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DROWNING

EZYAN ZAMZUARY



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DEFINITION…

• Drowning syndromes: range btwminimal aspiration of water withgood survival to severe pulmonary

injury with death

• Drowning: a process ehwreby airbreathing animals succumb on

submersion in a liquid

• Near drowning: submersion withtemporary survival



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pathophysiology



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DROWNING can be primaryevent but can also happens

secendory to:• Seizure

• Head/spine trauma

• Cardiac arrythmias

• Hypothermia

• Alcohol/drug ingestion• Syncope

• Apnea



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Classification of victim

• Asymptomatic

• Symptomatic

– Altered vital signs, anxious appearance,tahypnnea, hypoxia, methabolicacidosis, Altered level of consciousness,neurologic deficit, cough, whizzing,

hypothermia, vomiting, diarhhoea• Cardiopulmonary arrest

– Apnea, asystole, VT/fibrillation,

bradycardia



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Pre-hospital care

Carefull Immediate rescue from water↓

Assessment of ABCs

↓

Cervical spine control/protection

↓

Initiate CPR if necessary→↓

breathing

High flow O2 via facemask

Non breathing

PPV

Fail to recover spontaneousrepiratory effort or remain

unconscious

Endotracheal

Intubation

HOSPITAL



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Hospital careGCS ≥ 13

SPO2>95

GCS < 13

SPO2<95

Cervical spine clear Clear

Ancillary test Only as indicated ABGFBC, BUSE, glucose,

PT/APTT, CK, urinemyoglobine, urine drugscreenCXRECG

Respiratory support O2 Keep SPO2>95% Intubation and PPV as

needed

monitor Oxygen saturation Oxygen saturationAcid-base status Temperaturevolume status

OBSERVE 4-6 H ICU



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Secondary survey

• Head to toe examination

– Look for possible cause of incident

–

Altered sensorium after recussitation – Head injury

– Cervical spine injury

– Epilepsy – Cardiac dysrhythmias

– Diving injuries

– Serial GCS assessment



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management

Correction of ….

• hypoxia

• Volume depletion and acidosis• Hypothermia

• others



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hypoxia

• Maintain spo2 > 95%

• O2 supplement for all patient

• ET intubation – Altered level of consciousness and

inability to protect airway or handle

secretion – Respiratory failure

– High alveolar –arterial gradient: PaO2 of 60-80mmHg or less on 15L oxygen nonrebreathing mask



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volume depletion andacidosis

• Volume depletion is common,secondary to PE andintracompartmental fluid shift,

regardless of the type of fluidaspirated

– Rapid volume expansion using isotonic

crystalloid(20mls/kg) or colloid• Most acidosis is restored after

correction of volume depletion and

oxyfenation



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hypothermia

• All wet clothing should be removedand patient dried

•

Provide adequate insulation(wrap ptin clean and dry blanket)

• External warming if necessary

• All fluids given should be warmed



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others

• Nasogastric tube placement –removal of swallowed water anddebris

• Bronchoscopy may be needed if suspected to have foreign material,such as debris or vomitus plugs in

the airway



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COMPLICATION

PULMONARY

• Pulmonary hypertension

• Postobstructive pulmonary edema• Pneumonia

• Chemical pneumonitis

CNS

• Primary CNS injury

• Secondary CNS injury



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COMPLICATION

CARDIOVASCULAR

• Hypovolemia d/t fluid losses frincrease capillary permeability

• Myocardial dysfunction

• Primary arythmias

INFECTION



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OUTCOME

• Uncomplicated

– Asymptomatic/mildly symptomatic

• Observed 4-6hours

– Secondary drowning

• Respiratory deterioration after intial stablepresentation



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Complicated

• Not requiring CPR

– Complete recovery within 48 hours isexpected

– some with significant aspiration maydevelop severe ARDS

• Bystander CPR(at scene) guarded

prognosis

–

Paeds: 20% die in hospital; 5% severeHIE



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• CPR in ED poor prognosis

– Sustain significant anoxic or ischemicinsult to the brain/ vital organs

– Complete neurologic recovery is rare



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REFERENCE

• Near drowning, guide to theessentials in emergency medicine;shirly ooi 2004

• tintinelli



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• THANK YOU

drowning ane

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