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EMERGENCIES
(2)
Drowning Strangulation Altitude related illness
Diving related disorders
SUBMERSION
INJURIES
Drowning & Imminent
drowning
PATHOLOGY OF SUBMERSION
For submersion injuries which cause death in less than 24 hours we use
the term drowning
Imminent drowning is defined as survival more than 24 hours after
suffocation by submersion
Risk populations: small children, teenagers and elders
PATHOLOGY OF SUBMERSION
Inability to keep the head above the water (cannot swim)
Circumstances
Inability to react to stimuli medical causes: seizures, stroke or head trauma
predisposing to
Muscle exhaustion (associated with hypothermia)
drowning
Hydrocution syncope
Plunging accident
Stomach fills
Laryngeal with Deglutition
spasm stops submersion reflexes Initial protection
liquid Parasympathetic activation
Bradycardia
Apnea
Peripheral vasoconstriction
Invasion of the
respiratory tract with
submersion liquid
PATHOLOGY OF SUBMERSION
Inactivation of surfactant
Micro-atelectasis
Fresh water Temporary haemodilution Septic complications
Important hemolysis hiperK VFib
PATHOLOGY OF SUBMERSION
Anoxia the major consequence of drowning Pulmonary injuries &
CNS damage
Cerebral hypoxia cerebral edema & vascular endothelial injuries
Coagulation disorders
Trombocytopenia, DIC, due to hypoxia, hemolysis, septic complications
Final outcome
PATHOLOGY OF SUBMERSION- DIAGNOSIS
Group I Stress induced by water Predictors of favorable outcome
Victim did not inhale water Age > 3 years, female
Group II Mild hypoxia Water T < 10C
Water entered the airways, but the victim was quickly Duration of submersion short (minutes)
removed Absence of inhalation
Respiratory discomfort, cough, tachypnea, rapid pulse, Resuscitation within the first 10 minutes
few bronchial rales Mild hypothermia (35-33C)
Preserved consciousness Rapid recovery of the spontaneous
Group III Severe hypoxia obnubilation/coma cardiac activity
Respiratory distress, tachypnea, dyspnoea, cianosis Arterial pH > 7.10
Diffuse bronchial rales GCS > 6, conscious patient
Pupillary reflex - present
Group IV anoxia circulatory arrest of anoxic origin
PATHOLOGY OF SUBMERSION - TREATMENT
AT THE PLACE OF THE ACCIDENT IN THE HOSPITAL
Drying & covering with an isothermal Group I Heated victim
blanket glucose & hospitalized follow-up 24h
Evacuation of swallowed water Group II Gastric drainage
through a nasogastric tube O2/mask
Admission for 48h & follow-up (clinical situation
Heimlich maneuver only for foreign may worsen)
respiratory bodies
Group III O2/mask
Endotracheal intubation + assisted ventilation
INDICATIONS FOR ENDOTRACHEAL
INTUBATION Group IV Cardio-respiratory resuscitation
1. Disorders of consciousness (GCS <8) / External defibrillation is possible without risks
important agitation
2. Hypoxemia (SaO2<90%) which does not
correct with oxygen administration
3. Hypothermia < 38C
4. Exhaustion
PATHOLOGY OF SUBMERSION - TREATMENT
Respiratory syndrome
constant, of different intensities: tachypnea/bradypnea, apnea
dyspnea, due to laryngeal edema
acute pulmonary edema, very severe
Treatment
Simple analgesics (aspirin, paracetamol, ibuprofen)
Acetazolamide is very useful when administered early
Dexametazone 4-8mg/6h
Bringing the patient to lower altitudes
High altitude syndromes
Pulmonary edema Main cause of death
Healthy young, at an altitude of 2000-7000m
Fast access to altitude, without acclimation
Non-cardiogenic pulmonary edema = pulmonary hypertension + injury of the alveolar-capillary
membrane hydric retention
Clinical diagnosis
Effort dyspnea rest dyspnea irritating cough + chest pains & intense asthenia
Typically during night, cough & pink mucous expectoration/ hemoptisis
Permanent & early cyanosis
Crackles in the lungs
Treatment
Bringing the patient to lower altitudes 500-1000m remission of pulmonary edema
Necessary time for PE remission only with O2, without lowering altitude = 36-7h
Nifedipine 10mg sublingual/ 15 minutes PHT & O2Sa
Rarely necessary ETI+MV (PEEP)
High altitude syndromes
Cerebral edema Progressive neurological deterioration during the acclimation period at 3500-5000m
Frequently associated with high altitude pulmonary edema
Diagnosis
Rapidly installed
Altered mental status, ataxia, stupor coma
Headache, nausea, vomiting inconstant
Focal neurological signs (distorsion of brain structure & compresion)
Fundus examination: papillary edema retinal hemorrhages
Treatment
Immediate lowering of altitude
O2 therapy
Hyperosmolar solutions (manitol 0.25-0.5g.kgc in bolus / saline less sensitive to cold)
Dexametazone 8mg/6h
High altitude syndromes
Ischemic stroke, Secondary to changes in hemostasis, alteration of vascular endothelium, circulatory stasis
thromboembolic Lower extremities DVT, pulmonary embolism of high altitude
events and TIA which regresses after O2
bleeding aspirin 300mg/day + hydration & O2 therapy
Retinopathy of 9% of climbers (alpinists)
high altitude Retinal edema, papillary hyperemia, retinal hemorrhages
Injuries spontaneously cure within 10-14 days, only by adequate oxygenation
Peripheral edema Swelling of the face & lower extremities, spontaneous improvement or after descent
Pharyngitis & cough due to alterations of mucoasa (dry, fissures due to dehydration & ventilation )
bronchitis antibiotics do not help (injuries are not provoked by infectious agents)
Solar dermatitis Severe pain, photophobia, foreign body sensation in the eye, tearing, important conjunctive edema,
chemosis and palpebral edema
Spontaneously cures after 24 hours
Chronic Those who live at high altitudes
polycythemia of Important polycythemia (Hb 20-22 g/dl), headache, sleep disorders, alteration of peripheral
high altitude circulation, sleepiness
(Monge disease) Movement at a lower altitude, phlebotomy
Respiratory stimulants (acetazolamide 250mg x 2/day p.o. sau medroxiprogesterone acetate 20-60
g /day)
DIVING RELATED
DISORDERS
DIVING RELATED DISORDERS
Barotrauma
Due to pressure variations influencing volume of free gas in the body, especially that within less compliant cavities.
Decending dive Ascending dive
Middle ear barotitis media or the cry of Middle ear the air expands, Eustachio tube opens pressure
the ear equalization, otherwise strong dizziness, but temporary
Pain, hemorrhage of tympanic
membrane it breaks Teeth cavities/improper treatments, the air inside the tooth -
Strong vertigo, syncope risk of pain/fracture
drowning Gastrointestinal abdominal colic (gas distension gastric rupture
Pulmonary barotrauma (pulmonary overinflation/lung explosion
Maxillary & frontal sinuses syndrome) pneumomediastinum; pneumothrorax
Previously damaged, NO pressure The air entering the pulmonary circulation gas embolism
equalization The brain the most vulnerable; cerebral artery gas embolism
pain & mucous edema, submucosal
hemorrhage & detachament of sinusoidal
lining from the bone mask epistaxis
DIVING RELATED DISORDERS
Biochemical accidents
Provoked by the gas from the inhaled content, when its partial pressure reaches toxic levels
Hypercapnia PaCO2 > 0.05bar in the arterial blood
Favored by physical exercise, cold, anxiety
Stop physical exertion, ample exhalation
Nitrogen narcosis: disorientation, behavioral disorders, decrease in response to stimuli, alteration of the
neuromusculary coordination and global hypoesthesia
Risk of drowning
From a depth of 30 m, usually at 70m
Decompression sickness
Type I pain, involve the joints, the extremities and the skin + possible lymphatic obstruction with lymphedema
Type II severe form with
Neurological manifestations (involvment of CNS and especially of spine)
vestibulary (dizziness)
cardio-vasculary (dyspnea)
Usually the symptoms of the decompression sickness appear at a few minutes or hours after returning to the surface,
but may appear within days after diving.
DIVING RELATED DISORDERS - DIAGNOSIS