A Story of an Unfortunate Man. …which coincidentally teaches some environmental nuggets. Are you sitting comfortably?. There once was a man called Jack. Jack was an avid reader. One day he was basking in the midday sun, reading his Roald Dahl book, when he realised he felt a bit hot….
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…which coincidentally teaches some environmental nuggets
There once was a man called Jack. Jack was an avid reader. One day he was basking in the midday sun, reading his Roald Dahl book, when he realised he felt a bit hot…
No prognostic significance
AF with slow ventricular response in 50% with mod hypothermia
AF and other arrhythmias; 2/3 decr in HR and CO; Osborn waves common
31 Shivering stops (24-35, very variable)
30 O2 consumption and CO2 production decr by 50%
Incr myocardial irritability, ectopics; threshold for spontaneous bad arrhythmidefibrillation
and antiarrhythmics become ineffective
Double intervals between drug doses
29 Pupils dilated
VF may occur
28 HR 30-40
BMR decr by 55-65%; major acidosis
25 Risk of asystole; CO 45% normal
Cerebral blood flow 1/3 normal
24 Loss of vascular tone and cerebrovascular autoregulation
23 Absent corneal and oculocephalic reflex
22 Max risk of VF
20 HR 20
19 EEG flat, appears dead
The simple approach
Modell & Conn 1984 – in ED within 1 hr of rescue (paeds)
Here he is pictured with his discharge summary and the SMO On Call (Bernard?)
Jack was discharged home. Here he is, pictured with his discharge summary (Bernard had finished his shift).
We’re not covering that cos we’re not bloody Australian.
From Auerbach: Wilderness Medicine, 5th ed. ( Submersion or near-drowning) Fig 68.4.
Most text books will support a trial of NIV if blood pressure and GCS appropriate, however there are no literature to support its use
Start low and titrate up
Vt low – 6mls/kg
PEEP 5-10 cm H20 only if PaO2 < 60 on FiO2 <0.6
Ventilate for 24 hours to allow regeneration of surfactant
Vandenet al. Part 12: cardiac arrest in special situations: drowning:2010 American Heart AssociationGuidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:Suppl 3:S847-8
Guenether U et al.Extendedtheraeutic hypothermia for several days during extra-corporeal membrane-oxygenation after drowning and cardiac arrest: two cases of survival with no neurological sequelae. Resuscitation 2009;80:379-81
WARNER et al. Recommendations and consensus brain resuscitation in the drowning victim. Bierens JJLM, ed. Handbook on drowning: prevention, rescue and treatment. Berlin: Springer-Verlag, 2006:436-9
If at 4 - 6 hours:
CXR, ABG normal
Normal vitals on air
Remain ASx = discharge with advice
Consider foreign material in airway (approx. 50% of surf submersions)
Salbutamol / Ipratoprium nebs for bronchospasm
NG placement on free drainage may improve ventilatory distress
High risk for vomiting and gastric content aspiration
Most will require fluid resuscitation secondary to diuresis
Beware hypothermia and trauma
Fresh Water/Salt Water/Polluted water
How many mls/kg does the average submersion injury aspirate ?
How many mls/kg aspirate of salt water causes alteration of
Orlowski et al instilled differing NaCl conc into dog ETT tubes
No head down positioning
No Heimlich maneuver
No prophylactic antibiotics
I can’t bring myself to say what happened next. Let’s just skip over that part of the story.
or Full thickness <2%
or Full thickness 2-10%
or Full thickness >10%
Burns of special areas (hand, face, feet, ears, perineum,
crossing major jts)
Inhalational / electrical burns
Complicated by # / trauma
Burns in high risk pt
Red, moist V painful
Yellow, white, dry Variable pain
Wait…Jack was now a woman????