“Camels & Bats & MERS Oh My”

The Economist May 14, 2014 www.economist.com/node/21602198

Andrea L. Williams, PhD, RN

EMS Education Specialist

Clinical Associate Professor

UW Emergency Education Center & UW-SON

Recent MERS–nCoV News Reports

CNN Medical Report - MERS CoV Virus Report 4-29-14 http://www.cnn.com/2014/04/29/health/mers-camels/

USA Today Report 5-17-14http://www.usatoday.com/story/news/usanow/2014/05/17/mers-corona-virus-saudi-arabia-illinois-indiana-infection/9217731/

CNN MERS CoV Camel Report 5-3-14http://www.cnn.com/2014/04/29/health/mers-camels

Saudi Arabia – To prevent Middle East Respiratory Syndrome, Saudis wear mouth and nose masks to watch camels at their farm, outside Riyadh.

Photographer: Fayez Nureldine/AFP via Getty Images

Understand the possible mechanisms of transmission, pathophysiology, signs & symptoms and treatment for Middle East Respiratory Syndrome

Describe precautions that need to occur for pre-hospital & hospital providers

OBJECTIVES

MERS-nCoV: Mechanism of Transmission

Identified in September 2012

Similar to coronaviruses found in bats

Isolated in camels in Qatar, Egypt and Saudi Arabia-unknown if camels are the source of the virus

Human to human infection in health care workers noted

Lab test for active infection and antibody test for previous infection

MERS-nCoV Transmission

Transmitted through the air through droplets from coughing or sneezing

Transmitted through close personal contact: touching or shaking hands

Spread by touching contaminated objects or surfaces and then touching your eyes, nose, or mouth

Transmitted in the Middle East by the same mechanisms when in close contact with dromedary camels used for racing, transportation, food, and as pets.

Virus found in camel feces & urine, unpasteurized camel milk & cheese, and in camel meat

Virus found in camel feces which may be dried and used for fuel.

Countries in the Arabian Peninsula with Lab-Confirmed MERS Cases

Saudi ArabiaUnited Arab Emirates

(UAE)QatarOmanJordanKuwaitYemenLebanonIran

Countries with Travel-Associated Cases

United Kingdom (UK)FranceTunisiaItalyMalaysiaPhilippinesGreeceEgyptUnited States of America

(USA) Netherlands***CDC takes back report of MERS spread person to person in U.S.

MERS nCoV Cases and Deaths

562 Cases of MERS CoV worldwide with 180 deaths

Recently spread to IranSaudi Health Minister

fired after a spike in Mers CoV cases (49 new cases), in April 2014

http://www.cidrap.umn.edu/news-perspective/2014/04/two-mers-antibody-studies-may-help-quest-treatment

Middle East Respiratory Syndrome (MERS-nCoV is caused by a novel beta coronavirus that usually causes a severe respiratory illness which has resulted in deaths in ~ 30% of individuals with confirmed infections. It is called a coronal virus because it appears to be surrounded by a crown.

Middle East Respiratory Syndrome

History & Symptoms of MERS-nCoV

History of travel to Middle Eastern Countries where MERS-nCoV is prevalent

Upper Respiratory SymptomsFeverCoughShortness of breathHypoxemiaPneumonia

Gastrointestinal Symptoms Nausea

VomitingDiarrhea

Kidney Failure

Treatment

Supportive CareNo vaccine to dateResearchers have

found that monoclonal antibodies - MERS-4 and MERS-27, have strong neutralizing activity against MERS-CoV.

Prevention While in Flying

Wash hands oftenAvoid touching your faceAvoid close contact with sick peopleDon’t share cups or eating utensils. Clean and disinfect surfaces like door handles, toys,

tray tops, etc. Practice the "Canadian salute" of coughing and

sneezing into your elbow.

Prevention in Middle East

MERS-CoV can survive for a long time in milk and suggested that consumption of unpasteruized milk, common on the Arabian Peninsula, could be a source of infection. Pasteurization kills the virus.

Don’t drink unpasteurized milk or eat unpasteurized cheese.Camel meat should be thoroughly cooked, not eaten rawDon’t drink camel urine (Believed to have medicinal benefits)What should be done about camel feces dried for fuel?

New Prevention Guidelines Qatar June 2014

Qatari has put into effect standards for protection of camel workers. Frequent hand washingUse of protective facemasks—although temperatures of up to 50°C make this almost impossible

Use of protective clothing and gloves

Prevention of Transmission to Healthcare Providers

Airborne Infection Isolation Room (AIIR)Limit the number of healthcare providers present during the aerosol-

generating procedures (ETT placement) to only those essential for patient care and support.

Conduct the procedures in a private room and ideally in an AIIR Gloves Gowns Eye protection (goggles or face shield) Respiratory protection that is at least as protective as a fit-tested

NIOSH-certified disposable N95 filtering face piece respirator. If a respirator is unavailable, a facemask should be worn. In this

situation respirators should be made available as quickly as possibleMonitor healthcare providers for 14 days after the last known contact

with the sick patient.Healthcare providers should stay home when sick!

Do Not Eat Anything You Cannot Positively ID

“Every mushroom is edible, but some only once."

Galerina autumnalis Brown cap, small fragile ring on

the stem. The lower part of the stem is usually darker brown, sometimes with little tufts of hyphae. Above the ring the stem is usually lighter tan in color and lacks ornamentation. The gills are ~ the same color as the top of the stem and darken with age. The mushrooms are only about 2-5 cm in diameter and the stems are usually less than 2 inches (5 cm). The spore print is a rusty brown.

False Chanterelle

False Chanterelle, is an orange funnel-shaped mushroom which has been confused at times with the true chanterelle

Orange cap up to 8 cm across, initially convex but becoming funnel-shaped. The decurrent gill-like structures are orange, rib-like folds and forked. The orange stem is ~ 5 cm high and lacks a ring

The spore print is white.

Chanterelle Look-a-like Mushrooms

Jack O'lanterns grow in large groups with the stems attached. Chanterelles are usually solitary or in a small bunch with separate stems.

Jack o'lanterns are more orange, less yellow.

Chanterelles will always be near trees due as they are mycorrhizal fungi. Jack O'lanterns may appear where there are no trees.

False Chanterelle “Poisoning” Symptoms

Tom Volk, a leader in mycology from the University of Wisconsin, describes the False Chanterelle or Jack-o-lantern mushroom poisoning as, "Omphalotus olearius won't kill you - it will just make you wish you were dead."   Due to vomiting and diarrhea for several days after ingestion.                      

                          

                 

Isoxazole Derivatives Poisoning

Mushrooms - Amanita muscaria , A. pantherina , A. gemmata , A. cothurnata , A. frostiana , A. crenulata, A. strobiliformus , Tricholoma muscarium

Symptoms occur 30 minute to 2 hours after ingestion, and last for several hours.

Symptoms of Isoxazole Derivatives Poisoning

Nausea and vomiting are quite common,

Central nervous system effects: confusion, visual distortion, a feeling of greater strength, delusions, convulsions, drowsiness, fall asleep and can not be roused. In rare cases the coma-like state can last for more than 24 hours.

No deaths in 100 yearsSpontaneously awaken

Case Presentation

A 24 y/o calls 911 with complaints of abdominal pain and sweating. On arrival to the scene or on arrival to your ED you find the patient to be diaphoretic, with drenching sweats, copious salivation and lacrimation, as well as crampy abdominal pain. He vomits twice and has another episode of diarrhea. Otherwise, his vital signs were stable. His pupils were measured at 3 mm bilaterally and were reactive to light. On auscultation of the lungs, there were coarse crackles up to the mid lung bilaterally.

What is your differential diagnosis?

A 32 y/o family member calls 911 after having episodes of crampy abdominal pain with diarrhea and vomiting as well as blurred vision 2 h after consuming the mushrooms. She also had profuse sweating, lacrimation, and coarse crackles

Inocybe species, Clitocybe dealbata - Muscarine Symptoms of Poisoning

GI Symptoms 20 minutes to 4 hours of ingesting

the mushrooms, and include nausea, vomiting, cramps, and diarrhea

Muscarine Symptoms –SLUDGE-M Excessive salivation, sweating, tears,

lactation (in pregnant women), severe vomiting and diarrhea. May be accompanied by visual disturbances, constriction of the pupils, irregular pulse, decreased blood pressure, and difficulty breathing. Death can occur from respiratory failure.

Treatment of Muscarine Poisoning

Supportive careAtropine

2014 Muscoda Morel Mushroom Festival

2014 Muscoda Morel Mushroom Festival

Case Presentation

The Communication Center dispatches you to the home of an elderly couple (or an elderly couple arrive in the ED), who are complaining of headache, severe nausea, vomiting and diarrhea a couple of hours after eating Morel mushrooms they picked in the woods near their home.

Gyromitrin Poisoning Symptoms

Symptoms occur within 2 to 24 hours after eating a False Morel/Gyromitra esculenta s

Headaches Abdominal distress Severe diarrhea, and vomitingIn severe cases, liver and kidney

damageRed blood cell damage Convulsions & coma can occur

Gyromitrin Poisoning Treatment

Supportive CareGastric decontamination with activated charcoal may

be beneficial within a few hours of consumption. Treat severe vomiting or diarrhea with intravenous

fluids. Monitoring of methemoglobin levels, electrolytes, liver and kidney function

Dialysis Blood transfusions for hemolysis of red blood cells Methylene blue for methemogloinemiaVitamine B6 Pyridoxine for neurologic symptomsFolinic acid replacement

Case Presentation

You receive a 911 call or the 55 y/o female is admitted to your ED with complaints of severe abdominal pain and bloody diarrhea. They are lightheaded with dizziness.

What are your concerns?

What is your differential diagnosis?

Amanitas - The Death Cap & the Destroying Angel

Mushrooms : Amanita phallodies, A. ocreata, A. verna, A. bisporigera, Conocybe filaris, Galerina autumnalis, G. marginata, G. venenata, Lepiotia castanea, L. helveola, L. josserandii & close relatives.

Account for 90 percent of all poisonous mushroom cases.

Amanitas have a bulbous base Death Cap

Caps are generally greenish in color, with a white stem and gills.

The Death Destroying Angel smells sickly sweet White stalk and gills Bulbous base The cap can be pure white, or white at the edge and

yellowish, pinkish, or tan at the center. Has a partial veil, or ring (annulus) circling the upper stalk,

and the gills are "free," not attached to the stalk. The most telltale of the features is the presence of a volva,

or universal veil,

Mechanism and Symptoms of Amanitas Poisoning

a-amanitin slowly attacks the enzyme RNA polymerase in all body cells, particularly the liver. Ultimately affects the central nervous system and kidneys.

As little as 1/3 of the cap may be eaten resulting in death

Stages & Symptoms of Amanita Poisoning

First stage is a latency period of 5 to 24 hours after ingestion, in which the toxins are actively destroying the victim's kidneys and liver, but the victim experiences no discomfort. There may be a feeling of unease

Second stage is a period of about 24 hours characterized by violent vomiting, bloody diarrhea (cholera-like), and severe abdominal cramps.

Third stage is a period of 24 hours during which the victim appears to recover (if hospitalized, the patient is sometimes released!)

Fourth stage is a relapse, during which kidney and liver failure often occurs, leading to death. There may be more than one relapse.

Amanitas Poisoning Treatment

Fluid and electrolyte replacementOral activated charcoal and lactulose IV penicillinCombined hemodialysis and hemoperfusion in two 8-hour

sessions some with "IV thioctic acid, others IV silibininMilk thistle

Prevention of Mushroom Poisoning

Only eat mushrooms you have positively identified yourself. Identify mushrooms a second time during preparation and

cook them properly, unless you know that the species can be eaten raw.

Do not combine mushroom types. Retain a sample of any mushroom you are not well-

experienced with for analysis in case of poisoning. Inform yourself about deadly mushrooms that are look-alikes

of edible ones. "Deadly twins" differ regionally, so take into account regional variation.

Do not gather mushrooms that are difficult to identify, unless you have expert knowledge.

Consume only a small amount the first time

Mushroom Safety Tips

Be cautious with white-capped mushrooms or mushrooms with white gills; this eliminates many hard-to-identify species, including several deadly species.

Do not eat wrinkled, brain-like, or saddle-shaped mushrooms. Beware of any mushroom with a ring on its stalk or any

mushroom that grows out of a cup or has an enlarged base. Avoid LBM's. Species of Little Brown Mushrooms can rarely be

determined by non-professionals. Avoid Boletes which have red pore mouths or which bruise

blue or taste bitter. Do not eat any puffball that is not pure white and uniform in

texture inside. Keep each species that you collect in a separate container. Be aware that some mushrooms cause reactions when

consumed with alcohol.

Wisconsin Creates New Crossbow Season

“With the official signature of Governor Scott Walker the dawn of a new age is finally upon Wisconsin hunters.  Once only legal for hunters age 65 or older, or those with physical disabilities preventing them from using a compound or traditional bow, crossbows will now be legal for hunters of all ages throughout the state's archery deer hunting season.”

Longbows, Crossbows, Composite Bows & Arrow Injuries

A Wisconsin man was injured when fired the crossbow and stuck his thumb in the path of the bow string.  In so doing, he severed part of his thumb. EMS and first responders had a difficult time locating the amputated part, which could not be attached.

Injury prevention education – Teach users to, “Never allow your fore-grip hand’s fingers or thumb to move above the barrel’s flight deck or into the bow string or cables’ release path.”

Types of Bows

Crossbow Injury

Case

A 16-year-old boy sustained a penetrating injury to his left wrist and hand from a broken arrow shaft. This occurred when a hollow carbon fiber arrow broke while he was attempting to shoot it from a compound bow. The shaft of the arrow, broken at its mid portion, entered the left wrist

Arrow Injuries

Treatment of Patient with Arrow Impalement

XrayCT scan to map the

trackSurgical Removal

Pre-hospital & Emergency Treatment of Arrow Impalement

1. Stabilize the arrow/treat as an impaled object by applying adhesive tape or another stabilizer to the base of the shaft.

2. Wrap a clean towel or gauze around the base of the shaft, and then apply direct pressure on the bleeding wound.

3. Assess for and treat airway, breathing issues and shock 4. Avoid moving or bumping the arrow during transport.5. Provide a duplicate arrow if possible to healthcare providers.

A duplicate arrow will help medical professionals determine the size and shape of the arrow and know if they have retrieved all the pieces of the arrow from the victim.

Pro’s and Con’s of Crossbow Hunting

Pro’s - Crossbows allow hunters to get out in the woods more often, and allow them to be more successful hunters.

Pro’s - Crossbow hunting has increased hunting license revenue and has increased the number of bow hunters.

Pro’s – Crossbows provide an effective game control management tool.

Con’s – Increased harvest of deer will decrease the numbers available for gun season.

Con’s – Bow Season may need to be shortened in the future due to increases in harvest affecting long bow hunters.

Con’s – Rifle hunters will move to crossbows shifting more hunter’s into Bow Season resulting in shortening of the season.

Flood Warnings are in Effect for Nearly all of the Local River Gauge Sites in Southern

Wisconsin.

www.youtube.com/watch?v=5ibCL6zMeOk

Firefighters Save 2 from Truck that Rolled into Flooded Ditch – Ashley Luthern Milwaukee

Journal Sentinel June 18, 2014

Two men were injured when their truck rolled over on Highway 41/45 on Wednesday morning and landed in a flooded ditch, the Germantown fire chief said.

"They were very lucky it didn't end up upside down because they could have drowned," Fire Chief Gary Weiss said.

Firefighters Save 2 from Truck that Rolled into Flooded Ditch

Firefighters had to deal with chest-high water in the ditch from heavy rainfall and crossed the ditch by laying ladders across the water to the truck.

Flash Flooding in Wisconsin

LAKE DELTON, Wis. — Flash floods inundated a southwest Wisconsin town Monday for the second time in 10 months, while 60 miles away an embankment along a man-made lake gave way, unleashing a powerful current that ripped homes off their foundations.

The swollen Kickapoo River engulfed nearly the entire village of Gays Mills, WI, forcing about 150 people to evacuate. The town was reduced to a grid of canals with cars submerged up to their windows and parking lots looking like lakes, just as it was last August.

http://www.youtube.com/watch?v=JME8XU8rZNI

Flash Flood Statistics

Thousands of Wisconsinites live along rivers that are periodically swollen from melting snow or rains associated with thunderstorms

Flash flooding is the Number One killer during thunderstorms

One of the most common and widespread of all natural disasters

84 Americans died from floods in 2013Six inches of fast moving water can move

a vehicle & knock over an adultTwo feet of water is enough to make most

cars float At least a couple people in Wisconsin had

to be saved from raging waters in April 2014

Flooding in McFarland, WI

Flash Floods - Floods That Happen in a Flash!

Flash floods generally develop within 6 hours of the immediate cause.

A rapid rise of water over low-lying areas. Flooding may occur well away from

where heavy rain initially fell. (This is especially common in the western United States where low lying areas may be very dry one minute, and filled with rushing water from upstream the next)

Rainfall from slow-moving or multiple thunderstorms over the same area, rapidly changing the water levels in stream or creeks and can turn small waterways into violent, raging rivers

Urban areas are especially prone to flash floods due to the large amounts of concrete and asphalt surfaces that do not allow water to penetrate into the soil

Causes & Effects of Flash Floods

Heavy rains falling over a short period of time (a few hours or less) Ice jams or debris jams on rivers Dam or levee breaks.  The sudden buildup of water can cause a large crest of water to move quickly downstream, wiping out most everything in its path.  Capable of rolling boulders, tearing out trees and destroying buildings quickly with little or no warning Can cause mudslides. June 2013 a mudslide from a flash flood & debris left on Highway 78 outside of Mazomanie resulted in rerouting traffic

Flash Floods from Rainfall & Snow Melt

Wisconsin Flash Floods

1884 Eau Claire – A 27-foot flood carried away houses and all the bridges in Eau Claire, WI

1911 Sparta - Heavy rains filled the upstream tributaries to the Black River, two dams above Black River Falls gave way. The river rose 20 feet over its already high level and rushed through city all day. 80 buildings and 42 acres of land, including entire hillside neighborhoods, were swept away

1943 Black River Falls - Bear Creek jumped its banks after torrential rains. Homes and businesses were inundated 3-4 feet deep, bridges were washed out, and roads destroyed. In addition, water mains broke, which not only reduced the water supply but contaminated water still available. At least one person drowned

1993 Statewide Flooding in WI – Snowy winter, 2-3 times normal rainfall in Upper Mississippi Valley. Thunderstorms with 2 to 7 inches of additional rain on June 17-18 resulted in every major river in Wisconsin flooding; 20 dams were overtopped, broken, or washed away.

2008 Southern Wisconsin – Seven southern counties received more than a foot of rainfall in June. The town of Ontario received more the 6 inches on June 8, and Baraboo more than 17 inches during the month. Lake Delton, in the Wisconsin Dells, breached its dam and emptied into the nearby Wisconsin River on the 9th

Dangers of a Flash Flood Rescue

Land Rescues from Raging Water http://www.huffingtonpost.com/2013/01/25/

australian-boy-flash-flood_n_2551901.html Most rescue boats can only accommodate three or four people

Boat Rescues of Flash Flood Victims

If someone falls into the water, a spotter on the boat would try to keep them in sight for as long as possible.

Rescuers need to prioritize the injured, young and elderly

Most rescue boats can only accommodate three or four people

Hazards to Rescuers

Environmental Hazards Extreme temperatures Heat & Cold – Hypothermia, hyperthermia, exhaustion Weather – rain, snow, winds, fog

Water/Aquatic Hazards – Seaweed, bacteria/viruses, biohazards, sharp objects, crushing objects, raging water

Electrical hazards Operation hazards

Sieves, Strainers Eddies, waves, upstream V’s, downstream V’s

Personal hazards Tripping Steep slippery terrain Drop offs Stationary objects Holes, manholes Entanglement or injury from hidden obstructions above and below

the water Drowning

Swift Water Characteristics

Eddies - Upstream water flows around obstructions in the current leaving a void on the downstream side of the obstruction, causing the downstream to flow upstream to fill in the void behind the obstruction.

Upstream V's – Caused by water striking an object and water going around it. An area that may be trapping a subject against an obstacle.

Downstream V's - Caused by water moving around several obstacles coming together in the path of least resistance. These Downstream V's will contain some of the fastest moving water in the channel. If the subject does not become trapped, the downstream V's have the highest probability of containing the subject.

Pillows are also indicators of a submerged or partially submerged obstacle. The pillow will lie upstream if the obstacle is completely below the surface & downstream if the obstacle extends above the surface.

Holes - Void formed by water swirling around the obstacle. Water flows back into the hole to fill the void which may cause a strong flow of upstream current immediately following the obstacle.

Swift Water Characteristics

Strainers – Debris forms a colander to trap

A Sluice is a narrow section of the waterway.

PPE

Proper PPEWet suit, dry suit, exposure suit

Personal Floatation Device

Kayak HelmetLifelines/ropesLeather glovesHiking or work boots Waterproof flashlight or headlamp

WhistleKnife

Scene Assessment

Scope, magnitude and type of water rescue Equipment & resource needs

Boats Tow trucks Rescue lines Pike poles Air-charged hoselines Inflatables that can be dropped

Environmental factors including Changing weather Amount of remaining daylight Water levels Current change Hazards Number of victims Risk:Benefit – Rescue vs Recovery Access

Evaluate the victim – Condition of the victim. Can they assist in the rescue

Water-Rescue Principles

Reach – Throw - Row – Go Reach using long, handled tools, such as pike poles, to try to reach

victims. Throw ropes with life rings or other floating devices victims. Air-filled

objects, such as footballs or soccer balls, can be thrown to victims so they have something to hold onto while in the water.

Push, motor or row boats to victims if necessary. Row - Boats can be extremely dangerous in fast water rescues.

Propellers on outboard motors can become entangled in branches, vines or other debris or even in fences in higher floodwaters

Go - Rescuers entering the water, need PPE floatation gear, head and foot protection, survival or flotation suits. Boots are tied tightly to reduce the amount of water, hydrocarbons, chemicals or other hazards that can get in. Tie off rescuers so they can be retrieved quickly. They need to carry a knife to cut the rope if they become entangled

Reach

Throw

Receiver Position Instructions

Stabilization LineStabilization LineAllows victim to maintain head above waterAllows victim to maintain head above water

Row

Shallow Water CrossingShallow Water Crossing

Crossing to VehicleCrossing to Vehicle

Go For Help!

Mechanism of Injury in Flash Floods

Low water crossings – drownings http://www.nws.noaa.gov/os/water/XWATER/PAM/

VIDEOS/30SEC/30SEC.MOV

Most vehicles will then tend to roll over, trapping those inside and washing them downstream

Electrocution - Water covering the electrical outlets or cords are submerged. If you see sparks or hear buzzing, crackling, snapping or popping noises --get out! Stay out of water that may have electricity in it!

Trauma due to fast moving sharp and dull objects in the water – punctures, lacerations, crush injuries

Assessment of Victims of Flash Floods

Scene Safety ABC’s or MARCH = Massive Bleeding,

Airway, Respirations, Circulation, Head & Hypothermia

Secondary Survey

Temperature 37 (98.6) 36 35 (95)

33 (91.4) 32 (89.6) 31 (87.8) 28-30 (82.4-86) 27 (80.6) 20 (68)

Clinical Findings Normal Increased metabolism Maximal shivering

Altered mental status Shivering stops/pupils dilate Non-palpable pulses

LOC / V-fib / Muscle rigidity No DTR / No pupillary reflex Asystole

Features of Hypothermia

Rewarming Techniques

Passive External Rewarming

Active External Rewarming

Active Core Rewarming

Core temperature continues to fall after rewarming is instituted

Simple temperature equilibrationRestoration of peripheral circulation

sets up a countercurrent flow with cold, acidotic blood shunted to the core

Core Temperature Afterdrop

Treatment

Hypothermia can be rewarmed passively if mild (> 32oC) and the patient is stable

Unstable and temp < 32oC - aggressive active core rewarming & partial cardiac bypass if condition deteriorates

Cardiac instability and risk of V-fib begins < 30oC

Vital signs are difficult to assess at temperatures < 30oC

Do not begin CPR if organized rhythm is present and temp is < 30oC

Soft Tissue, Musculoskeletal & a Variety of Injuries from Debris in Flood Water

AbrasionsLacerationsPuncture woundsAvulsionsHematomasCrush injuriesLimb entrapmentSprains & strainsFractures & dislocationsHead injriesOther

Drowning

Half of the drowning deaths in 48 states occur in motor vehicles

Steps to Get Out of a Vehicle that is SubmergingDon’t Panic, Don’t Use Cell Phone – You have ~ 1 minute to get out1st Unclick seatbelts2nd Roll down or break the window (Preferably back)3rd Don’t open the door4th Children out first (Youngest to oldest)5th Get out through the open window ASAP!6th If you can’t break the window hold your breath till the

pressures equalize then open the door.

http://www.popularmechanics.com/outdoors/survival/tips/how-to-escape-a-submerged-car-15510924

Prevention of Injury During Flash Floods

Avoid flooded bridges Never drive through flooded roadways.  Turn around, don't drown.  Be especially cautious at night when it is harder to recognize flood

dangers. When a flash flood is headed your way, you may only have seconds

to save your life.  Abandon all personal property and flee to higher ground if a flash

flood is approaching. Any delay, even for a second, could be the difference between life and death

If your vehicle stalls, abandon it and seek higher ground immediately

Camp well above the stream level.  It is also a good idea to plan an escape route in advance should a flood occur

Don’t allow children to play near high water, storm drains, or ditches

Flash Flood Watch is a warning to be alert to rising water & prepare to move to higher ground

Flash Flood Warning a flash flood is occurring or is imminent in a specific area.  Residents need to get out of the danger area and head to higher ground immediately warning

Turn Around Don’t Drown

Flooding can undermine roadbeds

Other Injury Prevention Reminders

Stay out of basement, or any room, if water covers the electrical outlets or if cords are submerged.

Monitor local radio and television (including NOAA Weather Radio), internet and social media for information and updates.

Get out of areas subject to flooding and get to higher ground.

If told to evacuate, do so immediately. Be sure to lock your home as you leave. If you have time, disconnect utilities and appliances

Do not walk through flood waters.

Disaster Supplies & Communications

Have disaster supplies on hand. Flashlights, headlights & extra batteries Portable, battery-operated radio and extra batteries First aid kit and manual Emergency food and water/pet provisionsNon-electric can opener Essential medicines Cash and credit cards Sturdy shoes Ask an out-of-state relative or friend to serve as the "family

contact” since it is easier to call out on long distance lines

Remember Post Traumatic Stress for Victims & Rescuers

Don’t Let the Rains Fall