How Lifeguards would know the
severity, treatment and outcome
of drowning on the accident site
Dr David Szpilman
ESTABLISHED FOR ALL LIFEGUARDS:
Cardiopulmonary arrest = Start CPR immediately.
Respiratory arrest = Start artificial ventilation immediately.
These cases compose only 0.5% of all
cases rescued by lifeguards at the beach
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What about 99.5% of all cases rescued at
the beach, what should be done?
?
Should we give oxygen in all cases? , if so, how much?
Should we call an ambulance?
Should we transport all of them to a hospital?
Should we release or keep them a while in observation?
How are we to know the prioritization on a busy day?, and
How are we to know which cases need an EMT or an MD?
On a busy day, as a lifeguard, would you get
medical support as quickly as you needed?
or
Do you need to know how to act
appropriately and confidently
in those cases?
2
That´s why rescuers need a
DROWNING CLASSIFICATION SYSTEM
It gives the exact severity of the case
It gives exactly what approach should be taken
It advises when to call an ambulance
It advises when to call an EMT or a MD
It reassures lifeguard’s in front of the population, and
It allows Lifeguards and MD teams to speak the same language
DROWNING CLASSIFICATION SYSTEM
How it was created and applied in Rio de Janeiro
It was updated from a classification system from 1972
It was based on the evaluation of 41,279 rescues
The final group evaluated came from 1,831 medical reports
It was based on beach and hospital attendance
Only clinical parameters were considered to facilitate the use
It was adapted to be understood by lifeguards
It’s been used since 1973 by more than 1,400 lifeguards in Rio de Janeiro
It was recently (2001)
(2001) validated by a 10 year study with 46,060 rescues,
of which 930 (2%) were drownings attended at the DRC
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Drowning Classification - BLS
Based on evaluation of 1,831 cases - CHEST - September 1997
On shoreline
Check victim’s response - Can you hear me?
No
Yes
Open airways - look, listen, and feel respiration
CSI ?
BREATHING
PRESENT?
Yes
No
in mouth & nose
Absent
GREAT AMOUNT
Give 2 mouth-to-mouth
ventilations and check Carotid
pulse/signs of circulation
Carotid pulse present ?
No
Check COUGH and FOAM
OF FOAM
SMALL
AMOUNT
RADIAL PULSE ?
yes
No
OF FOAM
COUGH
WITHOUT
FOAM
Yes
Basic Life Support (BLS) - Drowning - Szpilman 1997
Drowning Classification - BLS
Based on evaluation of 1,831 cases - CHEST - September 1997
NO COUGH or FOAM IN MOUTH or NOSE
Mortality - 0%
Evaluate and release from
the accident site without
further medical care
4
Drowning Classification - BLS
Based on evaluation of 1,831 cases - CHEST - September 1997
COUGH , WITHOUT FOAM in MOUTH or NOSE
MORTALITY - 0%
1. Warm and calm the victim.
2. Advanced medical attention or oxygen
not usually required
Drowning Classification - BLS
Based on evaluation of 1,831 cases - CHEST - September 1997
SMALL AMOUNT of FOAM in MOUTH or NOSE
MORTALITY - 0.6%
1. Oxygen - 5 liter / min by nasal cannula.
2. Warm and calm the victim.
3. Hospital observation from 6 to 48 hours.
5
Drowning Classification - BLS
Based on evaluation of 1,831 cases - CHEST - September 1997
LARGE AMOUNT of FOAM in MOUTH & NOSE
RADIAL PULSE PALPABLE (normal blood pressure)
MORTALITY - 5.2%
1. 15 liters / min of oxygen by face mask at the accident site.
2. Right side recovery position.
3. ACLS and hospitalization in ICU required.
Drowning Classification - BLS
Based on evaluation of 1,831 cases - CHEST - September 1997
LARGE AMOUT of FOAM in MOUTH & NOSE
NO RADIAL PULSE (low blood pressure)
MORTALITY – 19.4%
1. 15 liters/min of oxygen by face mask.
2. Monitor breathing with care (may stop breathing).
3. Right side recovery position.
4. ACLS immediate with mechanical ventilation and I.V fluids.
5. Urgent hospitalization in ICU required
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Drowning Classification - BLS
Based on evaluation of 1,831 cases - CHEST - September 1997
ISOLATED RESPIRATORY ARREST
MORTALITY - 44%
1. Start artificial ventilation immediately (in-water) and keep it at a rate of
12 per min. Victim usually recover after a few breathing.
2. After restoring ventilation, follow guideline for grade 4
Drowning Classification - BLS
Based on evaluation of 1,831 cases - CHEST - September 1997
CARDIOPULMONARY ARREST
MORTALITY - 93%
1. Start and continue CPR.
2. No one is considered dead if hypothermic. Do not give up!
3. Do not resuscitate if submersion time over 1 hour or obvious
physical evidence of death.
4. After successful CPR, victim should be followed as closely as
possible and treated as grade 4.
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CLASSIFICATION and MORTALITY (n = 1831)
GRADE
1
2
3
4
5
6
NUMBER (n)
1189
338
58
36
25
185
Mortality
0 (0.0%)
2 (0.6%)
3 (5.2%)
7 (19.4%)
11 (44%)
172 (93%)
P < 0.0001
38,975 considered rescues cases were excluded from this table
Using clinical classification at the accident site
we can recommend the treatment and
know exactly the likelyhood of death.
Dr
Dr David
David Szpilman
Szpilman
How we use a
classification system
Helicopter
Helicopter
Victim
Victim
PWC
PWC
Boat
Boat
Lifeguard
Rescue Begins
Lifeguard
Beach support
Resquest
ACLS help
----
ACLS
SZPILMAN 2000
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9
10
Lifeguard first checks the need for ACLS call.
If unconscious, ACLS is dispatched immediately.
Check
ventilation/circulation
and start
resuscitation if
arrested
Sun shelter
Compressions
X
Ventilation
Liquid
(crystaloid)
Aspirator
OTT plus Bag
Back Board
Desfibrilator
& ECG Monitor
Medication
Pulse oxymeter
IV route
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If victim is alive, lifeguard treat the patient
first and then call ACLS, if needed
94.5% are discharged home
directly from the accident site
5.5% need to be transported to DRC
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ACLS - ambulance
ACLS - helicopter
for difficult access
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LIFEGUARDS and MEDICAL STAFF
ONE TEAM, ONE GOAL
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