3. Drowning
s 8000 deaths per year in US
s 4th most common cause of death in adults
s 3rd most common cause in children
s Males have 5 times greater death rate
s Blacks have 3 times higher death rate
s 40% of deaths are < 4 yrs old
s 50% of those who die in swimming pools
are < 10 yrs old
4. Risk Factors
s Age
s Location
s Gender
s Race
s Ability to Swim
s Drugs and Alcohol
s Underlying Disease
5.
6. Submersion Injuries:
Pathophysiology
s Asphyxia: Anoxic and ischemic injury
s Fluid Overload
s Pulmonary Injury
s Hypothermia/Diving Reflex
7. Asphyxia/Hypoxia
s Breath holding +/- laryngospasm
s PAO2 falls rapidly in 1st minute
s PACO2 rises and pH falls less rapidly
s Hyperventilation - PACO2 rises less while
PAO2 falls at about the same rate
10. Response to Submersion
s Stage I (0-2 min)
– Aspiration and laryngospasm
s Stage II (1-2 min)
– Swallows water
s Stage III (variable)
– Laryngospasm aborted (85-90%) and
aspiration of water
s Stage III (variable)
– Laryngospasm reoccurs with anoxia, sz,death
11. Fresh Water Drowning
s Hypotonic
– Hemodilution
s Decreased electrolytes, Hct, Hgb
– Hemolysis
s Hyperkalemia
s Increased CVP
12. Salt Water Drowning
s Hypertonic
– Draws water into respiratory tract
– Hemoconcentration
s Increase electrolytes, Hct, Hgb
s Decreases CVP
13. Fluid Aspiration
s Animal studies found that 22 ml/kg
needs to be aspirated before serum
electrolytes change
s Usual aspiration into lungs < 3-4 ml/kg,
however swallowed water can be
aspirated later
s In most series: serum electrolyte
changes are mild, non-life threatening
14. Pulmonary Injury
s Aspirated fluid decreased PaO2 due to reflex
contraction of terminal airways leading to V/Q
mismatch
s Fresh water destroys surfactant leading to alveolar
collapse and retards transudation of fluid causing
intrapulmonary shunt and hypoxemia
s Salt water leads to fluid filled but perfused alveoli
leading to intrapulmonary shunt and hypoxemia
s Aspiration of fluid leads to increased pulmonary
resistance and decreased compliance
16. Hypothermia
s Exerts protective effects through
reducing cerebral metabolism
– decreases to 50% at temp of 28o C
– below 22o C, cerebral activity abolished
s Diving Reflex:
– Neurogenic reflex which shunts blood away
from nonessential organs
– Associated with bradycardia
– Triggered by submersion of the face, fear,
and cold water
17. Hypothermia
s May cause the following:
– Compromised neutrophil migration and release
– Decreased drug metabolism
– Abnormal platelet number, morphology, function
– Decrease cardiac contractility and arrhythmias
– Vasodilation, hypotension, renal failure, death
18. Clinical Presentation
s Variable presentation:
– Awake and alert
– Awake, lethargic
– Children may have had brief apnea
– Hx of choking, coughing or vomiting
– Comatose
– Cardiac arrest
19. Clinical Exam
s Pulmonary
– Resp distress, rhonchi, rales, wheezing
s Cardiovascular
– Arrythmias, ischemia
s GI
– Abd distention, vomiting, aspiration
s Neurological
– Signs of cerebral hypoxia
s Hypothermia
s Associated Injuries: C-spine
20. Prehospital Care
s Safety of rescue workers
s Pull victim out of water
s Mouth to mouth resuscitation
s Suspect head/neck injuries - backboard
s BCLS/ACLS as needed
s Administer oxygen
s Avoid heimlich maneuver/lung drainage
s Transport all patients
21. Emergency Department
Assessment
s ABC’s
s Vital signs - including rectal temp, pulse ox
s Oxygen
22. Asymptomatic Patient
s Hx - incident, submersion time, temp of water,
trauma involved, drug/alcohol, past health, current
complaints
s PE - also assess for other injuries
s Lab - ABG, CXR, CBC, Chem-7, U/A, think C-spine
s Tx - Oxygen at 8-10 liters, IV, Monitor, Observe for
4-12 hours
23. Symptomatic Patient
s HX/PE - same as for asymptomatic pt
s Lab - consider PT/PTT, LFT’s, CPK’s
s Tx
– open airway, remove emesis particles, NGT
– oxygenate at 10 l/min
– consider CPAP or intubate with PEEP
– Warm patient
– Hospitalize in monitored environment
24. CPR
s Airway and intubation
s ACLS protocol with attention to acidosis
s C-spine protection
s Mechanical ventilation with PEEP
s No steroids or prophylactic antibiotics
s Maintain urine output at 50 cc/hr
25. Respiratory Assessment
s Clear the airway, achieve ventilation
s ABG
s CXR
s Assess gag and cough reflexes, ability
to protect airway
26. Intubation
s If pCO2 > 50
s If pt requires > 40% FiO2 to maintain
adequate paO2
s Gross pulmonary edema
s Poor or absent cough and gag reflexes
27. Ventilation
s CPAP - spontaneously breathing with
hypoxia
s PEEP - decreases intrapulmonary
shunting, reduces V/Q mismatch, and
increases the functional residual
capacity resulting in increased PaO2
s PEEP may also prevent secondary
drowning from RDS
s PEEP disadvantage - may worsen
cerebral edema
28. Ventilation
s Persistent hypoxia may be result of
aspirated foreign material - aggressive
suctioning or bronchoscopy may help
s ECMO - consider in patients unresponsive
to 100% oxygen and PEEP
29. Pulmonary
s Bronchospasm can be treated with
beta-agonists
s Steroid administration has not shown
survival benefit
s Prophylactic antibiotics have not
demonstrated improved survival
30. Cardiovascular
s Monitor HR, rhythm, BP, cap refill, UO
s Consider CVP/PAWP monitoring
s Adequate fluid resuscitate before using pressors
s Monitor volume status
s Treat metabolic acidosis with bicarb
31. Neurologic Assessment
s Primary importance for prognosis
s Assess level of consciousness - AVPU
s Assess GCS
s Level of consciousness in ED:
– A - Awake
– B - Blunted
– C - Comatose
s C1 - decorticate
s C2 - decerebrate
s C3 - flaccid
32. Cerebral Resuscitation
s Goal is to keep ICP below 20 mm Hg and
CPP above 50 mm Hg
s Primarily depends on rapid stabilization,
correction of hypoxia and acidosis
s Treat agitation, seizures
s Treat increased ICP:
– elevate head, hyperventilate
– osmotic and loop diuretics
– barbiturates
33. Cerebral Resuscitation
s Unproven therapies:
– therapeutic dehydration
– induced hypothermia
– barbiturate coma
– paralysis
– Ca channel blockers
– oxygen radical scavengers
35. Hypothermia Management
s Below 28’ C - arrhythmias occur
s Below 25’ C - hypotension
s Management:
– Remove wet clothes
– Internal rewarming techniques
s NG irrigation, enemas, Foley, lavage
s If pt sustained prolonged hypoxia/asphyxia
consider maintaining core temp near 30’ C
36. Prognostic Variables
s At the Scene:
– Length of submersion
s > 5 minutes associated with poor outcome
– Water temperature
– CPR initiated
– First gasp within 5 minutes of CPR
37. Prognostic Variables
s In the ED:
– CPR still required
– pH < 7.0 - 7.1
– Submersion hypothermia
– Mechanical ventilation
– Level of consciousness
– Pupils
38. Pediatric Survival
s Unfavorable outcome if
– comatose state
– lack of pupillary reflex
– male sex
– initial blood glucose concentration
s In 194 children, rule was 100% specific with
65% sensitivity
Graf, Ann Emerg Med, 1995
39. Secondary Drowning
(Post immersion syndrome)
s Onset delayed from 1 to 72 hours
s Occurs in 2-15% of near drowning cases
s Respiratory deterioration and possible death
s Mechanism:
– loss of surfactant from chemical, anoxic or
osmotic damage to the pneumatocytes
40. Immersion Syndrome
s Sudden death after immersion in very
cold water
s Cause thought to be vagally-mediated
bradyasystolic cardiac arrest or
ventricular fibrillation
42. Drowning Prevention
s Public education
s Legislation
s Proper supervision
s Mandatory CPR for pool owners
s Mandatory swimming lessons for children
s Proper use of life preservers
