Prehospital Academy Lesson 37.3
Trauma: Drowning and Altitude Injuries Overview
This lesson discusses the prehospital assessment and management of drowning and altitude-related injuries and illnesses for EMTs. Both categories present unique physiological challenges and require specific interventions to ensure positive patient outcomes. Understanding the definitions, pathophysiology, and appropriate care is crucial for effective emergency medical response.
Drowning
Drowning is defined as the process of experiencing respiratory impairment due to immersion or submersion in liquid. It is a spectrum ranging from non-fatal events with or without morbidity to fatal drowning.
Key Concepts:
Immersion: Airway is above the water, but water splashes over the face.
Submersion: Airway is under the water.
Pathophysiology: As a person struggles, they may inhale water (aspiration), leading to laryngospasm and/or direct lung injury, which impairs gas exchange and results in hypoxemia. Hypoxemia eventually leads to loss of consciousness, apnea, and cardiac arrest.
Avoid Obsolete Modifiers: Terms like "near drowning," "wet drowning," "dry drowning," "saltwater drowning," or "freshwater drowning" are no longer recommended as the final pathway (hypoxemia and cardiopulmonary arrest) is the same regardless of the initial details.
Prehospital Management:
Scene Safety: Do not enter the water unless properly trained and equipped. Ensure the scene is safe.
Remove from Water: Safely remove the patient from the liquid environment.
Primary Assessment (ABCs):
Airway: Open airway, clear any foreign material. Be prepared for copious secretions and vomitus.
Breathing: Administer high-flow oxygen. If breathing is absent or inadequate, begin positive pressure ventilations (PPV) immediately. Intubation may be necessary for advanced providers.
Circulation: Check for a pulse. Begin CPR if absent. Hypothermia may cause a very slow pulse; continue CPR if unsure.
Temperature Management: Patients may be hypothermic. Remove wet clothing, dry the patient, and cover with warm blankets. Handle hypothermic patients gently.
Spinal Immobilization: Consider if there is any suspicion of diving injury or other trauma associated with the drowning event.
Monitor & Transport: Continuously monitor vital signs and level of consciousness. Rapid transport to a medical facility.
Altitude-Related Injury and Illness
Altitude illness occurs when individuals ascend to high altitudes too quickly, not allowing their bodies to acclimatize to the decreased atmospheric pressure and lower partial pressure of oxygen.
Types of Altitude Illness:
Acute Mountain Sickness (AMS): Most common form.
Symptoms: Headache (primary symptom), nausea, vomiting, fatigue, dizziness, insomnia. Similar to a severe hangover.
Onset: Typically 6-12 hours after ascent.
High Altitude Cerebral Edema (HACE): A severe and potentially fatal form of AMS, involving brain swelling.
Symptoms: Worsening AMS symptoms, altered mental status, ataxia (loss of coordination - a key sign).
Progression: Can rapidly lead to coma and death if not treated.
High Altitude Pulmonary Edema (HAPE): A severe and potentially fatal form of altitude illness, involving fluid accumulation in the lungs.
Symptoms: Shortness of breath at rest, cough (often productive of frothy sputum), weakness, chest tightness, tachycardia.
Progression: Can lead to severe hypoxemia and death.
Prehospital Management:
Descent: The most crucial intervention for any severe altitude illness is immediate descent to a lower altitude.
Oxygen Administration: Provide supplemental oxygen to maintain adequate SpO2.
Rest & Warmth: Keep the patient warm and at rest.
Medications (ALS/Medical Direction): Dexamethasone for HACE, Nifedipine for HAPE may be considered if within scope and with medical direction.
Monitor & Transport: Continuously monitor vital signs, mental status, and respiratory effort. Rapid transport to definitive medical care.
Critical Thinking Questions
You are called to a patient who has just been pulled from a swimming pool and is unresponsive. What is your immediate and most critical intervention?
Explain why "not dead until warm and dead" is a guiding principle in the management of severe hypothermia, especially in drowning victims.
A hiker at high altitude complains of a severe headache, nausea, and disorientation, and is having difficulty walking a straight line. What altitude illness do you suspect, and what is the definitive treatment?
Why are terms like "wet drowning" and "dry drowning" no longer recommended in emergency medical services?
Discuss the importance of scene safety before attempting to rescue a drowning victim, and what precautions should be taken if you are not trained in water rescue.