Author: David Szpillman (01-15)

1. How Lifeguards would know the severity, treatment and outcome of drowning on the accident site Dr David Szpilman

2. E STABLISHED FOR ALL LIFEGUARDS : These cases compose only 0 . 5% of all cases rescued by lifeguards at the beach Respiratory arrest = Start artificial ventilation immediately. Cardiopulmonary arrest = Start CPR immediately.

3. What about 9 9. 5% of all cases rescued at the beach, what should be done? How are we to know which cases need an EMT or an MD? ? 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

4. Do you need to know how to act appropriately and confiden tly in those cases? On a busy day, as a lifeguard, would you get medical support as quickly as you need ed ? or

5. That´s why rescuers need a DROWNING CLASSIFICATION SYSTEM It a llows Lifeguards and MD teams to speak the same language It gives the exact severity of the case It gives exactly what approach should be taken It a dvise s when to call an ambulance It a dvise s when to call an EMT or a MD It r eassure s lifeguard ’s in front of the population, and

6. DROWNING CLASSIFICATION SYSTEM How it was created and applied in Rio de Janeiro It was recently (2001) validated by a 10 year study with 46,060 rescues, of which 930 (2%) were drowning s attended at the DRC 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 w ere considered to facilitate the use It was adapted to be underst ood by lifeguards It ’s been use d since 1973 by more than 1,400 lifeguards in Rio de Janeiro

7. Carotid pulse present ? Yes No Yes Check COUGH and FOAM in mouth & nose GREAT AMOUNT OF FOAM RADIAL PULSE ? yes SMALL AMOUNT OF FOAM No Basic Life Support (BLS) - Drowning - Szpilman 1997 Give 2 mouth-to-mouth ventilations and check Carotid pulse/signs of circulation Check victim’s response - Can you hear me? No Yes BREATHING PRESENT? Absent No Open airways - look, listen, and feel respiration COUGH WITHOUT FOAM CSI ? 6 3 2 Rescue 1 4 5 On shoreline Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997

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

9. Grade 1 COUGH , WITHOUT FOAM in MOUTH or NOSE MORTALITY - 0% 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

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

11. Grade 3 Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 LARGE AMOU N T 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.

12. Grade 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 immediat e with mechanical ventilation and I.V fluids. 5. Urgent 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%

13. Grade 5 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 restor ing ventilation , follow guideline for grade 4 Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 ISOLATED RESPIRATORY ARREST MORTALITY - 44%

14. Grade 6 1. Start and continue CPR . 2. No one is considered dead if hypothermic. Do not give up! 3. Do not resuscitate if s ubmersion time over 1 hour or obvious physical evidence of death . 4. After successful CPR, victim should be followed as close ly as possible and t reated as grade 4. Drowning Classification - BLS Based on evaluation of 1,831 cases - CHEST - September 1997 CARDIOPULMONARY ARREST MORTALITY - 93%

15. CLASSIFICATION and MORTALITY (n = 1831) Using clinical classification at the accident site we can recommend the treatment and know exactly the likelyhood of death. Dr David Szpilman 38,975 considered rescues cases were excluded from th is table GRADE NUMBER (n) Mortality 1 1189 0 (0.0%) 2 338 2 (0.6%) 3 58 3 (5.2%) 4 36 7 (19.4%) 5 25 11 (44%) 6 185 172 (93%) P < 0.0001

16. Lifeguard Rescue Begins Victim Lifeguard Beach support Resquest ACLS help PWC Helicopter Boat SZPILMAN 2000 How we use a classification system ACLS -- -- --

21. Lifeguard first check s the need for ACLS call. If unconscious, ACLS is dispatched immediately. Check ventilation/circulation and start resuscitation if arrested

22. Desfibrilator & ECG Monitor OTT plus Bag Liquid (crystaloid) Sun shelter Pulse ox y meter Aspirator Medication Back Board IV route Compressions X Advanced Cardiac Life Support is done on the accident site Ventilation

23. If victim is alive, lifeguard treat the patient f irst and then call ACLS, if needed

24. 94.5% are discharge d home directly from the accident site 5.5% need to be transport ed to DRC

25. ACLS - ambulance

26. ACLS - helicopter for difficult access

27. Drowning Resuscitation Center

28. ONE TEAM, ONE GOAL LIFEGUARDS and MEDICAL STAFF

29. ONE WORLD, ONE DROWNING LANGUAGE WE CARE ABOUT