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THE SERIOUSNESS OF A COPPERHEAD ENVENOMATION

YOU THINK YOU KNOW ABOUT COPPERHEAD ENVENOMATIONS? THINK AGAIN.

Let me begin by saying I’m ethnocentric, and this article refers to the copperheads found in the United States. I’m not talking about the Australian copperheads of the Austrelaps genus.

Taxonomy is always changing, which is sometimes a necessary nuisance and other times nothing more than a testament to pride, greed, and obstinance. By the time I finish typing this, copperhead taxonomy may have changed again. When I first got into toxicology, there was one species of copperhead (Agkistrodon contortrix) with five subspecies (contortrix, mokasen, laticinctus, pictigaster, and phaeogaster). Now people tend to think them as two species: A. contortrix (Eastern copperhead) and A. laticinctus (Broad-banded copperhead).

A. contortrix © Lisa Powers/Froghaven Farm

I don’t think there is enough envenomation literature out there that distinguishes the different species and subspecies, so I’m going to talk about them generally.

Copperheads account for the plurality, and maybe the majority, of venomous bites in the United States. From 2012 through 2016, there were 9,247 copperhead bites reported to the American Association of Poison Control Centers. In comparison, there were 1,234 bites from cottonmouths, 4,912 rattlesnake bites, and 400 coralsnake bites. I don’t have the #s for unknown native pit vipers or exotics immediately available, and time is of the essence, so you’ll have to learn to live with the disappointment of not knowing.

Of course, many bites go unreported to U.S. poison centers, so we don’t know the real #s for the various type of snakes. But presumably the relative frequencies would be preserved.

Nonetheless, lots of bites. But because there are soooo many physicians out there, most have treated very few, if any, envenomations. And yet this does not stop them from perpetuating nonsense when it comes to copperhead envenomations.

IS A COPPERHEAD BITE A BIG DEAL?

Far too frequently I hear people minimize the significance of copperhead bites. Physicians – and lay people – will state that they’re “no big deal”.

That may be true, depending on how you define “big deal”. Copperhead envenomations are not going to keep the earth from spinning on its axis. They won’t change the way northerners mispronounce the word “pecan”. And they won’t stop the Golden State Warriors from dominating the NBA for the foreseeable future. (Mind you, I’m not happy about this. I’m just realistic. Go Rockets!!!!)

A. contortrix © Lisa Powers/Froghaven Farm

If you equate “big deal” with death, then it is sorta true that copperhead envenomations are not THAT big of a deal. Death is pretty rare. But, I would like to point out, there have been fatal copperhead envenomations. Hells bells, there was a death in 2014 and another in 2015. In that same span, there were 10 deaths from rattlesnakes. There were no reported deaths from coralsnakes or water moccasins (cottonmouths) in those years. This is in the U.S., I should specify…. Again, I’m ethnocentric. And on a time crunch because I really want to watch the last two episodes of Stranger Things season 2.

Related:  Snake Bites & Misinformation

Finally, if you define “big deal” as having the ability to ruin your day and significantly affect your life for the next few weeks, and possibly months and years, copperhead envenomations ARE a big deal. And it makes me apoplectic that some healthcare providers minimize the significance of copperhead bites, especially when patients are exhibiting severe signs and symptoms right in front of them.

In the same National Poison Data System data from the AAPCC, 2.13% of copperhead envenomations resulted in death or major effects, defined as signs that were life-threatening or resulted in significant residual disability or disfigurement. This is not nearly as much as the 8.84% of rattlesnake bites with death or major effects, but it’s more than 1.94% of water moccasin (cottonmouth) bites. I’m not sure if 2.13% vs. 1.94% is a statistically significant difference, but it does make me wonder why most people make a big deal about water moccasins (which they should) but disregard copperheads (which they should not do).

In a study of untreated copperhead bites in North Carolina, there was follow up for 7 patients with mild bites (which they defined as tissue injury limited to the immediate bite site without systemic manifestations) and 8 patients with moderate bites (defined as extension of local tissue effects to a major joint proximal to the bite site +/- systemic manifestations such as nausea or abnormal coagulation studies without clinical bleeding). The median length of disability for these patients was 42 days (range 5 – 365 days). I’d say 42 days of disability is pretty significant.

Annually, I treat ~ 50 bites at the bedside and ~ 50 bites over the phone or computer as a snakebite consultant. Copperheads account for approximately 65% of all of snake envenomations, Let me tell you, I’ve seen some pretty impressive bites. About 20% of confirmed copperhead bites would be considered “severe” because of local findings and/or systemic involvement, typically in the form of hematotoxicity, including coagulopathy, hypofibrinogenemia, and/or thrombocytopenia. While I have your attention, I want to reiterate “confirmed” copperheads, which has nothing to do with their religious training. I think too many studies are weakened by inexact species identification. I list the species as “unknown” unless the snake has been positively identified in person or via photograph of the actual “herp perp”. In my follow up clinic I have also seen patients who went untreated elsewhere, and there are a lot (gaggles, maybe even herds, clutches, or colonies) of folks with permanent effects, even months after the bite.

Related:  Snakebite Management (in hospital) - Pit Vipers

A. contortrix © Lisa Powers/Froghaven Farm

DOES A PATIENT REALLY NEED ANTIVENOM IF BITTEN BY A COPPERHEAD?

Okay, so I have demonstrated that copperhead envenomations can be bad. Why is that important? I’m glad I asked. It’s important because we can (and, as I am about to argue, should) do something about them.

At the time of this writing (September 2018), there is one antivenom that is FDA-approved for the treatment of all North American pit vipers. Crotalidae Polyvalent Immune Fab (ovine), better known as CroFab®. In the initial studies in the mid-1990s, back when the drug was known as CroTab, copperheads were not included. So, until recently, there was no documented evidence of efficacy against copperhead bites.

However, in 2017, Gerardo et al (and, like Paul Simon sang, “you can call me al” because I’m one of the co-authors), published the first double-blind, placebo-controlled, randomized clinical trial of CroFab in mild and moderate copperhead bites. And we found a few important things:

75% of patients who were treated with antivenom were back at baseline by 31 days, whereas it took 57 days for 75% of untreated patients to return to baseline. At 14 days post-bite, patients who were treated with antivenom had a clinically and statistically significantly better performance on the patient-specific functional scale. They were better on performing tasks they identified as important in their lives
Nobody treated with antivenom required opioids after 21 days, whereas it took 90 days for the untreated group to be opioid-free. In this age of widespread opioid abuse, misuse, and dependence, I think that’s yuuuge.

A more recent sub-analysis of the data by Anderson et al (I’m still al) demonstrated that early treatment with antivenom (defined as within 5.47 hours of envenomation) resulted in better outcomes than late treatment:

Patients in the early treatment group had a median time of 17 days to full recovery; the untreated group took an average of 28 days.

TREAT AN ENVENOMATION LIKE YOU WOULD TREAT A FIRE.

A. contortrix © Lisa Powers/Froghaven Farm

This makes complete sense. I often compare envenomations to fires. If you treat early and aggressively, before the fire (bite) spreads, you can extinguish it with fewer resources and less resultant damage than if you wait for it to spread. If you treat after the fire (bite) has spread, there is more damage and you use more resources, only to get a less complete response.

In the unified treatment algorithm for the management of crotaline snakebite in the U.S. by Lavonas et al, treatment (for pit vipers in general) was recommended by the panel for systemic toxicity or when local effects crossed one major joint. Some panelists even recommended treating finger bites that did not have extension past a major joint if there was any significant injury. I totally agree! If you see there’s evidence of a more-than-minimal envenomation, you treat. Yet in some places (I’m looking at you, my adopted Lone Star State) many physicians who treat snakebites wait until the local damage has spread across two joints. This baffles me. This dithering results in more injury and less likelihood that the recovery will be complete.

Related:  Debunking the Myth that Antivenom is More Dangerous Than a Snakebite

SO WHY THE RELUCTANCE TO TREAT?

Well, a lot of times it’s because of ignorance. Doctors may be unaware that copperheads can cause serious injury. They may not realize that antivenom is effective against copperhead bites. Maybe providers have concerns about the safety of antivenom. All drugs have the potential for adverse events, right?! However, CroFab does have an excellent safety profile. In a meta-analysis by Schaeffer et al in 2012, there was an 8% incidence of acute adverse reactions. More recently, Kleinschmidt et al found an 2.3% incidence of acute adverse reactions. In the pediatric population the incidence skyrocketed all the way to 2.7%. Heck, standing between me and a kolache is more dangerous!

The last common argument for withholding treatment is that most people recover, eventually, and antivenom is expensive. I agree it’s not cheap. But neither is a permanent disability. Even a prolonged absence from work can be financially devastating. I think it’s better to treat the patient liberally and then help him or her find a way to pay for treatment if needed than to withhold/delay treatment and miss that opportunity to do the most good.

Too many people want to separate copperheads from other native pit vipers. Rather than focus on the species, I recommend looking at the patient. If he or she has a more-than-minimal pit viper bite, treat it aggressively, irrespective of the species. You only have one chance to make a first impression, and you have only one opportunity to treat before things get hinky.

A. contortrix © Lisa Powers/Froghaven Farm

WHAT TO DO IN THE UNFORTUNATE EVENT OF A BITE?

  1. Go to the hospital, and read these beforehand so you’re prepared: Snakebite pre-hospital management and Snakebite in Hospital (Pit vipers) and Snakebite in Hospital (Coralsnakes).
  2. Reach out to us at the National Snakebite Support Group for access to snakebite experts.


 Spencer Greene, MD 09/12/2018

About 

Spencer Greene, MD, MS, FACEP, FACMT is the Director of Medical Toxicology and an Assistant Professor in the Henry J.N. Taub Department of Emergency Medicine at Baylor College of Medicine. He directs the only medical toxicology service in Houston. Clinical interests include salicylates, anticonvulsant toxicity, physostigmine, alcohol withdrawal, and envenomations, and he consults on more than 100 bites and stings annually, including snakebites, spider bites, asp envenomations, and jellyfish stings. He serves as a consulting toxicologist for the Southeast Texas Poison Center and has directed the annual Houston Venom Conference since its creation in 2013. He was also the course director for the American College of Medical Toxicology's Natural Toxins Academy.

Tips for Icing Injuries Safely and Effectively


As an instructor, you already know that first aid guidelines include applying ice to an injured body part, such as a bone, joint or muscle injury. However, questions that often arise in class are:

  • What type of ice is best?
  • What shouldn’t be used?
  • How long should ice be applied?

Here are some facts to remember when applying ice to an injury:

“Frozen water” ice is best: Several studies show that crushed ice, shaved ice, and ice cubes are the most effective at cooling the body. Instant ice packs are not as effective at cooling the body, and often do not last as long as frozen water ice.

Frozen vegetables: A makeshift ice bag of frozen peas can also be effective in a pinch, as peas have a high water content and the bag can conform to any body part. However, frozen peas may warm up more quickly than ice and not provide as much of a therapeutic effect.

Be careful with instant ice packs: The temperature of Instant ice packs, which become cold via a chemical reaction, can vary greatly. Some instant ice packs can become too cold initially, which can damage the skin. Others may not become cold enough, or stay cold long enough to have a meaningful effect on an injury.

Use a wet barrier: If a barrier is used between the skin and ice, it should be wet. This helps the cold application penetrate deeper into body tissue.

Do not ice continuously: NSC First Aid programs recommend icing an injured body part for 20 minutes (or 10 minutes if icing produces discomfort), remove for 30 minutes, then reapply. The “more is better” approach should not be used when icing an injury. Continuous icing can potentially cause tissue and nerve damage, and some studies show that it may actually have the reverse effect by increasing swelling.

RESCUE BREATHS: ARE THEY GONE OR NOT?


By guest blogger Bill Rowe, Director of Content Development

I still remember the day when the 2010 CPR and ECC guidelines were released and the primary message from the news media was that rescue breaths were eliminated from CPR. Headlines screamed, broadcasters announced with great fanfare, and sound bites ruled… rescue breaths were gone!

But it really wasn’t that simple.

First, let’s clear up the main point. For people that become trained lay providers of CPR, rescue breaths are still a critical part of their ability to perform CPR. They are still part of standardized layperson training.

Let me see if I can help clear things up.

First, some related anatomy. There are two main ways that cardiac arrest occurs. The most common is sudden cardiac arrest.  As its name implies, sudden cardiac arrest happens abruptly, and mostly to adults, when the electrical system of the heart short-circuits, the mechanical pumping action stops, and forward blood and oxygen flow ceases. A victim of SCA usually collapses and becomes unresponsive. Normal breathing stops, except for occasional non-productive agonal gasps. This is the most common form of treatable cardiac arrest. Immediate CPR to buy time for early defibrillation provides the best chance for survival.

When sudden cardiac arrest occurs, uncirculated oxygen remains in the bloodstream. Research has shown that doing chest compressions, without rescue breaths, can circulate that oxygen and be as effective in doing it as traditional compression/rescue breath CPR for the first few minutes.

This is where the idea of eliminating rescue breaths got started. Other contributing influences included the potential for giving rescue breaths to be unpleasant, such as after injury or vomiting, and there is more detail in learning how to do them, including keeping the tongue from blocking the airway and making an airtight seal when blowing.

Getting rid of rescue breaths for sudden cardiac arrest looked like a reasonable concept.      

However, the other common path to cardiac arrest is secondary cardiac arrest, when there is an initial airway or breathing problem that prevents oxygen from entering the body. The lack of available oxygen will progressively weaken and slow the heart rate down until the heart stops. Secondary cardiac arrest occurs from things such as drowning, opioid overdose, and suffocation. This is the most common way cardiac arrest occurs in children.

Different from sudden cardiac arrest, an essential part of the treatment for secondary cardiac arrest is providing effective rescue breaths. Getting oxygen into the body and circulated to heart tissue will stimulate the heart to beat faster and become stronger. An improving heart and the resulting oxygen to the brain can stimulate the breathing effort.

So, getting rid of rescue breaths can make CPR a whole lot easier for treating the problem of sudden cardiac arrest, but will not help someone survive a secondary cardiac arrest. How should we train lay providers in CPR?

The correct answer is that we can do both kinds of training, depending on the person being trained.

Nothing has changed in traditional standardized CPR provider training. Students learn and practice both chest compressions and rescue breaths to be able to manage both sudden and secondary cardiac arrests. If a person has the time, this is the recommended training to take.

But what about all of those who are not able to take traditional training? Keeping in mind that sudden cardiac arrest is much more likely than secondary cardiac arrest, what about a simpler approach for the masses that can be learned in minutes with little or no practice?

In 2010, the CPR guidelines were updated with the concept of compression-only CPR as a separate option for untrained bystanders. This was based on the concept that, for at least a few minutes, chest compressions alone could circulate the remaining oxygen in the bloodstream of a victim of sudden cardiac arrest. Evidence showed that, in this circumstance, compression-only CPR was just as effective as traditional CPR with compressions and breaths.

Learning compression-only CPR is easy. If a person collapses in front of you, put the heels of both hands on the center of the person’s chest and push. Push repetitively, push fast, push hard, and don’t stop until an AED is attached and analyzing.  Awareness in compression-only CPR can be accomplished through things such as public service announcements, posters on walls, lunch-time talks, and short half-time presentations at sporting events.

So, rescue breaths were not eliminated for trained lay CPR providers, just for the much shorter and broader awareness of compression-only CPR.

As an authorized instructor of our core ASHI and MEDIC First Aid training programs, you are a critical conduit to students in clarifying the difference between traditional and compression-only CPR, and the limitation of compression-only CPR training.

We should remain committed to providing hands-on skills training to as many people as possible in both compressions and rescue breaths. We should provide awareness training in compression-only CPR when we can, but always encouraging those participating to go further and learn more.

All the First Aid Stuff That's Changed Since You First Learned It


When was the last time you took a first aid class? The ‘80s? ‘90s? Like everything in the medical field, first aid is constantly evolving, and what you may have learned to do as a first responder 10 years ago could be completely wrong today. Let’s take a look at some of the biggest changes over the last few years.

To help sort through all this medical knowledge, we talked with Jordan Ourada, EMS Liaison at HealthONE, who walked us through the most common procedures right now. He was also quick to point out that the research is constantly evolving, so if you’re in a position that demands it, keeping up with your first aid training is a must. Oddly, some of these standards have gone in and out of vogue over the years, so depending on when you learned basic first aid, some of your knowledge may still be up to date.

CPR Has Changed Completely


Cardiopulmonary resuscitation (CPR) was first introduced in 1960. Back then, the typical procedure was known as the ABCs: airway, breathing, chest compressions. You started with opening the airway to try and resuscitate the victim by giving them quick breaths through the mouth, then moved onto pumping on the chest to get the heart beating again. Depending on when you learned CPR, you may have also learned to put pressure on the patient’s windpipe to decrease the amount of air that entered the stomach. Back in 2010, this procedure completely changed.

Now, the recommended method is CAB: chest compressions, airway, breathing. One cycle of CPR includes 30 compressions, followed by two rescue breaths lasting about one second. The order changed because researchers found that the chest compressions are the most important part, and in a lot cases, the breaths are unnecessary. This type of CPR is best for drowning victims and people who collapse with breathing problems.

In fact, a “hands only CPR” or “compression only CPR” is now recommended for most emergencies we come across as bystanders (unless it’s a drowning victim or people who collapse with breathing problems. Regular CPR is still best in those cases). Ourada points out that in some cases, the breathing can actually do more harm than good and compression only CPR is recommended:

The American Heart Association is constantly studying and reviewing the most effective way to save a life in out of hospital cardiac arrest. While in the past it was common practice to do mouth to mouth resuscitation, it has been found that not only does that not help, it can make things worse by filling the belly with air making it more difficult to do effective chest compressions. It also increases the likelihood of the patient vomiting in your face which—let’s face it—is gross in addition to being hazardous to the health of rescuers. It is now recommended that the most effective way to resuscitate someone in cardiac arrest is consistent, deep and fast chest compressions without interruption.

Which is all to say, if you cannot give breaths, you should simply continue chest compressions at a rate of around 100 per minute (which is about the same as the song “Staying Alive”, as you may have heard) until help arrives or the person shows obvious signs of life-like breathing. It’s also worth noting that since CPR research is constantly evolving, it’s recommended that you take a CPR course every two to three years to keep up to date.

Applying Tourniquets Is Useful (Again)


Depending on when you took a first aid class, you either learned to apply tourniquets above bleeding wounds or learned expressly not to ever use one. Likewise, if you’ve ever watched any action movie ever, you just assume a tourniquet is appropriate for just about any kind of injury. However, studies published in the likes of the Journal of Trauma and this one in the Journal of Special Operations Medicine show the rate of complications is pretty low. Ourada explains:

Tourniquets were popular many years ago, then went out of vogue for a long time due to the risk of limb damage and compartment syndrome. In the last few years however, after extensive use and study by the military in the wars in the Middle East, tourniquets are back in a big way and have been found to be the most beneficial way to stop serious arterial (squirting) bleeding in limbs. You do want to be aware of how long it is on the limb as it does cause damage, but that takes a long time and ideally the injured person is on their way to a trauma center in that time.

So, when should you use a tourniquet? They’re best used to limit severe external bleeding on limbs. Before you apply a tourniquet, you should attempt to control open bleeding by applying direct pressure to the bleeding site until it stops. If it doesn’t slow down within about 15 minutes, then it’s time to use a tourniquet (and no, you don’t need to elevate the limb, that was also debunked). To properly apply a tourniquet, place it two to four inches away from the wound site, between the wound and the trunk of the body. Then, tighten it in a knot around the limb until the bleeding stops. Many first aid kits have tourniquets you can use that make the process a lot easier.

While tourniquets are back in vogue, it’s still only recommended you use them with proper training, so if you missed that in your first aid class, it’s worth heading back.

Don’t Induce Vomiting without Calling Poison Control


If you took a first aid class prior to 2010, there’s a reasonable chance you learned to induce vomiting when someone ingests a foreign, possibly toxic substance. It was so popular that people were told to keep ipecac around in the house just in case. It turns out this is a terrible idea.

The reasoning is pretty simple. In most cases, common treatments for when someone ingests toxic substances, (treatments like milk, activated charcoal, and ipecac), are unhelpful, and in some cases, harmful. Ourada says that depending on what the victim swallowed, inducing vomiting can do more harm coming back up than it did going down, so it’s always best to refer to the experts instead of going with some universal treatment plan.

Regardless of whether a first aid teacher may have told you, you should alwayscall Poison Control (1-800-222-1222) before doing anything at all.

Don’t Store Bare Severed Digits In Ice


When you lose a digit, say a finger or toe, the old advice said your best bet to get it reattached was to put the digit on ice and make your way to the hospital as soon as possible. While that’s partially true, and makes for a great scene in a movie, it’s not the whole story. Putting it directly on ice is a bad idea.

When you place an amputated digit directly on ice, you risk damaging it. Ourada explains:

Do not throw the digit straight on the rocks because that can freeze and damage the skin and vessels. It’s best to wrap the amputated part in cloth or paper towels and then put in a cooler or a cup of ice to keep it cool. Avoid direct ice contact and avoid placing it in liquid and water logging it. Get to a trauma center as soon as possible.

Once you get to a trauma center, they can reattach the digit provided it’s still in good shape. If things go well, the victim will regain use of it completely.

Similarly, if someone loses a tooth, the previous recommendation was to simply get to a dentist as soon as possible with the tooth in hand. Now, it’s recommended you store the tooth in Hank’s Balanced Salt Solution, propolis, egg white, coconut water, Ricetral, or whole milk. If none of these are available, you can also store the tooth in the victim’s own saliva until they can get to a dentist.

Never Put Something In a Seizure Victim’s Mouth


You may have heard that when you witness someone having a seizure, you should place an object between their teeth for them to bite down on so they don’t swallow or bite off their tongue. If your first aid knowledge is really old, you maybe also learned to restrain the victim. Both of these are incredibly wrong. Sticking something in a seizure victim’s mouth can cause them to choke, and restraining them can lead to broken bones or other injuries.03:03

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Tech 911: Third-Party Chargers

6/20/18 4:33pm

Seizures are tough to watch, because you can’t really do anything. The best you can do is clear the area and try to make the victim as comfortable as possible. Ourada’s suggestions are pretty simple:

Old wisdom says to place something in the victim’s mouth, like a wooden spoon, to keep them from biting their tongue. This is not recommended as you can do damage by trying to force something into their mouth, and it also creates a choking hazard. The best thing to do if you see someone seizing is to help lower them to the ground if they are not already there and try to put something soft under their head so they don’t strike their head on the ground while seizing.

Beyond that, the CDC adds that while your first reaction might be to offer water to a victim as soon as they stop seizing, you should always wait until they’re full alert before doing so.


Heat Exhaustion or Heat Stroke

Safe at Home - Guide to First Aid and Safety for Kids

One of the most important functions that parents must do is protect your children at home and away from home.

Unfortunately, keeping your children safe at home is a very difficult task. In the course of a normal day, children, regardless of the age, are exposed to a number of potential dangers. These dangers could result in cuts, bruises and scrapes to more serious medical problems such as broken bones, allergic reaction and head injuries.

While it is not expected that parents will be able to treat all medical emergencies, it is very important to know what you should do if it happens at your house. The first step is to assess the extent of the injury. If it is a simple cut or skinned knee, cleaning the wound and bandaging it to keep it clean and dry may be all that is needed. However, if your child has sustained a serious burn or is in a great deal of pain, at trip to the emergency room or a call for an ambulance may be needed.

Medical care should only be done by a trained professional. However, by assessing the situation you may be able to provide some basic first care. To help parents provide proper care and to keep children safe at home, we have provided a selection of resources that you can use. But, remember if you are unsure of the extent of injuries, you must contact a medical emergency service or if they are mobile enough without pain, a visit to your local emergency facility.

Basic Disaster Supplies Kit

Why You Should Learn Compression-Only CPR

Learn CPR: You Can Do It!

Mayo Clinic: First Aid

Kids Health: First Aid & Safety

MedlinePlus: First Aid Tips

Boy Scouts of America: First Aid and Safety

Wilderness First Aid Basics

First Aid Fact Sheets

CPR Facts and Stats

WebMD: First Aid and Emergencies

Injuries & First Aid

First Aider's Guide to Alcohol

Broken Bones / Dislocations for Broken Bones

First Aid-Fractures

Emergencies and First Aid

First Aid & Safety

Basic First Aid: What to Do

First Aid Booklet

Common First Aid Accidents

First Aid Book for Kids

Child and Baby First Aid Tips

CPR on Kids

First Aid Kits

First Aid Kit Essentials

First Aid Tips to Teach Children

What You Need In A Family First Aid Kit

First Aid Measures Kids Should Practice

Credits to Emily’s List Girl Scout Emily who recommended that we add this page

Dry Drowning

Dry drowning — a rare, but potentially deadly condition — is on the minds of countless parents after a 4-year-old Texas boy died a week after his family went swimming.

When his 4-year-old daughter ingested water while in a kiddie pool on a family vacation, Dr. Sanjay Mehta's concern about the incident didn't stop after she coughed up water.

Mehta watched his daughter closely over the next day until it was clear to him that there were no lingering effects from the pool water.

But don't chalk up his reaction as an overly worrisome parent. Both doctors and lifeguards are asking parents to be informed about "dry drowning," a rare, but potentially fatal reaction the body can have to what many may see as a harmless water mishap. It's also called "secondary or delayed drowning,"

"She was asymptomatic," said Mehta, a board-certified pediatrician and division chief of CentraState Medical Center's Pediatric Emergency Department. "But I definitely wasn't going to be shy about going in (to the emergency department)."

More: Can you save your child? An EMT's guide to handling emergencies

Dry drowning has come into the spotlight (in 2014) after a California mom's blog post about her 2-year-old son's harrowing experience went viral.

The condition can be confusing, in part, because of the terminology behind drowning, an incident that many in the general public associate with a person dying.

The World Health Organization defines drowning as a "respiratory impairment from either an immersion or submersion in a liquid." Medical professionals then break those incidents into either fatal or nonfatal drownings.

There were 3,602 unintentional drowning deaths in 2015, the latest year for which data is available, according to the U.S. Centers for Disease Control and Prevention. Of those, 636 where children 14 and younger. 

Parents: What does a baby need? Here are some must-have items

That same year, the CDC estimates another 9,816 people were treated for nonfatal drownings, of which 5,549 were 14 or younger, according to CDC data.

Secondary drowning is the damage to the lungs, which causes problems for the patient to get the oxygen he or she needs to breathe.

Data is not available on how frequently dry drowning occurs because it is not tracked. Mehta estimates he'll see several cases over the summer, roughly one a month.

Gene Hession, the lifeguard training officer for Long Branch and the president of the Monmouth County chapter of the U.S. Lifesaving Association, said he's seen it happen two times in the more than 40 years he's been a lifeguard.

What to look for

But experts say what parents should keep in mind is that the effects might not appear for hours after the initial drowning.

"I think the take-home point is if there is ever some sort of submersion event or an immersion event, don't just let it go. Keep an eye on the child," Mehta said. "If there are any symptoms period, seek immediate attention. Don't wait."

Those symptoms include persistent coughing, difficulty breathing, a child's face or lips changing to blue, purple or white, or the child just seeming lethargic.

Healthy living: Parents should tell their kids to go play outside

All are signs a child's oxygen levels might be low. Caught in time, a child can be given oxygen or more advanced methods of resuscitation if needed.

The symptoms might not be as apparent to parents or they could be interpreted as something else, like a cold developing or asthma, Mehta said. But the key difference parents have to remember is if an incident occurred with water earlier that day or potentially as long as 72 hours prior, he said.

"If there was some sort of event involving water, they should go to the emergency department. Talk to their doctor, but also go to the emergency department to be evaluated," he said.

Hession, the lifeguard training officer in Long Branch, is even sterner in his warning to parents. Any time a child ingests water in a mishap at the beach, the policy is to go to the emergency room.

"You can't be too careful with that. You think they're alright and three hours later, they're dead," he said. "We exercise extreme caution. If a kid swallows water, he's going to the ER, no ifs, ands or buts."

What happens to the body

Even a small amount of water can cause dry drowning.

As little as 1 to 2 milliliters of water per kilogram in a child's weight — a little less than an ounce for a 3-year-old — can cause a body to react, said Dr. Sanjay Mehta, a board-certified pediatrician and division chief of CentraState Medical Center's Pediatric Emergency Department.

So what exactly is happening in the body?

The water can cause one, or potentially all, of three responses, Mehta said.

The water, including chlorinated pool water, can irritate the surfactant, a liquid coating of the lungs that keep them functioning. The water can either wash out or keep the surfactant from forming.

It can also cause bronchospasm, a tightening of the muscles around the bronchial tubes in the lungs, which constricts the airways and reduces a person's ability to get oxygen.

The body can have a systematic reaction to the water. The blood vessels in the lungs can become leaky and cause pulmonary edema, or a build up of fluid in the lungs, which reduces the ability to breathe and could cause a person to drown in their own bodily fluids.


Press the Chest – Fast and Deep!


Performing Quality CPR

   

Cardiopulmonary resuscitation (CPR) is vital to the survival of a cardiac arrest victim. When someone goes into sudden cardiac arrest, their heart is no longer pumping oxygenated blood to the brain and vital organs. CPR circulates oxygenated blood remaining in the body to minimize neurological damage until defibrillation can be administered. It may also convert someone in a state of asystole (flatline) into a rhythm that is “shockable” by an automated external defibrillator (AED), allowing the heart to reset itself. Statistics for best survival rates usually mention “High-Quality CPR”, but what makes CPR high-quality?

When it comes to out-of-hospital bystander CPR, there is one factor which is always variable in each situation – bystander CPR is performed by humans, and humans come in different sizes, capabilities, knowledge, and responses. Even trained EMS professionals may perform tasks differently depending on their fatigue, training, and the particulars of a situation (environment, trauma level, on-lookers, etc.).

To define “High-Quality CPR” for teens and adults, there are certain courses of action identified by the American Heart Association’s 2015 CPR & ECC Guidelines to maximize the benefits of CPR, and they are simple:

Compressions at a rate of 100-120 per minute

Compressions at a depth of 2” – 2.4”

Full recovery of chest after each compression

Minimal interruptions to compressions

In a nutshell: “Press the chest – fast and deep” until an AED is utilized (and again after, if necessary), EMS arrives, or the person shows signs of life.

Note rescue breaths are not included in this list. The AHA (American Heart Association) does recommend rescue breaths at a rate of 30 compressions to 2 breaths when the rescuer has been trained and is confident in the technique, so interruptions to the compressions are no more than 10 seconds (and still stresses the importance of breaths when performing CPR on children and infants), but has recognized “hands-only” CPR is an effective alternative when the rescuer is not confident in their ability to provide ventilations or is untrained. Hands-only CPR also removes the potentially uncomfortable step of placing one’s mouth onto the mouth of a stranger if no mask is available.

Never hesitate to attempt CPR, regardless of experience or skill level. Someone in cardiac arrest is already clinically dead, and you cannot make them any more dead! Any CPR is better than no CPR, and if there is an AED handy, it should be retrieved and deployed as quickly as possible for the victim’s best chance for survival.  

Remember: “Press the chest – fast and deep!”

Hea(r)t Health – 5 Ways to be Cool

Keeping cool when the heat is on

   

 

The hottest days of summer are upon us. Depending on where you live, you may be seeing temperatures in excess of 100°F! While most of us can withstand the heat for short periods of time with our natural bodily cooling mechanisms like sweating and evaporation, for some with cardiac conditions this time of year can be particularly challenging to heart health. Medications for heart conditions or a heart which is functioning at an impaired level can lead to heat induced complications. Here are five ways to be cool this summer:

  1. Water!  

Water is your best bet for quenching your thirst, regardless of what those commercials for sodas, sports drinks, juices, and beer tell you! Drinking water keeps you hydrated without the extra calories from sugars, harmful chemicals from artificial sweeteners, or the dehydrating effects of caffeine added to other beverages. Think about it – the adult human body, on average, is about 60% water. It is the one almost universal necessity for most life forms on the planet. 

Why is this especially crucial for those with heart conditions? When your heart is not functioning at full capacity, or is being slowed by medications such as beta blockers, its ability to pump enough blood to the skin to produce sweat diminishes. Without sweat on your skin, there is no evaporation to facilitate cooling. When adequately hydrated, your body is better able to regulate its temperature, taking strain off your heart. Ask your doctor how much water he recommends you take in every day, as too much water can also be an issue depending on your medications and particular heart condition.  

In fact, the recent emphasis on drinking more water has caused an increase in a condition known as hyponatremia. In a nutshell, if you drink more water than your kidneys can handle, the electrolyte concentration in your blood becomes diluted and your sodium levels drop dangerously. Extreme sports enthusiasts who drink water constantly (especially marathon runners) have succumbed to this condition which has a range of unpleasant symptoms such as nausea and vomiting, headache, confusion, fatigue, irritability, muscle weakness, cramps and, in the worst cases, seizures, coma, and death.  

Water is beneficial in ways other than simple hydration as well. It can help cool you if you have difficulty sweating due to medications by placing a cool, moist towel under the arms, on your wrists, on the back of your neck or in the groin area. A cool bath or shower can also help bring body temperature down. 

  1. Cool Air

The reason we feel most uncomfortable in hot humid weather is because once the humidity in the air reaches levels over 75%, it becomes more difficult for the sweat on our skin to evaporate and it gets harder to effectively cool ourselves. Air conditioning works in two ways – one, it (obviously) cools the air; and two, it dries the air. If you do not have air conditioning at your home, find someplace that does – especially in extreme heat with high humidity during peak heat hours of the day (typically from noon until 3 p.m.) Movie theaters, malls, grocery stores, the library, or a friend’s house with air conditioning are just a few options. Some communities offer “cooling stations” – businesses or community centers which are air conditioned and open to the public to come in and escape the extreme heat. Some are even staffed with medical personnel.

Fans are a good last-ditch effort, but they only work to a certain extent, especially once the air temperature is higher than body temperature. You may be moving the air and helping with evaporation to a degree, but fans generally do little but blow hot air around once the thermometer tops 100°. Fans are effective at helping to circulate air conditioned air, however, and can help move cool air around a home, especially if you are using a window unit.

  1. Change of Routine

Many of us look forward to the summer months when we can get outdoors and exercise, work in our garden or enjoy other outdoor activities. If you typically do these activities in the afternoon during spring and fall, switching to early morning or late evening routines in the summer, when the sun is not at its strongest, is your best choice. Avoid being out between noon and 3 pm if you can. The sun comes up sooner and hangs around longer so you have plenty of hours in the day. Oh, and use sunscreen! Always! Wear a hat and sunglasses for further protection.

Don’t push yourself. Take frequent breaks if you find yourself becoming fatigued or short of breath and get another drink of water while you rest!

  1. Buddy Up and Check Up!

If you go out in the heat, take a friend and make sure your cell phone is charged and you are carrying enough water for both of you, especially if you plan to do something you are not normally used to doing. Too many times we overdo it, especially when trying something new. Days over 100° are generally not the best times to take up a new sport, so stick to activities you are confident you can do comfortably and take your time! If you can’t take someone with you, make sure someone knows what you are doing, where you are going and when to expect you back. 

Maybe it’s not you who has difficulty in the heat, but a friend or family member. Elderly folks tend to have a harder time coping with the heat and, with many on fixed incomes, they are afraid to spend the extra money to run their air conditioning. Check in on them regularly! Make sure they are eating and drinking properly, taking the medications they need to take, and staying cool.   

  1. Keep It Light!

Heavy, protein-laden meals require more blood to digest. Have you ever noticed your heart pounding a little harder after a big steak dinner? By eating smaller, lighter meals more frequently, and including foods heavy on water content like juicy fruits (oranges, pineapple, melon, and berries are good choices) and crisp vegetables (cucumbers, celery, lettuces, bell peppers and tomatoes all contain more than 90% water), you will give your heart a break and stay hydrated. If you are exercising or working in the heat, try foods rich in potassium to prevent cramping – bananas, tomatoes, lima beans, and sweet potatoes fit the bill nicely.  

Light also applies to clothing. Lightweight loose fabrics such as cotton and linen allow sweat to evaporate more easily and lightly colored clothing reflects heat rather than absorbing it. Avoid dark, heavy synthetic materials and tight clothing for maximum comfort and cooling efficiency.

The bottom line is to know your limits, talk with your doctor about recommendations based on your particular medications and condition, listen to what your body is telling you, and use common sense when temperatures reach extreme levels. Be cool!

What Happens After Cardiac Arrest


The Long Term Effects of SCA

   

 

Sudden Cardiac Arrest (SCA) survivors understand the preciousness of life – that one moment you can feel perfectly fine and the next wake up in the ICU a few days (or weeks!) later with no idea you have been through SCA, CPR, and defibrillation, listening to the stories your loved ones and hospital staff tell you about your ordeal. And that is only if you are mentally cognizant. Some survivors suffer severe neurological damage as the result of a lack of oxygen to their brain during sudden cardiac arrest and face a long road of therapy to regain a “normal” life. It’s a frightening prospect. So what is a “normal” life for the majority of SCA survivors?

Implantable Cardioverter Defibrillator (ICD)

Many people who have been through SCA receive an implantable cardioverter defibrillator (ICD). An ICD is a device placed just under the skin in the chest with leads connected to a patient’s heart. It performs the same function as an AED (automated external defibrillator). ICDs monitor the heart’s rhythm constantly, act as a pacemaker when the heart goes out of rhythm, and automatically apply a shock to the heart when it detects fibrillation. An ICD delivers immediate treatment without delay.  

Post Traumatic Stress Disorder (PTSD)

PTSD is most often associated with soldiers returning from combat situations, but it can also be found in persons who have suffered profound dangerous experiences or trauma in other ways. Car accidents, domestic violence, and severe health issues such as sudden cardiac arrest are examples. In the case of PTSD associated with SCA, there is a debilitating fear of a recurrence which keeps patients from enjoying their everyday activities since they do not know when it might happen again.  

General Anxiety and Depression

Not as severe as PTSD, sometimes the patient will feel general anxiety. Those patients with ICDs report anxiety around the possibility of feeling the shock from the device, which would indicate they once again could have been in a sudden cardiac arrest situation, not to mention the discomfort associated with the shock. Depression is also sometimes present, although it is usually reported in the first 6-12 months after resuscitation, and largely as a result of the loss of memory and the frustrations from coping with the physical and neurological stresses of recovery to varying degrees.

Long-Term Treatment

Once it has been determined what caused a patient’s sudden cardiac arrest, there are several options for procedures and drug treatment.

Procedures may include:

Coronary angioplasty
Coronary bypass surgery
Radiofrequency catheter ablation 


Corrective heart surgery – if your sudden cardiac arrest was brought on by a structural heart defect, your cardiologist may recommend specific surgeries to address your particular concerns with an eye toward preventing further complications.

Medications are almost always prescribed for long-term care.

Doctors use various anti-arrhythmic drugs for emergency or long-term treatment of arrhythmias or potential arrhythmia complications. A class of medications called beta blockers is commonly used in people at risk for sudden cardiac arrest. Other possible drugs include angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers or a drug called amiodarone (Cordarone, Pacerone).1

Side effects will be discussed when you meet with your doctor to decide the best options based on the underlying condition which caused the sudden cardiac arrest to occur and to potentially prevent further incidences. 

Life Expectancy

While exact statistics on life expectancy after SCA are difficult to find due to the sheer number of victims each year, it is estimated “More than 80 percent of SCA victims who are discharged home from the hospital live at least one year. More than half live another five years after resuscitation. Most people who survive SCA can return to their previous level of functioning.”2

Summary

Modern science and medical techniques have made it possible to survive cardiac arrest. As the public becomes more aware of the signs, symptoms, and treatments for SCA, early intervention with CPR and defibrillation should be able to save more lives and increase the likelihood of a viable life afterward. The sooner a victim of SCA receives CPR and defibrillation, the better their chances for neurological recovery. While the underlying problems which caused the SCA would still be present, at least patients would have a chance to address those problems and continue on.here.

Footnote1:

http://www.mayoclinic.org/diseases-conditions/sudden-cardiac-arrest/diagnosis-treatment/treatment/txc-20164901

Footnote2:

http://www.sca-aware.org/sudden-cardiac-arrest-faqs#faq23