Advocacy Project: Drowning Prevention

Lindsay M. Stewart, MD
July 26, 2012

University of Nevada School of Medicine

Disclosures
No current research No financial investments

Objectives
1. MEDICAL KNOWLEDGE 2. PATIENT CARE 3. INTERPERSONAL & COMMUNICATION
SKILLS 4. PRACTICE-BASED LEARNING & IMPROVEMENT 5. SYSTEMS-BASED PRACTICE 6. PROFESSIONALISM

In the Community

July 11, 2012

1. MEDICAL KNOWLEDGE
Learn what constitutes a drowning Understand the pathophysiology Review findings at autopsy

Drowning
the process of
experiencing respiratory impairment from submersion/immersion in liquid Can be any kind of fluid

Peden M, McGee K, Sharma K. The injury chart book: a graphical overview of the global health burden of injuries. Geneva: World Health Organization, 2002.

Terminology
1. Nonfatal drowning- if the person is rescued at 2.
3.
any time; the process of drowning is interrupted Fatal drowning- if the person dies at any time as a result of drowning Water rescue- any submersion or immersion without evidence of respiratory impairment

Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

Phases of Drowning
1. 2. 3. 4. 5. 6.
Submersion Struggle Exhaustion Drowning Loss of consciousness Death

Pathophysiology
Fresh water
(0.6% NaCl) - water passes from lungs to blood- hemodilution; denaturation of surfactant -> alveolar collapse -> decr lung compliance -> severe V-Q mismatch -> hypoxia -> neuro damage
Electrolyte shifts -> Cardiac arrhythmias

Blood Lung Tissue

Blood Lung Tissue

Pathophysiology
Sea water
blood into lung tissue- hemoconcentration
Na incr -> severe pulm edema (3% NaCl) - water passes from

Blood

Lung Tissue

Histology
Pulmonary edema Plant material in bronchus

Findings on Autopsy
Fine white froth in the mouth,

nose, lungs and air passages Water-logged lungs Venous congestion and fluid blood Water in the stomach and intestines

Findings on Autopsy
Middle ear hemorrhages

2. PATIENT CARE
Identify patients at risk Perform accurate H&P Develop appropriate treatment plan

More at Risk?

OR

Males: ~80%

Females: ~20%

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2011 Apr 6]. Available from URL: http://www.cdc.gov/injury/wisqars

More at Risk?
1-4 yo OR 5-8 yo

Children ages 1 to 4
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2011 Apr 6]. Available from: URL: http://www.cdc.gov/injury/wisqars

More at Risk?

OR

OR

Minorities: AA 1.3x W; NA & Alaskan 1.7x W

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2011 Apr 6]. Available from: URL: http://www.cdc.gov/injury/wisqars

More at Risk?

OR

Others at Risk
Low income, neglected Poor education

Aquatic exposure

Alcohol use, risky behavior

Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

Also at Risk
Epilepsy pts
Risk of drowning is 15-19 times higher than those without epilepsy!!!

Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

Also at Risk

Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

H&P for Well Child Check

What questions should
you ask? When should you ask them? What should you look for on physical exam?

Initial Resuscitation
CPR
Resp? -> rescue breathing only Cardiac? -> ABC 5 rescue breaths 30 compressions 2 rescue breaths 30 compressions

Aspiration risk

Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

Pre-Hospital Care
BLS until PALS available O2 by face mask at 15L Early intubation & mech ventilation Peripheral IV or IO Correct hypotension with crystalloids If CPR does not result in cardiac activity,
epi or norepi may be considered
Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

ED
Secure airway Insert NG tube Thermal insulation Find out if precipitated
by injury or medical condition Phys exam, CXR, ABG

Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

PICU
Follow guidelines for ARDS Keep on vent at least 24 hrs even if gas
exchange appears to be adequate Little evidence supporting glucocorticoid use Pneumonia often misdiagnosed No evidence supporting use of specific fluid therapy, diuretics or water restrictions Induced hypothermia (32-34C) for 24 hrs may be neuroprotective

Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

Complications
SIRS Sepsis & DIC possible in first 72 hrs after
resuscitation Renal insufficiency or failure (rare)

Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10.

3. INTERPERSONAL & COMMUNICATION SKILLS

Apply skills to different cultural
backgrounds, SES, developmental levels Develop rapport Use a team approach

Counseling
Dont lecture Dont talk down to or belittle Do ask questions Do offer suggestions Do assess for understanding

How do you develop rapport?

Drowning Prevention

Formal swimming lessons Designated supervision Buddy system Seizure disorder safety Learn CPR Use personal flotation devices

Barriers such as fences Lock up pool toys No holding breath contests Obey beach warnings Watch for signs of rip currents Avoid alcohol

4. PRACTICE-BASED LEARNING & IMPROVEMENT

Acknowledge barriers Analyze your skills & practice them Evaluate the effectiveness of your

encounter Identify ways to improve compliance

Possible Barriers?

Evaluate Your Encounter

Did you have good rapport? What did you do well? What can you improve on?

Ways to Improve Compliance

Handouts Videos Make it relevant Repetition Follow up on it

5. SYSTEMS-BASED PRACTICE
Review incidence rates Understand cultural norms & health

beliefs Invest in the health literacy & awareness in your community

Incidence
In 2007 there were ~4,000 fatal unintentional
drownings in the U.S.
~3,500 non-boating related ~500 boating-related incidents

> 1 in 5 people who die from drowning are

children 14 and younger 2nd leading cause of unintentional injury-related death for children ages 1 to 14 years

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2012 July 23]. Available from URL: http://www.cdc.gov/injury/wisqars

Statistics
19% of drowning deaths in children occur in
public pools with certified lifeguards present Of all preschoolers who drown, 70% are in the care of one or both parents at the time of the drowning and 75% are missing from sight for 5 min or less 92% of children who survive are discovered within 2 min following submersion, and 86% of children who die are found after 10 min

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2012 July 23]. Available from URL: http://www.cdc.gov/injury/wisqars

Statistics
Among children 1-4 yo, most drownings
occur in residential swimming pools, and 11% occur in portable pools

>50% of drownings among infants occur

in bathtubs, buckets or toilets
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2012 July 23]. Available from URL: http://www.cdc.gov/injury/wisqars

Southern NV Health District

Southern Nevada Health District [online]. Drowning and Near Drowning Statistics. [cited 2012 July 20]. Available from URL: http://www.southernnevadahealthdistrict.org/stats-reports/drowning-statistics.php

Myths About Swimming

1. You shouldnt swim right after eating. 2. Clear pool water means clean pool water. 3. I only need to take a shower before swimming

4.
5.

if I havent bathed that day. As long as a child is wearing a diaper in the pool, theres no chance for contamination of the water. When I smell the strong odor of pool chemicals, it means the water is very clean.
Water Quality and Health Council [online]. [cited 2012 July 20]. Available from URL: http://www.healthypools.org/resources/swimming-pools-myths-facts/

Support In Our Community

Swim Lessons:
Clark County Parks & Recreation- Free Swim Squad- 1st Assessment $20 YMCA- 4 lessons $50 Bubble Swim School- $15, one day/wk x5 Private lessons- $22.50 Group swim- $15

Support In Our Community

CPR Lessons:
UMC- Free ($10 deposit required & refunded) UNLV & Amer Red Cross- Free

Safe Sitter Courses (ages 11-13):

UMC- Free, monthly

Support In Our Community

Life Jackets:
Walmart: $6.96 $13.96 $16.00

Recommend checking local Goodwill etc. Amazon: ~$5 -Ebay: ~$12

6. PROFESSIONALISM
Demonstrate cultural competency Emphasize medical ethics Reflect on professional impact

Professional Impact

References
1. 2.
Peden M, McGee K, Sharma K. The injury chart book: a graphical overview of the global health burden of injuries. Geneva: World Health Organization, 2002. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. [cited 2012 July 23]. Available from: http://www.cdc.gov/injury/wisqars Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med 2012;366:2102-10. Southern Nevada Health District [online]. Drowning and Near Drowning Statistics. [cited 2012 July 20]. Available from URL: http://www.southernnevadahealthdistrict.org/statsreports/drowning-statistics.php Water Quality and Health Council [online]. [cited 2012 July 20]. Available from URL: http://www.healthypools.org/resources/ swimming-pools-myths-facts/

3.
4. 5.