Drowning

5 Comments

• Chas McDonagh says:

  May 30, 2019 at 8:28 am

  Gentlemen,

  Excellent presentation as always.

  I am a SAR Winchman Paramedic working for the Coastguard and in my history of doing SAR in the RAF, I have been called to a dozen or so drowners. They are rescued in 2 rescue strops in the horizontal position for the reasons you give. Unless there are clear signs to ROLE, we carry on with ALS all the way to hospital. Couple of points which would you clarify.

  1. All of my drowners have been face down in the water, and there has been a lot of debate if they are immersed or submersed. As their airway is submersed then I have concluded that they are fully submersed as it is only the back which tends to be above water. Am I correct in this assumption?

  2. Although it may be longer than an hour or 90 minutes since we have been called, assuming temp above 6 degrees, I cannot know when they stopped swimming and when they started drowning. Therefore I continue. Am I correct in this conclusion.

  Again really love what you are doing and carry on with the brilliant work.

  Reply
  • James Y says:

    June 10, 2019 at 7:22 pm

    Hi Chas,

    Thanks for your message and really pleased to hear you’re enjoying the podcast. Your questions are very sensible and I think will echo the concerns/queries of many others. I’ll give you my interpretation of the literature….

    1. The immersion/submersion debate is really important as, under JRCALC, paramedics are only empowered to terminate resuscitation in cases of submersion and not immersion. If we look at Mike Tipton’s work and the ILCOR advisory statement: Recommended Guidelines for Uniform Reporting of Data From Drowning, they both state that submersion requires the head to be under the water. The “Cold Water Immersion” consensus statement from the International Lifesaving Society and JRCALC go a little further and state that submersion requires the entire body to be underwater, including the airways. Even though there is some disparity here, I think the message is the same – submersion realistically requires the patient to be underwater, not floating face down. This is probably because this will help with the selective brain cooling that Mike Tipton discusses as the potential reason for the neuroprotective function of cold water.

    2. I guess the first thing to highlight again is the JRCALC guidelines which only allow ROLE in submersion cases. Otherwise, I think your approach is very pragmatic and unless there is a clear timeline for the patient or there are any conditions unequivocally associated with death then I would continue ALS as you suggest.

    I think overall these cases are very difficult to prognosticate and the evidence surrounding it is not the strongest. Even the title of Mike Tipton’s work, which formed the basis of the ALS guidelines, includes the wording “based on Expert Opinion”. So, I think each case should be considered on its own merits, bearing in mind the guidelines and evidence surrounding it. For me, if there is even a small question as to whether the patient could have selective brain cooling/a chance of recovery then we should be resuscitating them, as we simply can’t know how they will do in the early, prehospital phase of their care.

    Hope that helps a little? Fly safe,

    James

    Reply
• Matt says:

  June 27, 2019 at 6:37 pm

  Evening guys,

  Great podcast as allows. Out of interest is there a timeframe for the effect of hydrostatic squeeze? I notice in the “Drowning” article by Szpilman et al. that the recommendation is to remove the patient in a vertical position with airway maintained, to prevent vomiting and further aspiration of stomach contents. At which point would you be considering the greater threat is posed by hydrostatic squeeze and then transition over to a horizontal rescue?

  Cheers,

  Matt

  Reply
• Chris says:

  February 18, 2021 at 2:41 pm

  The immersion/submersion debate is a difficult one. Most of the patients we attend have been there for some time and are then floating ‘face down’. We have also attended a number of shorter term drownings where on the most part they are also floating ‘face down’. Irrespective of time most patients we have dealt with that were ‘sub surface’ were trapped by something I.e plants, tree branches (strainers), human intervention etc and this was rare.

  I would suggest that more information and clearer definition in JRCALC needs to be published on the definition of submersion vs immersion to aid us all in the diagnosis of the drowned patient.

  One particular article suggest this:

  Submersion: the airway is below the surface of the liquid
  Immersion: the airway is above the surface of the liquid

  ( https://derangedphysiology.com/main/required-reading/trauma-burns-and-drowning/Chapter%204.0.7/immersion-submersion-and-drowning )

  My suggestion would be more towards an immersed patient being a patient that has either been washed up against or onto something or have attempted to catch their breath and cecum to the water due to exhaustion and would possibly a time limited exposure to the sub surface. A buoyancy aid may facilitate patient position to take on water and drown although facing upwards and may also be classed as immersion.

  Immersion, I would agree with my Winchman colleague above to suggest that a submerged victim has spent a more prolonged period in the water and could most likely be face down. It can be difficult for a body to be completely submerged due to air in clothing and natural buoyancy for a period of time. In our experience a sub surface body with no interference may have been submerged for some time prior to sinking

  Reply
• TrinaCon says:

  March 14, 2021 at 10:45 pm

  Excellent podcast as always! Thanks guys! Just wondering is there a quiz available to complete this as a CPD?

  Thanks,

  Trina

  Reply