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And welcome to our Marine Wilderness First Responder. This is the first of its kind and compliments are um awareness versus wonder. I am the Medical Director of Endeavor, medical doctor. I'm also a consultant in emergency medicine, working at the Royal Cornwall Hospital better than living by the sea. Unfortunately, we see more cases of drowning than we should. I'm passionate about trying to increase water safety. I volunteer for our local surf lifesaving club teaching the Nips. Also, I hope that this short presentation on near drowning and hypothermia will help as you look after potential casualties in the outdoor environment where you work and live. Thanks for listening. Our beach lifeguards prevent many drownings every year. Here's some reminders of where we should swim in order to be a little bit safer in the marine environment. If there's a red flag up, it's a no swimming day. The beach is closed. The lifeguards are not patrolling. They don't put this flag up lightly but they will do this if the conditions. Um and the risks outweigh the benefits of getting in the ocean. The single red and yellow flag shows it's a lifeguard on duty and on patrol two red and yellow flags indicate the area that someone else should swim between on a beach and the black and white ones are the C flags. This is to try to prevent boards colliding with swims. So what is no driving? Um Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid culture to popular belief, a CASS drams does not normally inhale an average amount of water. Actually, 90% of deaths and drowning are from a small amount of water into the lungs. But these small amounts of water do a lot of harm. This can inaccurate the surf factor and impaired gas exchange leading to Respi to stress. It's thought that about 10% of deaths are from what's so called dry jamming. In this instance, no water at all has actually entered the lungs, but there's a muscle spasm near the epiglottis and larynx blocking the airway. Although near drowning victims do not inhale a lot of water, they do swallow a lot of water. They will often vomit this on resuscitation. The most detrimental consequence of around of course is hypoxia lead to cardiac arrest and the duration of hypoxia is a critical factor in determining the victim's outcome. This is why time is everything on the rescue and why does this water cause so many problems? We've talked about the initial hypoxia that can lead to death and well, if not corrected within 3 to 4 minutes. How further down the line, you can also have immersion complications. This is due to irritation of the lungs um following the inhalation of small amounts of water and it can be delayed for several hours. For this reason, near drowning cases should be evacuated or taken to hospital for assessment. Even if they seem to for a couple of times in sort of your concerns that your casualty has taken a lot of water and close observation, they may need hospitalization. So if you're not close to a hospital may need evacuation. Um So let's get on to the management of drowsing. Now, um We'll divide this up into the prehospital treatments and the treatments once in hospital as I've already alluded to prehospitally, immediate resuscitation at the scene is vital. The treatment of near drowning involves four phases. Is he aquatic rescue? And there's basic life support, advanced life support and post resuscitation. I learned a phrase from the um the kayak guides that I work with um teaching them marine wilderness first responder. Um And I think this rescue technique is very important. They always say reach your throne, don't go if you're involved in trying to rescue someone from the water. The last thing anybody wants is for you to become a second victim. Try not to put yourself in any danger if you have a paddle. If you have something else, maybe a photo, maybe a ring that you can throw to the casualty. That is best. In the first instance, if your casualty conscious conscious, get them to hold on to your floating thing, whatever that may be um and get them to swim towards you is a last resort. Should someone enter the water to rescue casualty? And this ideally should be somebody trained with rescue equipment. If you do end up involved in rescuing someone out of the water who's unconscious, they need to be rescued in a horizontal position and we'll talk a bit more about this later. Once you a with the casualty in the water immediately, you need to check the airway and breathing rest breaths can be given in the water. Although this is tricky, ideally, they need five effective rescue breaths. This again is trying to address immediately the effect of hypoxia on the near drowning give the rescue rats, but CPR is ineffective in the water on a floaty kayak board or a small boat because the vessel will just go up and down. So if you're on a rescue board, you need to get the casualty to the shore as soon as possible, giving rescue breaths on the way if necessary to get on with some CPR cardio pulmonary resuscitation. Once in dry end, 999 needs to be called in this instance of the unconscious casualty, even if they appear to recover. And this is due to um the likelihood of immersion complications further down the line. So we're gonna break down our um our care of our casualty into our best order into the ABC S. And think about what's different in the near drowning casualty compared to our normal resuscitations. As you said, this poor victim will have swallowed a lot of water, even if they have not inhaled much and they are very likely to vomit. So if um, resuscitation of sense is successful and they remain unconscious, then they need to certainly be on their side in a safe airway position. If you're on a sleepy beach or hill, try to position the casualty. So their airway is rolled towards the downhill side of the hill. If it's on a beach, that'll be towards the sea. Suction is ideal um to remove debris um and other and then spare water from the um mouth, but you weren't able to clear the airway. Initially, you have aspirated water on the beam part, we need to give high flow oxygen, lifeguards will have oxygen. Um This is obviously essential in many of their rescues. 999 needs to be called as soon as possible though also to get more kits unseen. And when the physical care team arrive or a care team for advanced life support, then noninvasive ventilation needs to be considered early, especially if the casualty remains hypoxic. The team should also consider early tracheal intubation and control ventilation for victims who fail to respond to initial measures or who have a reduced level of consciousness with regard to cardiac arrest following submission. You pretty much follow A LS protocols. There's just a few nuances um as we've already said, the casualty should receive five rescue breaths. This reflects the fact that they are hypoxic as the most likely cause of the cardiac arrest. Following that the ratio of breaths to CPR is the same for any adult rescue. 30 compressions to two breaths and repeat in two minute cycles. A few nuances in the um resuscitation attempt for the near drainage patient are that they're going to be wet. So they need to be dried prior to defibrillation. They also say might be rather cold, certainly in England and if not anywhere, the water temperature is colder than the surrounding air. And patients will often become hypothermic if submersed or immersed for any length of time. We therefore follow the A S hypothermic protocols as well. Giving you the three shocks. If the casualty is less than 30 degrees, assuming you have a way of measuring this and withholding a LS drugs until casualty is more than 30 degrees, then doubling the interval until they are back to normal, you might know their temperature um at the scene. Therefore, continue with als as per protocol. With regards to the D and the E of the OY assessment, we need to consider traumatic injuries as well. On surf beaches, in particular, we need to be concerned about C spine injuries. Um and often casualties will have hit their head as they have come off their board or kayak and that could have been the cause of them getting unconscious. So we'll talk a little bit now about the post rescue care of the casualty. We've already said that they're at risk of acute respiratory distress syndrome after submersion. So the casualty should be evacuated from the scene. This may be by putting out Mayday, this might be calling the Coast Guard and it certainly involve calling 999. Pneumonia is common a few days down the line. However, we don't tend to give prophylactic antibiotics because they've not been shown to be of benefit. I have unfortunately seen someone who had, um, drowned in sewage and I certainly would recommend antibiotics in that case, if they do develop signs of pneumonia once in hospital, then of course, we will give broad spectrum antibiotics. Um Another common misnomer, is there a difference between drowning in salt water and fresh water? But this isn't true. There's no massive hyper os left involved in seawater and actually, we should treat the victims of near drowning in fresh or seawater. Exactly the same. Um, if you are somewhere where there's extremely cold water, less than five degrees and so much, and actually, the rapid onset of hypothermia may protect against hypoxia. And so these victims have survived for an amazing length of time. Um, her amazing length of submersion back to normal neurological function. So let's talk a little bit about hypothermia there are different stages of hypothermia according to the temperature of the casualty. And this is their core temperature that we're thinking about when we put them into these classifications. This isn't academic but worth thinking about just so we know what sort of signs we'll have with each stage of the hypothermia. So stage one is a stage, we've probably all experienced the temperature drops below 35 but it is still above 32 degrees C. The casualty is conscious and shivering. And the important thing is the conscious level. If they have any impaired consciousness, it implies that their temperature is less than 32 degrees and they've moved on to stage two of the hypothermia. This is also a very important stage because at less than 32 degrees, the casualty will no longer be shivering. Shivering is the body's attempt to restore hemostasis and without shivering, the casualty is unable to warm themselves up. They're therefore gonna need active warming measures. So stage two of hypothermia is between 32 down to 28 degrees. Centigrade, as you said, the casualty will no longer be shivering and they may have impaired conscious level below 28 degrees. The casualty will certainly be unconscious. They went to sovereign, but they will still have vital signs present. It ro slowed down, the heart rate will be very slow. The respiratory rate will also be slow and it will need a patient rescuer to elude these signs. This is stage three of hypothermia. By the time the casualty reaches stage four of hypothermia, less than 24 degrees, they will have no vital signs and will appear dead. This is where the um idea of you're not dead until your woman and dead comes in. Because if the casualty has cooled down very quickly, we can still survive completely neurologically intact at times if they have been apparently dead due to hypothermia that they need aggressive active warming measures and ongoing resuscitation. To achieve this. Fortunately, most of our cases are not that cold. They will just be in the marked hypothermic state for this. I like the uh the mnemonic ambles. So the les when somebody will grumble, they will mumble, they will fumble, they might stumble and these signs should be picked up either as the group medic or as a team leader out in their wellness, particularly um prone to hypothermia are Children. Um And so leading groups of Children in the water, I have definitely seen the initial stages of this. People become forgetful, speech becomes difficult, concentration becomes poor and they just get generally apathetic. The casualty will be shivering. They're trying to warm themselves up due to this, the pulse and the respiratory rate actually go up. We're not checking our BP in the wilderness, but it would be normal at this stage management. So the main thing about the management of mild hypothermia is to recognize it, recognize it in that case and recognize it as a risk in the rest of the group as well if you're with a group. So she's out of the water. We want to get them in a group shelter, insulate them from the ground, cover their heads and extremities with this. Also, we want to give them drinks and food. We want to consider external heat sources to areas which are sus particularly susceptible to heat loss growing the armpits in the neck. As you said before, the casualty should be rewarmed quickly. Um And evacuated rest for 24 to 36 hours is advised because they will have ongoing complications of hypothermia and they will be exhausted. You said try to rewarm as quickly as possible in these mild stages, but actually, it's very difficult to warm a casualty um in the outdoor environment. And that's why recognition is key. Once we get down to the moderate hypothermia, shivering stops, they might become very confused, might be unresponsive unconscious, the heart rate can become irregular and this is when we have to be particularly careful with the handling of our casualty because rough handling can actually trigger ventricular fibrillation. These casualties should be handled carefully and warmed slowly. Beach surfs and cool temperature. It can cause further instability with severe hypothermia. Signs of life may be undetectable. Clinically, the pupils can become fixed and dilated. However, the lowest successful survival was a very lady whose temperature dropped to 13.7 degrees C A 13 year old girl. So if there's no pulse and no fatal injuries, the casualty suffering from severe hypothermia should be placed in the recovery position and kept horizontal in the wilderness environment. It should then be rewarmed as able until the cool temperature is more than 33 degrees. This will need to be through passive and active external rewarming and can be very difficult. See, young should only be started if it can be given into a hospital. And this is because the CPR itself triggers the risk of ventricular fibrillation. Unfortunately, sometimes hypothermia is irreversible. Although you're not going to be able to successfully resuscitate your casualty. If the chest is not compressible, the abdominal muscles are not need or if you know that the core temperature is already less than 20 degrees. So all of that is very useful um in our assessment of the to casualty, it can be quite difficult to remember. Instead, I rather like this picture which helps us see where on the spectrum our casualty is with regards to hypothermia. As you can see in the mainly green section on the top left, the casualty is cold, stressed but not clinically hypothermic. My conscious, their movements are normal except for the fine movements which are starting to become a bit difficult. They're shivering and they roulette as we go through to mild hypothermia, the casualty remains conscious. This is when the movement is impaired, they're shivering. However, trying vigorously to warm themselves up and they're still completely alert, moving around in the bottom right corner, we have moderate hypothermia. In this case, the casualty is still conscious but they have impaired movement. They're now not shivering and they're not completely alert. When you come around to this bottom quadrant, the severe hypothermia, the casualty is unconscious. This is when we need to assume a severe hypothermia in the wilderness. So, as we're talking about the marine environment, um I'm going to talk a little bit about cold water immersion in itself as well, not with regards to the drowning, but just with what it does to the casualty. So these pictures here show us the help position, either in a group or on your own. This is very important in sea survival. So help stands for in this instance, heat elimination, lessening position. If a group, the group should huddle together, keeping their shoulders out of the water, their arms wrapped around each other so that they're not getting too much of cold water flowing into the armpits or groins. For this reason, the legs are also lifted up, you lose water temperature up to 20 times faster in water than you can in air through convective as well as conductive losses, the water's flowing. This is particularly evident. So trying to get into a position where you're reducing the flow of water around your body can be really, really important in the other picture. The Cashews on their own, but they are adopting their own help position. Oh, regardless of this, as the body starts to cool the breathing speeds up, the pulse rate increases and you get constriction of surface blood vessels. This happens in all instances when the body is submerged in cold water. However, it is the first minute of immersion and submersion in cold water, which is the most risky. You can get cold water shock instantly. Um And this can happen due to um gasping as the head is submerged. You can also get arrhythmias if you fall into a very hot water in that first minute. Ok. With the ongoing cooling of the body, you, as we've said earlier, start to get problems with muscle coordination. This obviously impairs the ability to swim and will increase the risk of drowning over time. That's why it's so important that um victims are able to call for help and then try to minimize their heat loss whilst awaiting rescue. If you are involved in extracting a casualty from the water, this should always be done in a horizontal position. It is because of the hydrostatic pressure around the victim's body whilst they're in the water. If we pull them up vertically, this is immediately lost blood from the cold heart goes into the legs leading um to a likelihood of arrhythmia. The cold heart will often go into the and this can lead to deaths and has done in the past before this was learned by rescue teams. So now let's talk a little bit about warming them up. Once they're on dry hand, we need to do all our active warming methods as we can. But we also need to prevent further heat loss. This is the hypothermia burrito wrap and it involves layers to prevent heat loss by um different methods. So we can lose heat from our bodies by conduction convection. The ra show and evaporation. So we need to try and prevent that. With these layers, you need ideally a waterproof layer on the very bottom that will help with some loss and the casualty will eventually end up wrapped up in this. We need a foam mat or similar something to get the casualty off the cold ground. It is often underestimated how much heat people lose by conduction through cold ground. So a phone mat or if you don't have a phone mat, boys the or clothes or something under the casualty. Oh This you should pop a four blanket. We should also put any other spare clothes dry with the casualty on top of this and then another foil blanket on top of the casualty. These five layers should help to reduce heat loss by conduction, convection, radiation and evaporation. The whole thing gets rolled up around the casualty gently if they're hypothermic. Um So that the only thing exposed is the airway and eyes remember to put a hat on the head release a lot of heat through our head and then get your casualty in their v wrap with other members of your team in a group shelter whilst awaiting further assistance from the rescue teams. So I hope um that short talk has helped with our understanding of what near drowning is most importantly, how to prevent it if we do have a casualty with a near drowning. Hopefully, now we've got a systematic approach of how to treat them and the special nuances that go with the hypoxia from that drowning. We also need to remember that often these casualties will be cold. We've talked about hypothermia in the stages of this and how to rearm our casualties. I look forward to seeing you on the course. Bye-bye.