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Hello. My name is Doctor David Lee GP Mountain Rescue and expedition doctor alongside faculty for Endeavor Medical. This presentation will cover choking anaphylaxis and drowning for the wilderness. First responder course, let's get started. Our learning objectives for these topics are as follows to recognize and treat the choking casualty to be able to explain anaphylaxis and treat promptly. Finally, we'll discuss drowning and some of its core management principles. So I imagine you're familiar with choking, but in a medical context, we're talking about airway obstruction. This can be partial or complete and this will influence our management of the condition alongside the common signs. It's important to ask someone, are you choking as their response will also help determine the next steps we take. This flow chart is from the Resuscitation Council UK Guidance 2021 that provides us with the expected course of action. When dealing with a choking casualty, starting with partial obstruction or a mild condition, the most effective way of clearing the obstruction is coughing. So if a casualty can cough, encourage them to keep coughing for Children, this can be more challenging and may require you to cough to demonstrate what you want them to do the severe condition or complete obstruction is defined by an ineffective cough. And this requires us to take further action. If they are still conscious, then start with five black blows with the heel of your hand between their shoulder blades. Check after each blow to see if the instruction obstruction has cleared if it remains. Then after the fifth blow, we will switch to abdominal thrust, standing behind the casualty, place your fist just underneath the sternum, push your other hand around the fist and pull in and upwards into the casualty, upper abdomen. Be careful to keep your head to the side. So not to accidentally head, but the casualty repeat these two sets of five actions whilst the casualty is conscious and the blockage remains. If the casualty becomes unresponsive, then guide them onto the floor. Perform a swift abc assessment and start CPR hopefully there's nothing I'm familiar there. But I'd highly recommend the Ice app that contains all the guidance for basic life support, choking and anaphylaxis. So how do we define anaphylaxis? Summarized here are the world allergy organization definitions. It is an acute life threatening response to an allergen that leads to impairment of our breathing and circulation systems. Some of you may be familiar with allergens, but here are the formal definitions. In short, an allergen is anything that causes an immune response. This is very similar to an antigen which is a substance that causes the response allergy is in the individual's response to the allergen and may lead to angioedema or localized swelling in the skin or mouth such as hives, wheels, tongue swelling, lip swelling. The most common causes of anaphylaxis are food medications and insect stings or bites. Working in the wilderness environment puts us at a greater risk of encountering these allergens. However, it's important for us to minimize the barriers to outdoor activity and therefore go prepared to help individuals with known allergies. Individuals with previous history of anaphylaxis are normally prescribed two adrenaline auto injectors to carry with them at all times. It's important for all team members to know the location of this emergency treatment when out in the wilderness environment, how to recognize anaphylaxis. Using our ABCDE primary survey model, you'll quickly recognize the features of anaphylaxis and the additional information that suggests exposure to an allergen will be able to initiate treatment promptly. Unfortunately, not all features will be present from the list below. And your edema may cause the airway to narrow and cause stridor or snoring noises. When the casualty tries to breathe, the respiratory rate will increase and the chest may sound wheezy like an asthmatic. Eventually anaphylaxis causes shock and this will be evident in the circulation assessment with weak pulses, high heart rate, cool clammy skin and lightheadedness. There is unlikely to be any deterioration in their conscious level early on. But over time, it may deteriorate as mentioned before hives or rashes may raise your suspicion of allergic reaction and potentially anaphylaxis. Once diagnosed, we require prompt action lie. The patient flat, elevate their legs. This helps manage the shock symptoms if still present. Remove the likely allergen such as an insect sting, maintain a patent airway and administer adrenaline through an intramuscular injection to the lateral thigh. This can be repeated every five minutes until symptoms are controlled and the patient improved. If a casualty requires adrenaline, they should be evacuated for ongoing monitoring in a healthcare establishment due to risk of a biphasic or second anaphylaxis reaction. This photo demonstrates the use of an adrenaline auto injector. The needle is housed within the device and is long enough to penetrate through outdoor wear into the lateral thigh. Muscle want to deploy it hold in place for three seconds for the device to discharge its medication. The needle will automatically retract into the device to remain safe. If using a second device, it is best to inject the other leg as the first dose may inhibit the absorption of the second dose. It is important to be familiar with any device carried by your team. This will help you gain awareness of the different doses provided for adults and Children and how to direct the device appropriately so that the needle goes into the patient and not into your hand. There are different doses for Children and adults when delivering these devices to Children. It's important to hold the limb still to allow the drug to be delivered over the three seconds. Adrenaline auto injectors can come in the different versions though some organizations will use adrenaline vials and draw medication up when required. This is significantly cheaper but has multiple steps required during the emergency process and requires regular refresher training to remain familiar. An alternative site to you using the outer thigh is the deltoid muscle in the shoulder more for interest and necessity. But adrenaline is a is a hardy drug and vials and auto injectors have been taken to polar and desert regions with no impact in their efficacy during drug shortages. It has also been extended for up to 12 months beyond its expiry date and worth being aware of if a party member is carrying out of date stock to summarize anaphylaxis is an emergency caused by an allergen. It presents with shock and respiratory difficulty. Your job is to recognize and treat with iron adrenaline. Some people might be wondering why I haven't mentioned steroids, antihistamines and inhalers. These have been relegated to footnotes in the resuscitation Council guidance. Although they have an impact on the symptoms of allergies, they are not life saving treatments and have led to deaths as people delayed the administration of the adrenaline. Moving on to the final topic of this session. Drowning. Let's get our definition right. Drowning is the process of experiencing respiratory impairment due to submersion or immersion in liquid with the potential consequence of death, disability or full recovery. This is the definition that was agreed in 2002 at the World Congress on drowning. Prior to this, there were numerous definitions including dry, wet and secondary drowning. None of which had any agreed meaning and no longer have any use. Drowning, disproportionately affects younger people. And each year, the National Water Safety Forum produced a wade report, a summary of all deaths involved in water, both coastal and inland within the UK. The latest one of 2022 there were 226 deaths um of which 40% had no intention of entering the water. Many of you may be swimmers and may be familiar with these steps but potentially never name them when an individual enters cold water. There is a shocked reaction, not the medical terminology of shock but a large gasp of several liters followed by hyperventilation. This lasts for the first few minutes but can be terminal if a non swimmer falls into the water and involuntarily takes a large breath of water. It's also the purpose of the RN program float to survive these first few minutes. It is important for casualties to keep their airway above the water and start to control their breathing. Once hyper ventilation settles, there's approximately 10 minutes in cold water before muscle strength starts to cease and cramp limiting your ability to swim. This is the 10 minute window when self rescue may be possible. When we talk about cold water, we mean less than 15 degrees which is present in most coastal waters till around late June in the UK. Once muscles start to stop working, the casualty may still be able to float. But as approximately one hour before hypothermia and dehydration start to inhibit their ability to protect their airway. Clearly, these processes are faster or slower depending on the water temperature and the three stages uh outline the 1 10 1 principle. The fourth stage will be discussed following our rescue. This slide is more for information than instruction. Please only undertake rescue procedures that you are trained to perform foundation safety and rescue courses and lifeguard courses, teach the shout reach throw to go water for rescuing casualties from water with the level of risk to the rescuer increasing. With each step, the figure on the slide is from the UK SA National Operations Guidance on Water rescue. There the time starts when the first reliable rescuer arrives unseen and undertakes their dynamic risk assessment to plan their rescue. Once an adult of average build has been under water for 30 minutes, there is no real chance of survival and the priority switches from a swift rescue to a safe recovery. If the water temperature is less than six degrees, then this time can be extended to 60 minutes as the cold water will have had a neuroprotective impact on the casualty after 60 minutes, rescue will only continue if the casualty is a very slim build or a child as they will have called fast enough to have potentially survived. After 90 minutes, the rescue will stop and recovery processes take over the casualty has been rescued and are approaching the shore first. It is best to bring them out horizontally. This helps maintain a stable BP. When suspended vertically in the water, the pressure from outside the body helps maintain the circulating pressure. If someone is pulled out vertically and this pressure is suddenly removed, then the BP drops and the casualty can have a cardiac arrest. So let's bring them out flat or horizontally. This allows you to maintain a patient airway with maneuvers or adjuncts. The airway has priority overseas spine protection. If possible to maintain the airway with a jaw thrust, then fine. But if you're struggling with the airway, then you've got to try alternatives following inhalation of water. The casualty will bring up a lot of frothy sputum. This is the surfactant, a chemical that lines the inside of the lungs to help them slide smoothly, um remove any large debris but don't get too worried about the froth if they need help with ventilation support through back valve mask or through pocket mask, as hypoxia or the lack of oxygen is the most likely cause of any cardiac arrest. A resuscitation starts with five ventilations. This is before any defibrillators are attached and before any phone calls for any lone responder, the breaths themselves may make the individual wake up and vomit, which will require a log, roll into the recovery position to help drain anything from the mouth. Make sure to treat the patient for hyperthermia following extraction from the water as well. And it's prudent for all drowning casualties to be assessed at hospital for any ongoing or deteriorating symptoms following the rescue. In summary, drowning is the process of experiencing respiratory impairment due to submersion or immersion in a liquid. With the consequence of either death, disability or full recovery. After 30 minutes underwater, there is little chance of survival but early rescue and early reversal of hypoxia is likely to provide a swift and full recovery. I'm finally, please only undertake a rescue you are trained and equipped to perform. That concludes this short series on choking anaphylaxis and drowning. If you have any questions, please get in contact with endeavor medical and we can point you in the right direction and support with any answers. Look forward to hearing from you. If anything from the talk has sparked an interest in any of the topics or you want to just read more about them. Then on this slide, you've got some of the references that we've used to put it together, including two interesting podcasts um from Basic Scotland and from the Prehospital podcast um alongside some of the Wildness Medical Society Guidance and the Research Council Guidance. Again, any questions let us know