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Presented by:Presented by:
Katherine June MercadoKatherine June Mercado
AnjelieAnjelie Dawn MendozaDawn Mendoza
TSUNAMI & TSUNAMI &
DROWNINGDROWNING
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DEFINITIONSDEFINITIONS
Drowning:Drowning:AsphyxiaAsphyxiaand death due toand death due tosubmersion in liquidsubmersion in liquid(usually water)(usually water)
Near Drowning:Near Drowning: isissurvival for more thansurvival for more than24 hours from24 hours fromsuffocation bysuffocation bysubmersion.submersion.
Tsunami:Tsunami: TsunamisTsunamisare ocean wavesare ocean wavesproduced byproduced byearthquakes orearthquakes orunderwater landslidesunderwater landslides.
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SOME INTERESTING STATISTICSSOME INTERESTING STATISTICS
99%99% of allof all drowningsdrownings occur inoccur inunsupervised waterunsupervised water ((free flowing)free flowing)
almostalmost halfhalfof allof all drowningsdrownings occuroccur iinnthe company of othersthe company of others (mostly adults)(mostly adults)
almostalmost halfhalfof allof all drowningsdrownings occuroccur lessless
than two metres from safetythan two metres from safety highesthighest risk category arerisk category are males 18males 18--3434
years oldyears old
nearlynearly 40%40%of allof all drowningsdrownings involveinvolvealcoholalcohol
overover halfhalfof victims who drowned whileof victims who drowned whileboating wereboating were not wearing lifejacketsnot wearing lifejackets
most children drown in homemost children drown in homeswimming pools, majority of them beingswimming pools, majority of them beingtoddlerstoddlers
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EPIDEMIOLOGY
Tsunamis:Tsunamis: earthquakeearthquake--inducedinduced
movement of the oceanmovement of the ocean
floor.floor.
LandslidesLandslides
volcanic eruptions, andvolcanic eruptions, and
meteoritesmeteorites
DrowningDrowning Males > FemalesMales > Females
In infants younger than 1 yearIn infants younger than 1 year
Bathtubs and buckets ofBathtubs and buckets ofwaterwater
Child abuseChild abuse
In children aged 1In children aged 1--5 years:5 years: Residential swimming poolsResidential swimming pools
In young adults aged 15In young adults aged 15--1919yearsyears
Submersion injuries usuallySubmersion injuries usuallyin ponds, lakes, rivers,in ponds, lakes, rivers,oceans, and other naturaloceans, and other naturalbodies of water.bodies of water.
Alcohol useAlcohol use
Water sportsWater sports
Cold waterCold water
Peak ages:Peak ages: 11-- 2 years old2 years old
1515--19 years old19 years old
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RISK FACTORSRISK FACTORS Intoxication with drugs/alcohol Venomous stings from aquatic
animals
Head/spinal injuries (Diving
accidents)
Hyperventilation syndrome (BreathHolding) which suppresses the
physiologic response to increased
CO2
Pre-existing medical conditions:
Seizures/DM/ Syncopal episodes
Seizures and cardiac arrhythmiasSeizures and cardiac arrhythmias
Syncope and apneaSyncope and apnea
HypoglycemiaHypoglycemia
MI/ Pre-existing cardiac disease
Hypothermia
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TypesTypes OOff DDrowningrowning Dry:Dry: 15% of cases
Small amount of H20 aspiratedSmall amount of H20 aspirated
It contacts the larynx which has a naturalIt contacts the larynx which has a naturaldefensedefense mechanism, called amechanism, called alaryngospasmlaryngospasm. The larynx expand to block. The larynx expand to blockthe airway, thus often preventing waterthe airway, thus often preventing water
from entering the lungs in.from entering the lungs in.
Wet:Wet:
85% of cases85% of cases
Fluid and electrolyteFluid and electrolyteimbalances occurimbalances occur
TheThe laryngospasmlaryngospasm relaxes asrelaxes as
the person loses consciousness,the person loses consciousness,
and water enters the lungsand water enters the lungs
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WET LUNGFresh Water TypeFresh Water Type
Water moves from alveoliWater moves from alveolito bloodstreamto bloodstream
HemodilutionHemodilution occursoccurs
O2O2 carrying capacitycarrying capacity
decreasesdecreases Water moves into redWater moves into red
cellscells
Red cells swell, ruptureRed cells swell, rupture Increase PotassiumIncrease Potassium
resulting to arrhythmiasresulting to arrhythmias Release ofRelease of hemoglobinhemoglobin intointo
bloodstream result to renalbloodstream result to renalfailurefailure
Loss of surfactant resultLoss of surfactant result
to collapse of alveolito collapse of alveoli
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Salt Water Type:Salt Water Type:
Water moves fromWater moves from
bloodstream to alveolibloodstream to alveoli
HemoconcentrationHemoconcentrationoccurs resulting tooccurs resulting to
shockshock
PulmonaryPulmonary edemaedema
occursoccurs
WET LUNG (CONT..)WET LUNG (CONT..)
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The difference in
pathophysiology of aspiration
of fresh water (hypotonic)
and salt water (hypertonic)
have little clinical
significance.
Fresh water drowning -
hemodilution & intravascular
hemolysis.
Sea water drowning
hemoconcentration and
hypovolemia
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Classifications of DrowningClassifications of Drowning
Active Drowning:Active Drowning: TheThevictim is vertical invictim is vertical inthe water, notthe water, notkicking, stillkicking, still
breathing and usuallybreathing and usuallymoving the arms inmoving the arms inthe effort to bob out ofthe effort to bob out ofthe water. The victimthe water. The victimcant call for help.cant call for help.
Passive Drowning:Passive Drowning: TheThevictim is facevictim is face--down indown inthe water.the water.
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NEAR DROWNING
Do not attemptDo not attemptswimming rescueswimming rescuewithout proper trainingwithout proper training
ThrowThrow -- TowTow RowRow --
GoGo Consider possible neckConsider possible neck
injury:injury: Diving accidentDiving accident
Swimming poolsSwimming pools
Inadequate historyInadequate history
Place patient onPlace patient onspineboardspineboard in waterin water
If possible, beginIf possible, beginpulmonary resuscitationpulmonary resuscitationin waterin water
Resuscitate all coldResuscitate all cold
water drowning (
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Summary of the drowning process:Summary of the drowning process:
1.1. Panic and violent struggle toPanic and violent struggle toreturn to surfacereturn to surface
2.2. Period of CalmnessPeriod of Calmness
3.3. Swallowing of fluid, followed bySwallowing of fluid, followed byvomitingvomiting
4.4. Terminal GaspTerminal Gasp
5.5. UnconsciousnessUnconsciousness
6.6. Possible SeizuresPossible Seizures
7.7. DeathDeath
*The time that this takes is variable, but it could be as*The time that this takes is variable, but it could be as
little aslittle as 12 to 20 seconds12 to 20 seconds from the firstfrom the first panic topanic to
unconsciousness.unconsciousness.
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AAssessment of the Patientssessment of the PatientHistoryHistory
Mechanism and duration ofMechanism and duration ofsubmersionsubmersion
Type and temperature ofType and temperature ofwaterwater
Time to institution of CPRTime to institution of CPR
Time to first spontaneousTime to first spontaneousbreathbreath
Time to return ofTime to return ofspontaneous cardiac outputspontaneous cardiac output
VomitingVomiting
Likelihood of associatedLikelihood of associatedtrauma, other precipitantstrauma, other precipitants(arrhythmia, MI, seizure,(arrhythmia, MI, seizure,
etc).etc).
Signs andSigns and
Symptoms:Symptoms:
Pulmonary edemaPulmonary edema
RespiratoryRespiratoryfailurefailure
ShockShock
AnoxicAnoxic
encelopathyencelopathy
Brain edemaBrain edema Cardiac arrestCardiac arrest
RespiratoryRespiratory
ManifestationsManifestations
CyanosisCyanosis
TrismusTrismus
ApneaApnea TachypneaTachypnea
WheezingWheezing
CardiovascularCardiovascular
ManifestationsManifestations TachycardiaTachycardia
ArrhythmiaArrhythmia
HypotensionHypotension
ShockShock
Cardiac ArrestCardiac Arrest HypotensionHypotension
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Pulmonary/airway:Pulmonary/airway:
Ineffective breathingIneffective breathing
DyspneaDyspnea Respiratory distressRespiratory distress
Crackles,Crackles, ronchironchi
Cough with pinkCough with pink--frothyfrothy
sputumsputum
Foreign body obstructionForeign body obstruction
Other:Other:
PanicPanic
ExhaustionExhaustion ComaComa
InjuriesInjuries
Core temperature slightlyCore temperature slightlybelow or higher thanbelow or higher thannormalnormal
VomitingVomiting
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MANAGEMENT ON SITEMANAGEMENT ON SITE
Get the victim out of theGet the victim out of thewater. CPR may bewater. CPR may bestarted while the victimstarted while the victimis still in the water.is still in the water.
If the victim is breathing,If the victim is breathing,place him on his side. Heplace him on his side. Heshould be able to ejectshould be able to ejectwater himself but mustwater himself but must
be carefully watched.be carefully watched. If not breathing, beginIf not breathing, begin
CPR and shout for help.CPR and shout for help.
Paramedics with ALSParamedics with ALSshouldshould intubateintubate thethe
victim with no heart orvictim with no heart orrespiration rate.respiration rate.
Establish IV line with Ringers
lactate (warmed if available ).
Keep open rate.
Follow the ACLS protocol
regarding drug therapy.
Drowning with severe
hypothermia, if heart rate is so
slow do not intubate since the
victim might develop asystole.
Start rewarming the patient.
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PrehospitalPrehospital ManagementManagement
Assess ABCsAssess ABCs
Clean airway of obstructionClean airway of obstruction
Control airway w/ chin lift orControl airway w/ chin lift orjaw thrust. Protect C spine ifjaw thrust. Protect C spine if
trauma is suspected.trauma is suspected. Begin mouth to mouth orBegin mouth to mouth or
mask ventilation if nomask ventilation if nobreathing present.breathing present.
Begin CPR if no heart rate isBegin CPR if no heart rate is
palpablepalpable Remove wet clothing andRemove wet clothing and
wrap in blanket.wrap in blanket.
For hypothermia, wrap in dryFor hypothermia, wrap in drywarm blanketwarm blanket
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Paramedics with Advance Life SupportParamedics with Advance Life Support
Unit Should:Unit Should:
IntubateIntubate the child if there is no HR orthe child if there is no HR orRRRR
Establish an IV line with warm RingersEstablish an IV line with warm Ringers
lactate. Anlactate. An intraosseousintraosseous infusion may beinfusion may be
used for children.used for children.
Further treatment at site includes:Further treatment at site includes:
Clean the victims mouth with the use ofClean the victims mouth with the use of
finger sweepfinger sweep
Place the victims in the head downPlace the victims in the head downposition to allow fluid drainage from theposition to allow fluid drainage from the
mouth.mouth.
Give oxygen in high concentration byGive oxygen in high concentration by
continuous positive air pressure.continuous positive air pressure.
Perform HeimlichPerform Heimlich manuevermanuever if needed.if needed.
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After initial stabilization,After initial stabilization,
victims who survive canvictims who survive can
be separated into threebe separated into three
groups:groups:
Awake victims who areAwake victims who areneuroligicallyneuroligically responsiveresponsive
and who have signs andand who have signs andsymptoms of respiratorysymptoms of respiratorycompromise.compromise.
Those with spontaneousThose with spontaneous
respirations Glasgowrespirations GlasgowComa scale of over 5.Coma scale of over 5.
Those with GlasgowThose with GlasgowComa scale under 4.Coma scale under 4.
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DROWNED/DEAD VICTIMSDROWNED/DEAD VICTIMS
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Labs andLabs and DDiagnosticsiagnostics
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No difference inelectrolytes and
hematocrit
Average drowningvictim aspirates 3-4ml/kg
No electrolyte orblood volume changes
seen until 22 ml/kgand 11ml/kgrespectively
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Blood gas analysis with coBlood gas analysis with co--
oximetryoximetry to detectto detect
methemoglobinemiamethemoglobinemia andandcarboxyhemoglobinemiacarboxyhemoglobinemia
ToxicologyToxicology to determine alcoholto determine alcohol
or illicit drug useor illicit drug use
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Chest xChest x--rayray to look for fluidto look for fluidin the lungsin the lungs
Neck xNeck x--rayray to look forto look for
fracturesfracturesHead CTHead CT to look forto look for
structural damage to thestructural damage to the
brainbrainECGECG to look for irregularto look for irregular
heart activityheart activity
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PATHOPHYSIOLOGY
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D
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NURSING DIAGNOSES
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Impaired Gas ExchangeImpaired Gas Exchange related factors: surfactantrelated factors: surfactantelimination,elimination, Bronchospasm,Aspiration,pulmonaryBronchospasm,Aspiration,pulmonary edemaedema..
Altered Cerebral PerfusionAltered Cerebral Perfusion related factors: prolongedrelated factors: prolonged
hypoxemia,impairedhypoxemia,impaired gas exchange.gas exchange.
Fluid Volume Excess/DeficitFluid Volume Excess/Deficit Risk for Decreased Cardiac OutputRisk for Decreased Cardiac Output
Risk for infectionRisk for infection
Ineffective breathing patternIneffective breathing pattern related to anxietyrelated to anxiety
AnxietyAnxiety related to hypoxemia, threat to deathrelated to hypoxemia, threat to death
Risk for decreased cardiac outputRisk for decreased cardiac output
Risk for injuryRisk for injury
HypothermiaHypothermia
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LIFE SAVING INTERVENTIONS
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Key Points of Management:Key Points of Management:
DrowningDrowning
Remove from water (effective CPRRemove from water (effective CPR
in water is not possible)in water is not possible)
Start CPRStart CPRHeimlich only for obstructionHeimlich only for obstruction
Move to medical facilityMove to medical facility
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Interventions:Manage and maintain ABCs
Assume cervical spine injury in all drowningvictims and stabilize and/or immobilize cervicalspine
Provide 100% 02 via nonrebreather mask
Anticipate need for intubation if gag reflex is absentEstablish IV access with 2 large bore catheters for
fluid resuscitation and infuse warmed fluids ifappropriate
Assess for other injuries
Remove wet clothing and cover with warm blankets
Obtain temperature and begin rewarming if needed
Obtain cervical spine and chest x-rays
Insert gastric tube.
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KKey points ofey points of MManagementanagement::
TTsunamisunami First aidFirst aid
Prevent hypothermiaPrevent hypothermia
Transfer to safer place in higher groundTransfer to safer place in higher ground
DecontaminationDecontamination
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MEDS
Mannitol (Osmitol) or Furosemide (Lasix)
may be given to decrease free water and
treat cerebral edema.
Antibiotic prophylaxis is not indicated
unless the patient was submerged in
grossly contaminated water or sewage.
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LIFE MAINTAININGLIFE MAINTAINING
INTERVENTIONSINTERVENTIONS
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DROWING
Monitor ABCs, V/S, and LOCMonitor ABCs, V/S, and LOCMonitor OMonitor O22 saturation and cardiac rhythmsaturation and cardiac rhythm
Monitor temperature and maintainMonitor temperature and maintain normothermianormothermia
Monitor for signs of acute respiratory failureMonitor for signs of acute respiratory failure
EndotrachealEndotracheal intubation with mechanicalintubation with mechanicalventilation for respiratory failure, persistentventilation for respiratory failure, persistenthypotension, or impaired airway protective reflexes.hypotension, or impaired airway protective reflexes.
NasogastricNasogastric tube placement for removal oftube placement for removal of
swallowed water and debris (Useswallowed water and debris (Use orogastricorogastric route ifroute ifhead or facial trauma is suggested.)head or facial trauma is suggested.)
Urinary catheter placement for assessment of urineUrinary catheter placement for assessment of urineoutputoutput
(continued)(continued)
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(cont)
Extracorporeal membrane oxygenation (ECMO)Extracorporeal membrane oxygenation (ECMO) --May be considered in the following circumstances:May be considered in the following circumstances:Respiratory compromise resulting from lack of response toRespiratory compromise resulting from lack of response to
conventional mechanical ventilation or highconventional mechanical ventilation or high--frequencyfrequency
ventilationventilationA reasonable probability of the patient recoveringA reasonable probability of the patient recovering
neurologic functionneurologic function
Persistent hypothermia from coldPersistent hypothermia from cold--water drowningwater drowning
BronchoscopyBronchoscopy if needed for removal of foreignif needed for removal of foreign
bodies, such as aspirated debris orbodies, such as aspirated debris or vomitusvomitus Intracranial pressure monitoring in patients withIntracranial pressure monitoring in patients with
traumatic brain injury or mass lesions (traumatic brain injury or mass lesions (egeg,,hematomas)hematomas)
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TSUNAMIS
Help provide save waterHelp provide save water
for drinkingfor drinking
Provide food and shelter
Disease control
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PSYCHOSOCIAL ANDPSYCHOSOCIAL AND
BEHAVIORAL INTERVENTIONSBEHAVIORAL INTERVENTIONS
AND SUPPORTIVE MANAGEMENTAND SUPPORTIVE MANAGEMENT
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DROWNING TSUNAMI
Provide informationProvide information Educating:Educating:
Fence all pools and spasFence all pools and spas
Know the weatherKnow the weather
conditions and locationconditions and locationof underwater hazardsof underwater hazards
before entering thebefore entering the
water.water.
Learn and observe waterLearn and observe water
and boating safety rules.and boating safety rules.
Always wear life jacketsAlways wear life jackets
especially on open water.especially on open water.
Never allow yourself orNever allow yourself or
children to swim alone orchildren to swim alone or
unsupervised.unsupervised.
Active listeningActive listening Provide emotional supportProvide emotional support
Give informationGive information
Discourage victims fromDiscourage victims from
repeated exposure to therepeated exposure to theeventevent
Refer patients toRefer patients totherapists or socialtherapists or socialworkers and mentalworkers and mental
health care serviceshealth care services
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PREVENTION OF COMPLICATIONSPREVENTION OF COMPLICATIONS
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DROWNINGDROWNING
TSUNAMITSUNAMI
ARDSARDS Aspiration pneumoniaAspiration pneumonia
Pulmonary edemaPulmonary edema
HypothermiaHypothermia
Interventions:Interventions: Monitoring of VS, LOC,Monitoring of VS, LOC,
ABCs, O2 saturation,ABCs, O2 saturation,
AuscultateAuscultate for adventitiousfor adventitioussounds in lungs or trachea.sounds in lungs or trachea.
Observe for signs ofObserve for signs ofcyanosis, inadequate chestcyanosis, inadequate chestexpansionexpansion
PositioningPositioning
OxygenationOxygenation
Provide warmed blanketsProvide warmed blankets
Water borneWater borne
transmissions andtransmissions andinfectionsinfections-- waterwater
purification, wastepurification, waste
removal, removal ofremoval, removal of
human and animalhuman and animalremains, and vectorremains, and vector
controlcontrol
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SOURCES:SOURCES: http://www.worldortho.com/dev/index.php?option=com_content&http://www.worldortho.com/dev/index.php?option=com_content&
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