983951 Fax: 24307168 [email protected] <www.szpilman.com> CHAPTER – DROWNING INTRODUCTION EPIDEMIOLOGY DROWNING DEFINITION AND TERMINOLOGY PATHOPHYSIOLOGY DROWNING CHAIN OF SURVIVAL – prevention to hospital Prevention Recognition & Alarming of incident Rescue and Basic Water Life Support (BWLS) On-land Basic Drowning Life Support (BDLS) Advanced Drowning Life Support (ADLS) on site Hospital OUTCOME AND SCORING SYSTEMS UNIFORM CLINICAL REPORTING OF DROWNING REFERENCES CHAPTER – DROWNING INTRODUCTION On a sunny weekend day, a family was invited to a barbecue at a friend´s swimming pool. Suddenly, the mother noticed her four year-old boy was missing. After about 7 minutes he was found at the bottom of the pool and brought up to the pool´s edge. He appeared dead and no one knew what else to do. This scenario is usual in many countries and transforms a happy time to a very dramatic moment and a future for every one involved of profound loss and grief, but also guilt for failure to protect, or even intense anger at those who did not provide adequate supervision or medical care. Drowning is an injury whose treatment may involve many layers of personnel from laypersons, lifeguards, and pre-hospital care providers as well as highly specialized hospital staff. Care of the drowning victim is unique in that bystanders or rescuers need specific skills that allow them to help the victim without becoming another victim. Furthermore, the rescuer’s role is critical since the opportunity for a good outcome rests almost entirely with care provided at the scene. If rescue and first aid from bystanders fail, delayed medical treatment can not compensate any more for the obtained hypoxic injuries, even when more advanced therapies are started. Interest in drowning rescue and resuscitation has existed for hundred of years and drove the development of the first resuscitation instruments, research, protocols, education and systems. At that time and now, drowning is one of the most frequent causes of injury deaths. For the current resuscitation community the main focus is on those with cardiac disease. This chapter will advocate that resuscitation of drowning victims should remain in the focus of the resuscitation community, at least for those who frequent privately or professionally aquatic environments. This is 80% of the earth surface. Although drowning tended to become a neglected, public health problem (1), it just recently has again started to receive the attention it deserves. At a medical and societal level, it must be recognized that every drowning related death or hospitalization signals the failure of prevention. EPIDEMIOLOGY • Drowning is responsible for more than 500,000 deaths around the world. • In the age group of 5 to 14 years, drowning is the leading cause of death worldwide among males and the fifth leading cause for females. • Worldwide, it is the leading killer of children 1-17 years in Asia. • Numbers of drowning rescues are unknown but vary widely depending on different geographic, cultural and economic resources available. Each year, drowning is responsible for more than 500,000 deaths around the world (2). These figures are an underestimation of the real figures. Especially in developing countries many drowning deaths are unreported (table 1(3)). Numbers of drowning vary widely depending on different geographic, cultural and economic resources. In some European countries many drowning deaths are intentional injuries, due to suicide, while in Australia, USA and Brazil the majority of drowning deaths are unintentional injuries. In USA, an estimated 40 to 45% of deaths happen during swimming (4). Mortality and, less frequently, hospitalization following drowning are the most commonly reported indicators of drowning injury. Age, gender, alcohol use, socioeconomic status (income, education, and ethnicity), exposure, risk behavior and lack of supervision are key risk factors for drowning. Considering all ages, males die 5 times more often from drowning than females. Young children, teenagers and older adults are the ages at highest risk of drowning. Worldwide drowning is the leading cause of death in the age group of 5 to 14 years among males and the fifth leading cause among females (5) and it is the leading killer of children 1-17 years in Asia. (6). In USA, drowning is the seventh leading cause of unintentional injury deaths for all ages and the second leading cause of all injury deaths in children aged 1-14 years (7). Many of these injuries occur in recreational water settings, including pools, spas/hot tubs, and natural water settings (e.g., lakes, rivers, or oceans). During 2001-2002, an estimated 4,174 persons on average were treated annually in U.S. Emergency Departments for nonfatal unintentional drowning injuries in recreational settings, and 3,372 persons died in 2001. Children aged less than 4 years of age accounted for nearly 50% of the ED visits, and children aged 5-14 years an additional 25%. An estimated 75% of nonfatal injuries occurred in pools, whereas 70% of the fatalities occurred in natural water settings. Approximately 53% of ED-treated patients required hospitalization or transfer to another hospital for more specialized care (8). In Brazil in 2003 with a population of 176 million inhabitants, 6,688 died (3.8/100,000 inhabitants) by drowning, the second leading cause of death for all causes among ages 1 to 14 years. The preponderance of drowning deaths (88%) was unintentional. Fatal drowning involved mostly 20-29 year-old individuals (22,1%), followed by 15-19 (16%), 30-39 (15%), 10-14 (11%), 40-49 (9%), 1-4 (8%) and 5-9 (7%). There was no sex distinction in death rates under 1 year of age, but males drowned 8.7 times more in those ages 20 to 29 (9). As one of the largest year around aquatic recreational areas in the world, Brazil provides a model for the development of a first responder system for drowning to compare with EMS systems in other countries. From 1984, a tremendous emphasis on lifesaving occurred when firefighters assumed the role of life guarding the beaches and in-land water spots around the country and many more professionals are available on duty. The development of a large cadre of these professionals on duty on beaches led to creation, in 1995, of the Brazilian Lifesaving Society supported by the International Lifesaving Federation (ILS) - the most important World Water Safety organization. A recently research on that matter analyzed the trends on drowning from 1979 to 2003 in Brazil (10). The effect of this initiative was a 30% reduction in drowning death rates from 1979 (5,42/100.000) to 2003 (3,78). Most of the decrease in death rates occurred from 1995 (4,91) to 2003 (3,78), suggesting that two interventions associated with maturation of the system - more lifeguards on duty and prevention campaigns - led to the dramatic decrease in drowning deaths (Graphic 1). On Rio de Janeiro beaches, drowning predisposing conditions are discernable in 13% of all drowning cases; the most common is use of alcohol (37%), then convulsions (18%), trauma (including boating accidents; 16.3%), cardiopulmonary diseases (14.1%), skin diving and SCUBA diving (3.7%), diving resulting in head or spinal cord injuries, and others (e.g., homicide, suicide, syncope, cramps, or immersion syndrome (11.6%) (11). This highlights that 87% of drownings occur with no reasons other than a negligent attitude of adults with themselves and with their children. In countries where beach culture is prevalent, the need for larger numbers of lifeguards on duty yearly around allows
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