case study near drowning - caccn study near drowning.pdf · perhilar, or diffuse pulmonary edema...

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Case Study:Case Study:

Near DrowningNear Drowning

Annabelle SmithAnnabelle Smith

RN, RN, BScNBScN

Case Study:

Near Drowning

Annabelle Smith

RN, BScN

Conclusion: Near DrowningConclusion: Near Drowning

Effects on surfactant key to treatment Effects on surfactant key to treatment requirements and survival requirements and survival

Initial hypothermia may be protective to Initial hypothermia may be protective to CVS & neurological systemsCVS & neurological systems

Water source importance debatable on Water source importance debatable on outcome resultsoutcome results

Amount of water & length in elements Amount of water & length in elements more importantmore important

Outline: Case StudyOutline: Case Study

••Definition Definition –– Near DrowningNear Drowning

••Presentation of our Presentation of our

••PathophysiologyPathophysiology

••Review of case studyReview of case study

••Conclusion Conclusion

Near DrowningNear Drowning

Aka Aka ““submersion injurysubmersion injury””

““survival, at least temporarily after survival, at least temporarily after

suffocation by submersion in a liquid suffocation by submersion in a liquid

mediummedium””

““wetwet”” near drowning near drowning -- aspiration of fluid aspiration of fluid

into lungsinto lungs

““drydry”” near drowning near drowning –– period of asphyxia period of asphyxia

secondary to secondary to laryngospasmlaryngospasm

Near Drowning SyndromeNear Drowning Syndrome

Depends on:Depends on:

––Duration of submersionDuration of submersion

––Amount of fluid aspiratedAmount of fluid aspirated

––Severity of hypoxiaSeverity of hypoxia

““One tough little ladyOne tough little lady…”…”

Aboriginal, 73 year old femaleAboriginal, 73 year old female

PMHX: DM2; HTN; HypothyroidismPMHX: DM2; HTN; Hypothyroidism

PSHX: PSHX: CholecystectomyCholecystectomy; R knee replacement; R knee replacementMedsMeds–– ASAASA

–– AmitriptylineAmitriptyline

–– NorvascNorvasc

–– LipitorLipitor

–– EnalaprilEnalapril

–– GlyburideGlyburide

–– MetforminMetformin

–– AvandiaAvandia

–– LL--thyroxinethyroxine

““One tough little ladyOne tough little lady…”…”

October 1 @ 1800October 1 @ 1800

Hunting moose in the Island Lake water Hunting moose in the Island Lake water system, Northern Manitobasystem, Northern Manitoba

Fell out of canoe while trying to assist her Fell out of canoe while trying to assist her groupgroup

Submerged for unknown amount of timeSubmerged for unknown amount of time

Son performed rescue breathingSon performed rescue breathing

Walked over an hour to STP nursing Walked over an hour to STP nursing stationstation

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@ STP nursing station@ STP nursing station

Initial vitals: Initial vitals:

–– Pulse 74Pulse 74

–– Resp. rate 30Resp. rate 30--4040

–– Temperature 30 degrees CTemperature 30 degrees C

–– O2 O2 satssats-- unable due to tempunable due to temp

–– NeuroNeuro: intact: intact

–– EKGEKG-- no acute changes; sinus rhythmno acute changes; sinus rhythm

–– C/S: crackles to bases; pink frothy sputumC/S: crackles to bases; pink frothy sputum

–– Projectile emesisProjectile emesis

–– RBS: 22.6RBS: 22.6

During During MedivacMedivac TransferTransfer

Frequent Frequent desaturationsdesaturations during flightduring flight

c/o:c/o:

–– GeneralizedGeneralized

pain pain

–– SOBSOB

–– Cough Cough

Arrives @ HSCArrives @ HSC

T 34 P 84 BP 96/59 RR 32 T 34 P 84 BP 96/59 RR 32

O2 O2 satssats with 15L 92%with 15L 92%

GCS 15/15GCS 15/15

Transferred to MICU Transferred to MICU

–– RR 53RR 53

–– BIPAPBIPAP

–– RespResp crackles at basescrackles at bases

PathophysiologyPathophysiology

Drowning begins with:Drowning begins with:

––Period of panicPeriod of panic

––Loss of normal breathing patternLoss of normal breathing pattern

––Breath holdingBreath holding

––Air hungerAir hunger

––Struggle by victim to stay above Struggle by victim to stay above waterwater

Aspiration > 11 ml/kg of body Aspiration > 11 ml/kg of body

weightweight……before blood volume before blood volume

changes occurchanges occur

Aspiration > 22 ml/kg of body Aspiration > 22 ml/kg of body

weight before electrolyte changes weight before electrolyte changes

occuroccur

Patient outcomes affected by:Patient outcomes affected by:

Initial treatment & time to Initial treatment & time to treatment centretreatment centre

Temperature of water Temperature of water

Length of submersion timeLength of submersion time

Presence of contaminantsPresence of contaminants

Freshwater / saltwater different Freshwater / saltwater different microorganismsmicroorganisms

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Patient outcomes affected by:Patient outcomes affected by:

Gram negative bacteria in drowning Gram negative bacteria in drowning

victims more virulentvictims more virulent

––Can cause immediate lethal sepsis Can cause immediate lethal sepsis

or infections months after incidentor infections months after incident

Strep or staph can also be presentStrep or staph can also be present

Fungus: incubation time 1Fungus: incubation time 1--4 weeks to 4 weeks to

6 months; often resistant 6 months; often resistant

Near Drowning: Pulmonary EffectsNear Drowning: Pulmonary Effects

Pulmonary insufficiency can develop Pulmonary insufficiency can develop insiduouslyinsiduously or rapidlyor rapidly

Leads to varying degrees of hypoxemiaLeads to varying degrees of hypoxemia

s/ss/s::

–– SOBSOB

–– RalesRales

–– WheezingWheezing

CXR / CT: vary from normal to localized, CXR / CT: vary from normal to localized, perhilarperhilar, or diffuse pulmonary edema, or diffuse pulmonary edema

Causes of Hypoxemia Causes of Hypoxemia

Reflex Reflex inspiratoryinspiratory efforteffort

Damage to surfactantDamage to surfactant

Decreased lung complianceDecreased lung compliance

Ventilation perfusion mismatchingVentilation perfusion mismatching

Intrapulmonary shunting Intrapulmonary shunting

……causes diffuse organ dysfunctioncauses diffuse organ dysfunction


Surface tension properties of surfactant Surface tension properties of surfactant

affectedaffected

Surfactant Surfactant ““washed outwashed out””

Water in alveoli Water in alveoli

–– Damages type 2 Damages type 2 pneumocytespneumocytes

–– Prevents production of new surfactant Prevents production of new surfactant

Loss of surfactant functionLoss of surfactant function

Near Drowning: Pulmonary Effects Near Drowning: Pulmonary Effects

Alveoli become unstableAlveoli become unstable

Complete/partial alveolar Complete/partial alveolar collapsecollapse……

Loss of ventilation resulting in Loss of ventilation resulting in intrapulmonary shunting & intrapulmonary shunting & hypoxemiahypoxemia

Near Drowning: Pulmonary Effects Near Drowning: Pulmonary Effects

Increased airway resistance secondary to:Increased airway resistance secondary to:–– Plugging of airway with debrisPlugging of airway with debris

–– Release of inflammatory mediators that result Release of inflammatory mediators that result on vasoconstrictionon vasoconstriction

–– May impair gas exchangeMay impair gas exchange

Combination Combination …… damage to damage to alveolar capillaries & alveolar capillaries & interstitiuminterstitium………… leads to ARDSleads to ARDS

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ARDS: develops within 48 hours in ARDS: develops within 48 hours in approximately 40% of approximately 40% of neardrowningneardrowningvictimsvictims–– Hallmarks of ARDS:Hallmarks of ARDS:

Decreased lung complianceDecreased lung compliance

Severe hypoxemiaSevere hypoxemia

Bilateral infiltrates on CXRBilateral infiltrates on CXR

Recovery occurs in 80% of casesRecovery occurs in 80% of cases

Only effective treatment is reversal of Only effective treatment is reversal of hypoxemia with mechanical ventilator hypoxemia with mechanical ventilator supportsupport

Neurologic EffectsNeurologic Effects

Hypoxemia & ischemia cause Hypoxemia & ischemia cause

neuronal damageneuronal damage

Can produce cerebral edema & Can produce cerebral edema &

elevation in ICPelevation in ICP

20% sustain neurologic damage 20% sustain neurologic damage ……

limits functional recoverylimits functional recovery

Cardiovascular effectsCardiovascular effects

Arrhythmias secondary to Arrhythmias secondary to

hypothermia & hypoxemiahypothermia & hypoxemia

Sinus Sinus bradycardiabradycardia & & atrialatrial fibrillation fibrillation

more common than ventricular more common than ventricular

fibrillation or fibrillation or asystoleasystole

Acid Acid –– Base & ElectrolytesBase & Electrolytes

Metabolic & respiratory acidosisMetabolic & respiratory acidosis

Significant electrolyte balances do not Significant electrolyte balances do not generally occur except those submerged generally occur except those submerged in unusual mediain unusual media

Dead Sea: extremely concentrated Dead Sea: extremely concentrated seawater leads to:seawater leads to:

–– HypernatremiaHypernatremia

–– HypermagnesemiaHypermagnesemia

–– hypercalcemiahypercalcemia

Renal EffectsRenal Effects

Failure rarely occursFailure rarely occurs

If it doesIf it does……

–– Usually due to acute tubular necrosisUsually due to acute tubular necrosis

Results from:Results from:

HypoxemiaHypoxemia

ShockShock

HemoglobinuriaHemoglobinuria

MyoglobinuriaMyoglobinuria

Back to our case studyBack to our case study……

Respiratory complication:Respiratory complication:

–– BipapBipap Oct 2 Oct 2 –– 44thth

–– ABG Oct 2:ABG Oct 2:

7.41 / 33 / 92 / 217.41 / 33 / 92 / 21

Pre intubation further Pre intubation further decompensationdecompensation::7.42 / 35 / 60 / 22 7.42 / 35 / 60 / 22

SatsSats: 88% with decrease to 20% during intubation : 88% with decrease to 20% during intubation

attemptsattempts

–– CXR : bilateral edemaCXR : bilateral edema

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Case study contCase study cont’’dd……

Required AC ventilation with paralysisRequired AC ventilation with paralysis

–– FentanylFentanyl; ; midazolammidazolam; ; propofolpropofol; & ; & rocuroniumrocuronium

AC : ARDS net protocol ventilation with trials of AC : ARDS net protocol ventilation with trials of

PSV for 8 daysPSV for 8 days

Hospital day 11: able to tolerate PSV ventilationHospital day 11: able to tolerate PSV ventilation

Hospital day 14: transfer to Seven Oaks Hospital Hospital day 14: transfer to Seven Oaks Hospital

ICUICU

–– PSV 20; peep 14PSV 20; peep 14

–– ABG: pO2 76; ABG: pO2 76; satssats 9494

CXR resultsCXR results

Oct 2: bibasilar pulmonary opacities Oct 2: bibasilar pulmonary opacities

with probable bilateral pleural with probable bilateral pleural

effusionseffusions

Oct 3: opacities predominate in Oct 3: opacities predominate in

mid/lower lungs; significant mid/lower lungs; significant

progression; pulmonary edemaprogression; pulmonary edema

Oct 4: @ 0830Oct 4: @ 0830-- no new changes; later no new changes; later

in dayin day-- R sided effusion; R sided effusion; intubatedintubated

CXR results contCXR results cont’’dd……

Oct 5: worsening L base R/T Oct 5: worsening L base R/T pulmpulm. .

Edema or ARDSEdema or ARDS

Oct 6: extensive alveolar Oct 6: extensive alveolar

consolidationconsolidation

Oct 10: extensive bilateral opacities Oct 10: extensive bilateral opacities

and consolidation; ARDSand consolidation; ARDS

Oct 11: increasing degree of Oct 11: increasing degree of

consolidationconsolidation

Culture ReportsCulture Reports

Oct 3: MSUOct 3: MSU-- >10*8 E. Coli>10*8 E. Coli

Oct 4: Oct 4:

–– SPT SPT -- 3+ PMN; 4+ GPC; 3+ GPB; 1+ GNB3+ PMN; 4+ GPC; 3+ GPB; 1+ GNB

–– ETT ETT –– 4+ PMN; 1+ GPB; 2+ GPC; 1+ GNB4+ PMN; 1+ GPB; 2+ GPC; 1+ GNB

Positive ETT secretions: strep pneumonia Positive ETT secretions: strep pneumonia & staph & staph aureusaureus

Temp did not elevate; WBC elevatedTemp did not elevate; WBC elevated

ABxABx: : cefuroximecefuroxime; ; cefotaximecefotaxime; ; azithromycinazithromycin; & ; & vancomycinvancomycin

Renal FunctionRenal Function

Scanty urinary output throughout hospital Scanty urinary output throughout hospital

staystay

LasixLasix usedused

On transfer: fluid balance +On transfer: fluid balance +veve: 17 L: 17 L

CreatinineCreatinine rise to 85 (admission 67)rise to 85 (admission 67)

No dialysis requiredNo dialysis required

Possible GI bleed (no source found)Possible GI bleed (no source found)

–– HgbHgb drop to 68drop to 68

CT CT abdabd: normal: normal

CT brain: normalCT brain: normal

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PatientPatient’’s final outcomes final outcome……

Transferred out of Seven Oaks ICU to Transferred out of Seven Oaks ICU to

general wardgeneral ward

Died November 15, 2007 due to Died November 15, 2007 due to

persistent pulmonary issuespersistent pulmonary issues




Importance of water source debatable in Importance of water source debatable in regards to treatment & patient outcomeregards to treatment & patient outcome


Be vigilantBe vigilant……..

Be preparedBe prepared……

ItIt’’s a matter of times a matter of time……

Appropriate, aggressive respiratory & Appropriate, aggressive respiratory &

multisystem support is the keymultisystem support is the key

•Be vigilant…

•Be prepared…

•It’s just a matter of

time…

•Appropriate,

aggressive respiratory

& multisystem support

is key

QUESTIONS ???QUESTIONS ???

Questions???




Water source importance debatable on Water source importance debatable on outcome resultsoutcome results


case study near drowning - caccn study near drowning.pdf · perhilar, or diffuse pulmonary edema...

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