DROWNING CLASSIFICATION SYSTEM FOR RESCUERS

1. DROWNING CLASSIFICATION SYSTEM FOR RESCUERS International Lifesaving Federation Medical Committee Primary author: Dr David Szpilman (Brazil) Member <david@szpilman.com> Approved: Dr. Steve Beerman (Canada), Chair Dr. Peter Wernicki (USA), Vice Chair Dr. Tony Handley (UK), Secretary Dr. Joost Bierens (Netherlands), Member Dr. John Pearn (Australia), Member Dr. Lorenzo Marugo (Italy), Associate Members Dr. Zaid Chelvaraj Abdullah (Malaysia), Associate Members 26, Gemeenteplein, Leuven 3010 Belgium Tel:32-16-35-35-00 Fax: 32-16-35-01-02, Email: ils.hq@pandora.be

2. ESTABLISHED FOR ALL LIFEGUARDS: Cardiopulmonary arrest = Start CPR immediately. Respiratory arrest = Start artificial ventilation immediately. These cases compose 0.5% of all cases rescued by lifeguards at the beach Basic Life Support (BLS) - Drowning - Szpilman 2004

3. 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? Basic Life Support (BLS) - Drowning - Szpilman 2004

4. 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? Basic Life Support (BLS) - Drowning - Szpilman 2004

5. 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 Basic Life Support (BLS) - Drowning - Szpilman 2004

6. DROWNING CLASSIFICATION SYSTEM How it was created and applied It was created in 1972 by MD and lifeguards working together It was updated in 1997 to a new medical perspective 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’sbeen used since 1973 by more than 3,000 lifeguards in Rio de Janeiro It was recently (2001) validated by a 10 year study with 46,060 rescues, of which 930 (2%) were drowningsattended at the Drowning Resuscitation center (DRC)

7. Helicopter Victim in Danger PWC Call for Back up Boat Resquest ACLS help Lifeguard Rescue Begins -- -- -- Lifeguard Beach support ACLS The lifeguard system Szpilman 2000 Basic Life Support (BLS) - Drowning - Szpilman 2004

8. Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 No Yes BREATHING PRESENT? CSI ? Yes Absent No GREAT AMOUNT OF FOAM SMALL AMOUNT OF FOAM COUGH WITHOUT FOAM RADIAL PULSE ? Signs of Circulation ? No On shoreline or Pool Deck Check victim’s response - Can you hear me? Call for Help Open airways - look, listen, and feel respiration Check COUGH and FOAM in mouth & nose Rescue Give 2 mouth-to-mouth ventilations and check signs of circulation No yes Yes 4 3 2 6 5 1 Click on numbers to see treatment Basic Life Support (BLS) - Drowning - Szpilman 2004

9. Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 No Yes BREATHING PRESENT? CSI ? Yes Absent No GREAT AMOUNT OF FOAM SMALL AMOUNT OF FOAM COUGH WITHOUT FOAM RADIAL PULSE ? Signs of Circulation ? No On shoreline or Pool Deck Check victim’s response - Can you hear me? Call for Help Open airways - look, listen, and feel respiration Check COUGH and FOAM in mouth & nose Rescue Give 2 mouth-to-mouth ventilations and check signs of circulation No yes Yes 4 3 2 6 5 1 Click on numbers to see treatment Basic Life Support (BLS) - Drowning - Szpilman 2004

10. Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 Evaluate and release from the accident site without further medical care Rescue NO COUGH or FOAM IN MOUTH or NOSE Mortality - 0% Basic Life Support (BLS) - Drowning - Szpilman 2004

11. Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 1. Warm and calm the victim. 2. Advanced medical attention or oxygen not usually required Grade 1 COUGH , WITHOUT FOAM in MOUTH or NOSE MORTALITY - 0% Basic Life Support (BLS) - Drowning - Szpilman 2004

12. Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 SMALL AMOUNT of FOAM in MOUTH or NOSE MORTALITY - 0.6% Grade 2 1. Oxygen - 5 liter / min by nasal cannula. 2. Warm and calm the victim. 3. Hospital observation from 6 to 48 hours. Basic Life Support (BLS) - Drowning - Szpilman 2004

13. 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. Grade 3 Basic Life Support (BLS) - Drowning - Szpilman 2004

14. 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 Grade 4 Basic Life Support (BLS) - Drowning - Szpilman 2004

15. Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 ISOLATED RESPIRATORY ARREST MORTALITY - 44% Grade 5 1. Start artificial ventilation immediately and keep it at a rate of 12 to 20 per min. Check signs of circulation regularly. 2. If possible use 15 liters/min of oxygen 3. After restoring ventilation, follow guideline for grade 4 Basic Life Support (BLS) - Drowning - Szpilman 2004

16. Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 CARDIOPULMONARY ARREST MORTALITY - 93% Grade 6 1. Start and continue CPR. 2. Use External Automatic Defibrilator if possible. 3. No one is considered dead if hypothermic 4. Do not resuscitate if submersion time over 1 hour or obvious physical evidence of death. 5. After successful CPR, victim should be followed as closely as possible and treat as grade 4. Basic Life Support (BLS) - Drowning - Szpilman 2004

17. Basic Life Support - DROWNING CLASSIFICATION and TREATMENTBased on evaluation of 1,831 cases - CHEST - Sep 1997 Check the victim in-water Conscious victim: bring back to shore/pool deck.; Unconscious victim - Shallow water: open victim’s airway, evaluate breathing, and begin mouth to mouth if necessary. Deep water: place the victim face up and open airway. If no spontaneous breathing, start mouth-to-mouth ventilation immediately at a rate of 12 to 20/min until reaching shore/swimming pool deck*. Mouth-to-mouth is possible in the water with 2 lifeguards or 1 lifeguard with lifesaving equipment. Do not check victim’s pulse while in the water. If no signs of circulation, don’t start chest compressions in-water, urgently bring the victim back to shore without further procedures. Victim transport to shore/pool deck should be with head up (except for hypothermic victim) On shore/pool deck - victim’s trunk and head should be at same level, even in sloping sites Do not spend time trying to drain water from the lungs. Victim position of head lower than trunk will increase the occurrence of vomit or regurgitation. On sloping beaches all the victims should be put initially parallel to the waterline, in dorsal position. Lifeguard with his back to the sea with the victim’s head turned to lifeguard´s left side. This facilitates the rescuers CPR maneuvers so that he does not fall over the victim and makes placing the victim in right lateral decubitus easier. Check the victim response No Yes Warning: if any suspicion of cervical spine injury(0,5%), be careful while open airways - use special techniques to do so. Check for breathing - Open airways - look, listen and feel for respiration Check for cough and/or foam in mouth/nose Yes BREATH PRESENT? Absent No LARGE AMOUT OF FOAM IN MOUTH/NOSE Rescue (0.0%) Give 2 mouth to mouth breaths and check for signs of circulation Evaluate and release from the accident site without further medical care Reaction to ventilation or any movement? RADIAL PULSE PALPABLE ? SMALL AMOUNT OF FOAM IN MOUTH/NOSE No Yes No Yes COUGH , WITHOUT FOAM IN MOUTH/NOSE Grade 5(44%) Grade 4(19.4%) Submersion time over 1 hour or obvious physical evidence of death (rigor mortis, putrefaction or dependent lividity). Grade 3(5.2%) 1. 15 liters/min of oxygen by face mask. 2. Monitor breathing with care (may still stop breathing). 3. Right side recovery position. 4. ACLS immediately with mechanical ventilation and I.V fluids. 5. Hospitalization in ICU required Continue mouth to mouth at 12 to 20 p/min until restore normal breath Grade 1(0.0%) 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. Yes No Grade 2(0.6%) 1. Warm and calm the victim. 2. Advanced medical attention or oxygen not normally required Grade 6(93%) 1. Oxygen - 5 L/min by nasal cannula. 2. Warm and calm the victim. 3. Hospital observation from 6 to 48 hours. Dead Start complete CPR with 15 external chest compressions and alternate with 2 breaths until normal cardiopulmonary function is restored, ambulance arrives or lifeguard exhaustion. After successful CPR, the victim should be followed as close as possible because another CPA may occur. Do not resuscitate MORGUE After restoring spontaneous breathing and pulse, treat as grade 4 Hospitalization Szpilman 2001 - Published in: Circulation 2000, 102 (suppl I):I-233-36 & Pediatric Clinics of North America, June 2001 Algorithm BLS:Near each grade the general mortality (%) is shown. Heimlich maneuver is only indicated with strong suspicion of foreign body obstruction; There is no difference in basic life support between different types of water drowning. (*)If the victim is grade 5, ventilation in-water can reduce mortality by almost 50%. CPA (Cardiopulmonary Arrest). References with the author <szpilman@globo.com><www.szpilman.com>

18. LIFEGUARDS and MEDICAL STAFF ONE TEAM, ONE GOAL

19. ONE WORLD, ONE DROWNING LANGUAGE WE CARE ABOUT Ils Medical Comission

20. The End? BIBLIOGRAPHICAL REFERENCIES 1. Orlowski JP, Szpilman D, “Drowning - Rescue, Resuscitation, and Reanimation” Pediatric Critical Care: A New Millennium, W. B. Saunders Company Pediatric Clinics Of North America - V48, N3, June 2001. Review. 2. Cummins RO, Szpilman D. Submersion. In: Cummins RO, Field JM, Hazinski MF, Editors. ACLS - The Reference Textbook. Volume II: ACLS for Experienced Providers. Dallas, Tx: American Heart Association; 2003:97-107. 3. Szpilman D. Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1831 cases. Chest. 1997 Sep;112(3):660-5. 4. Adult Basic Life Support. Guidelines for cardiopulmonary resuscitation and emergency cardiac care (ECC). Circulation 2000;102:I22–59.