PSDarchives.worlddrowningcongress

World Drowning Congress

7-11-02

Hi all,

The World Drowning Congress in Amsterdam was really wonderful. Experts from
all areas of rescue and prevention and hospital care and research attended
and gave their input. I took about ten pages of notes that I will do my best
to type up and post. I hope we can get some good discussions and further
information sharing from that. If there are any errors in information I
fully take the blame. I was writing as fast as I could, often in dark rooms,
and if anyone has ever seen my handwriting they would understand that errors
can occur. Here goes:

Notes from the World Drowning Congress notes:

½ million people drown annually. The mission of the Congress is the reduce
the risk and improve the outcome.

There are very different rates across countries. For example, the drowning
rate per 100,000 people in the UK and Germany is .7, while in Russia it is
15.

Drowning causes a large global burden - there are 1.3 million disability
life years lost from drowning.

Drowning is the 11th overall cause of death for children less than 5 years,
fifth for ages 5-14, 7th for adults under the age of 29.

Near drowning results in disability. For every one child who drowns, four are
hospitalized for near drowning.

Absence of adult supervision is the most common cause of child drowning in
developed countries. They showed a slide of wells in third world countries
that had a simple metal grate over it. That helped reduce the drowning
events of children who accidentally fall in to wells. So there are some
simple prevention methods that can be employed.

(How many of us have looked at any potential patterns of drowning in our
local areas to see what can be done to prevent them? Do teenagers trespass
and swim in a remote quarry and drown? Is there an area where cars are more
likely to enter the water? What about tub and pool incidents. And of course
please do not ignore possible foul play drowning.)

WHO will publish a book on drowning prevention, so keep a look out for it.

Epidemiology: Dr. Christine Branche, Dept. of Health and Services/Center for
disease control

$2.5 billion dollars spent in the U.S. on rescue, hospital care,
rehabilitation for drowning victims.

Decrease income and increase the incidence of drowning by country

1999 - 3529 deaths, 927 kids under the age of 15. Drowning is the tenth
leading cause of injury/death overall. 3% of kids hospitalized for near
drowning suffer severe brain damage.

7,840 people treated in U.S. for near drowning

Risk factors include age, gender, alcohol, socioeconomic status, lack of
supervision. Children and adults are risk factors. Teens and adults usually
drown in openwater.

Race and ethnicity are difficult to separate from economic disparities. For
U.S. adults and adolescents blacks are twice as likely as whites to drown
for every age bracket, except for the 1-4 year age bracket where white
children are four times as likely to drown as black children. This may be
because of increased access to pools for white children. (I would like to
suggest the possibility of increased homicidal drowning for white children
in that age group as something worth researching - I will say that most of
the cases that we have are white children.)

Pools, wells, drains are the number one locations for children 0-4 to drown
in. (I find it interesting that nonambulatory children are drowning in
pools, wells, and drains - doesn't that raise some potential red flags?)

In 1998 there were 100 children who drowned in bathtubs.

Near Drowning: immediate survival following asphyxiation due to submersion
in a liquid.

Drowning: death from asphyxia due to submersion in a liquid, including
deaths from complications of this event.

(these definitions changed a little by the end of the Congress)

Water-related disasters, can we be prepared: Slim Ray was the moderator.

1999 Hurricane Floyd - 10% of the fatalities were rescue workers.

Approximately 1/3 of flood drowning victims are rescuers.
Hurricanes - 59% of what kills people are inland floods, not storm surge.

Problems: dispatchers are not properly trained to get the right resources to
the right areas. Roads flood quickly so then it is too late to get the
resources to the right areas.

(this means that plenty of community pre-planning needs to take place to
create a set of procedures for every public safety agency to follow when
flood watches, warnings occur. A firefighter from Germany spoke about how
they have such a system and it has been working very well. Everyone knows
what to do ahead of time, and when an event occurs all they need to do is
set the system in motion. How many of your communities have done this, and
if they have can you tell us about it please.)

The majority of flood deaths in the U.S. are people driving cars and being
swept away.

26% of all fire fighters cannot swim.

(what percentage of personnel in your department of any kind cannot swim 200
yards in under 6 minutes, which is a very minimal swim? Those of you that
have PFD's, how many have gone to a pool and tried them, and worked on being
able to swim with them while wearing the clothes you probably would be
wearing with a PFD?)

A book by Dr. John Leech, the psychology of Survival was recommended. (Has
anyone read that?)

No way out is a video by the LA county office of education to education the
public on floods. It is worthwhile. (does anyone have contact information
for that video to purchase it?)

Andrea Zaferes
Lifeguard Systems & RIPTIDE

7-13-02

Hi Again,

Here's the second posting regarding notes taken at the World Drowning
Congress. Again, any errors are probably mine. Some of the medical stuff was
over my head. Some of you may understand it better. Again, I hope this
generates some good questions and discussions.

nosocomial infection: an infection acquired during hospitalization.
Hospital Treatment of ARDS (acute respiratory distress syndrome) - by
Luciano Galtinoni (?) Univ. of Milano

(there was a debate in a later talk about dropping the term near drowning.
Dr. Modell, one of the most important, if not the most important, father of
medical drowning research is the one who devised the term and wanted to keep
it. It was so amazing to actually be in meeting with him. wow. Anyway,
several of the other medical researchers wanted to do away with them term
and wanted either you drown, which means you are dead, or you didn't drown.
If you have later complications then you have later complications - an
important one being ARDS. I am not sure if that debate was resolved. What
was agreed upon was ditching the term "secondary drowning" since that does
not really exist. What exists is ARDS and that is one of the reasons this
talk was important. The concern I voiced about removing that term was that
in the field, when a person is rescued after a near drowning situation and
they think they are fine it is sometimes hard to convince them to go to the
hospital.The term secondary drowning can be helpful to convince someone to
go. Now we are going to have to say other complications such as ARDS and
explain that. Perhaps that will be just as effective. What do you think?)

Near drowning is a complex picture - salt vs. fresh, temperature,
electrolytes-acid base influence, circulation, respiration, nosocomial
infection....

There are very few fresh water drownings today in actuality because so much
of today's freshwater is contaminated. Contaminated water with time can lead
to nosocomial pneumonia, prevalent consolidation, low potential for
recruitment. ("recruitment" was a term used very much. My understanding of
it is not good enough to define here. Can anyone help us out please).

Near drowning is in part similar to the lavage model - surfactant wash out.
(lavage is the process of washing out an organ. It can be used to actively
rewarm internal organs as well, e.g. peritoneal lavage.)

Consider an abnormality in chest wall elasticity because of water ingested
into the stomach and bowels.

(this confused me): sometimes PO2 goes up because cardiac output goes down,
so don't completely rely on PO2 levels. PEEP has nothing to do with lung
opening (which is what the doctors work on doing for the near drowned
patient). Opening only has to do with inspiration.

PEEP (positive end expiratory pressure) (this is from a respiratory book:
"Expiration is classified as being either active or passive. Active
expiration occurs when either the expiratory muscles are active or the
ventilator generates a transrespiratory pressure difference which causes
flow in the expiratory direction. An example of a ventilator which causes
active expiration is a high frequency oscillator which uses a piston to
generate a sinusoidal transrespiratory pressure wave form. Because this
system generates a cycle of positive and negative pressure at the airway
opening, gas flow in the expiratory direction is augmented.

The significant characteristic of expiration is how the ventilator affects
the way the control variables return to their baseline values. Pressure,
volume, and flow are measures relative to end-expiratory or vase line values
and are thus initially all zero. During routine mechanical ventilation, the
baseline values themselves for transprespiratory pressure, lung volume, and
flow are zero for PEEP. The baseline values of any of these variables can
theoretically be controlled. This ability is the ability to control PEEP.
Whew.)

Recruit a patient in a prone position (isn't that wild?) - that is better
than a supine position, especially if there is a low potential for
recruitment. (although I was told that another presentation brought up the
issue that this requires special procedures because if the person is turned
back to supine, I think increased intracranial pressure can result without
proper pressure monitoring). Once the lung is opened it may collapse again.
Why, because it is heavy so it compresses. So prone is a better position.

Hearing crepitation close to the spine is assign that the lungs are opening.

Pulmonary Infections in the ICU after drowning. Dr. Giel Van Berkel.

125 patients with pulmonary edema, pneumonia, and mortality.

Pneumonia often occurs with ARDS. Pneumonia is usually simple to diagnose by
x-ray, but it is more difficult to diagnose if ARDS is present - hence in
near drowned patients.

Diagnosis: pulmonary infiltrate after 24 hours on chest x-ray with at least
three of the following: fever, leucocytosis, purulence of sputum, pathogenic
microorganism from sputum culture, or positive blood or pleural fluid
cultures.

Path: hypoxemia, aspirate water or gastric fluids, or secretions,
concomitment problems such as seizures, trauma, drug overdose.

Types of water: contaminates - can you tell what organisms were in the
water? He took cultures of 15 victim's lungs with pneumonia and found
eschericha coli as the most common, aeromone as the #2, aerobic gram
negative, fungi and other things. Yum. (I asked him if there was any way of
differentiating a drowning induced pneumonia from other causes of pneumonia
with my thought process being able to give hospitals red flags to children
that are dunked or drowned by parents who hide that crime. I was hoping lung
cultures could help. He said if aeromones and something else which he said
too quickly for me to get down, then it is most likely from an openwater
drowning. I think this warrants more research and could be very helpful in
homicidal drowning investigation.)

Look at early onset vs. late onset. Endogenous vs. exogenous, community
acquired vs. nosocomial to see who is at risk for pneumonia.

If mechanical ventilation was needed then the risk was 52%. If it was not
needed then only 3% of the patients got pneumonia.

Risk was not related to water type, admitted body temperature, neurological
state and rescue admission, use of corticosides and prophylactic
antibiotics. (interesting).

The lecturer did not recommend the use of prophylactic antibiotics as there
was no reduction in pneumonia if they were used.

stay safe and keep on learning always,

Andrea Zaferes
Lifeguard Systems & RIPTIDE

7-17-02

Here's some more notes.

Wade, thanks for the information on recruitment. Would it be correct to say
that it has something to do with the opening of the lungs necessary for
mechanical ventilation to occur?

Dr. Jack Haitsma gave a talk on Surfactant Therapy.

First let me give a little background for those that need it:

Our lungs are made up of tiny air sacs called alveoli. The average adult has
about 400 million of these gas permeable 6-cell thick membrane sacs that are
surrounded by pulmonary capillaries. When we exhale everything we can, we
still have about 2 pints of residual volume in our lungs to prevent lung
collapse. But there is something else that helps prevent lung collapse and
that is surfactant. Let's see how it does this.

When water forms a surface with air on one side the water molecules are
strongly attracted to each other that causes the water surface to always
"want" to contract. This is called surface tension. That's what keeps a
water droplet a droplet - a tight "contractile membrane" of water holds the
water into a ball. Stick your finger in water and pull it out and see the
water drop hanging down from your finger tip.

Now imagine water lining the inside of an alveoli (alveeolie not ravioli)
that is filled with air. The water wants to contract into itself - and if it
was allowed to the alveoli would collapse - as air was forced out if the
alveoli like would happen to an opened balloon. This force occurs in all
lung air spaces - an elastic contractile force called surface tension
elastic force.

Surfactant helps prevent alveolar collapse (atelectasis). It is a slippery
fluid lining the alveoli that is called a surface active agent. A surface
active agent, when spread across the surface of a fluid, greatly decreases
the surface tension of that fluid. Surfactant is secreted by special
epithelial cells that make up about 10% of the alveoli surface. Surfactant
is made of phospholipids, proteins and calcium ions. Surfactant does not
dissolve in fluid, rather it coats the fluid's surface. this happens because
one part of the phospholipid molecule is hydrophobic (hates water and gets
as far away from it as it can) while the other end of the phospholipid
molecule is hydrophilic (loves water) and stays attached to it. Think of a
barbell with one end that likes water and one end that doesn't. Put a lot of
these barbells on the surface of a water pool, and the would line themselves
one row think across the water with the water liking parts in the water and
the other side sticking up in the air.

The surfactant layer has 1/10th to 1/12th the surface tension of water.
Hence, surfactant counteracts the elastic contractile force.

Some interesting notes on atelectasis - the smaller the radius of the
alveoli, the greater the tendency to collapse. Therefore infant alveoli are
more susceptible to being collapsed - one of the many reasons it is so easy
to harm a baby when dunking the baby in water.

This also means that as air is expelled from alveoli, the radius decreases,
so the collapse pressure increases, and collapse is more likely (like in a
drowning victim's lung) Surfactant is very crucial to prevent lung collapse
in these tiny alveolar because it works even better in small alveoli because
surfactant molecules in small alveoli are squeezed together and therefore
more concentrated and therefore have an even lower surface tension.
Likewise, as we take more air in our alveoli, the surfactant molecules are
pulled further apart so the surface tension of the water becomes more
proportionately powerful and hence the alveoli are restricted from expanding
too much.

When freshwater enters the alveoli it is pulled into the pulmonary
capillaries by osmosis because blood has a higher salt concentration. That
destroys the surfactant layer. In saltwater drowning, salt is three times
saltier than our blood, so blood fluids can actually be pulled into the
alveoli, also destroying the surfactant layer. This in conjunction with
small alveolar radiuses from too little air in the lungs, and voila, alveoli
collapse, lung collapse.

Besides providing alveolar stability (Law of Laplace), surfactant also
serves as a barrier function to keep microorganisms out of the lungs and to
keep proteins from the blood from leaking into the lungs.

Decrease surfactant and osmotic pressure is increased so that fluid will
accumulate into the alveoli. This is bad. Alveoli become more permeable.
This increases the risk of ARDS (acute respiratory distress syndrome).

Dr. Haitsma's research found that patients given surfactant treatment in the
hospital had a decrease in mortality over 28 days.

Please, I know there are people on this discussion group with far greater
medical knowledge than I have. Please add to this.

Keeping drowning patients well ventilated in the field is important, and
rapid transport to a hospital where they can get PEEP and other ventilatory
support is critical. Don't delay but also don't rush and drop, bang, yank
them. Use professional rapid deployment motion. Make sure to seal the
patient's mouth and nose as you bring them up from the bottom and to the
shore/boat to prevent further water from getting in the lungs which will
further destroy the surfactant.. Those are my morals to this story. What
other morals can you add?

Thank you in advance.
stay safe,

Andrea Zaferes
Lifeguard Systems & RIPTIDE

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