DrowningDrowning

David Slocum MDDavid Slocum MD

Albany Medical CenterAlbany Medical Center

MiraclesMiracles

Matthew GrangerMatthew Granger 14 month old14 month old 20-40 minutes20-40 minutes

VocabularyVocabulary

Drowning – death within 24 hoursDrowning – death within 24 hours

Near-drowning – survival past 24 hoursNear-drowning – survival past 24 hours

Who?Who?

Usually young, healthy individualsUsually young, healthy individuals

2006 Drowning2006 Drowning

U.S.A. – 5000 diedU.S.A. – 5000 died

Worldwide – over 100,000 diedWorldwide – over 100,000 died

EpidemiologyEpidemiology

500,000 submersion events annually500,000 submersion events annually

2nd cause of death – children under 152nd cause of death – children under 15

Injury rangesInjury ranges TransientTransient Profound neurological deficitProfound neurological deficit

Three PeaksThree Peaks

ToddlersToddlers

AdolescentsAdolescents

ElderlyElderly

ToddlersToddlers

ToiletsToilets

BathtubsBathtubs

BucketsBuckets

Coastal AreasCoastal Areas

Swimming pools more likelySwimming pools more likely

AdolescentsAdolescents

StupidityStupidity

Young AdultsYoung Adults

AlcoholAlcohol 40% adult drownings40% adult drownings 75% boat drownings75% boat drownings

ElderlyElderly

Complicating FactorsComplicating Factors

Spinal cord injurySpinal cord injury

HypothermiaHypothermia

PanickingPanicking

SyncopeSyncope

SeizuresSeizures

PathophysiologyPathophysiology

Central Nervous System InjuryCentral Nervous System Injury

Pulmonary InjuryPulmonary Injury

Dry-drowningDry-drowning

10-20% of submersions10-20% of submersions

LaryngospasmLaryngospasm

HypoxiaHypoxia

Loss of consciousnessLoss of consciousness

Wet-drowningWet-drowning

Aspiration of waterAspiration of water

Dilution of surfactantDilution of surfactant

Diminished gas transferDiminished gas transfer

AtelectasisAtelectasis

Ventilation perfusion mismatchVentilation perfusion mismatch

Pulmonary InjuryPulmonary Injury

Contaminated foreign materialContaminated foreign material

Particulate matterParticulate matter

Bacteria Bacteria

VomitusVomitus

Chemical irritantsChemical irritants

PrognosisPrognosis

Submersion timeSubmersion time

Physiological scoring systemsPhysiological scoring systems

Two extremesTwo extremes

Fair cardiovascular and neurological Fair cardiovascular and neurological functionfunction Minimal disabilityMinimal disability

Unstable cardiovascular function and Unstable cardiovascular function and comacoma PoorlyPoorly Hypoxic CNS injuryHypoxic CNS injury

End Organ DamageEnd Organ Damage

Renal injuryRenal injury HypoxiaHypoxia MyoglobinuriaMyoglobinuria HemoglobinuriaHemoglobinuria

HematologicHematologic HemolysisHemolysis DICDIC

TreatmentTreatment

Prehospital CarePrehospital Care

ResuscitationResuscitation Time optimizes outcomeTime optimizes outcome

Removal from waterRemoval from water C-spine protectionC-spine protection

CPR ASAPCPR ASAP

AirwayAirway

BreathingBreathing High flow oxygen by facemaskHigh flow oxygen by facemask

Not BreathingNot Breathing Bag valve maskBag valve mask Endotracheal tubeEndotracheal tube

UnconsciousUnconscious

Protect from aspirationProtect from aspiration

Who to transport?Who to transport?

AmnesiaAmnesia

Loss or depressed consciousnessLoss or depressed consciousness

Period of apneaPeriod of apnea

Period of artificial respirationsPeriod of artificial respirations

Even if asymptomaticEven if asymptomatic

Don’t ForgetDon’t Forget

Warm patientWarm patient HypothermiaHypothermia

MonitorMonitor

IV accessIV access Warm isotonic fluidsWarm isotonic fluids

SummarySummary

Rapid, cautious rescueRapid, cautious rescue

Spine precautionsSpine precautions

Cardiopulmonary resuscitationCardiopulmonary resuscitation

Supplemental OxygenSupplemental Oxygen

TransportTransport

ED TreatmentED Treatment

Continue EMS careContinue EMS care AirwayAirway OxygenOxygen VentilationVentilation Warmed fluidsWarmed fluids Warming adjuntsWarming adjunts Treat associated injuriesTreat associated injuries

GCS > 12GCS > 12

Oxygen to keep sat > 95%Oxygen to keep sat > 95%

Observe 4-6 hoursObserve 4-6 hours

Pulmonary exam normalPulmonary exam normal

Saturation normalSaturation normal

Discharge homeDischarge home

No xray or labs neededNo xray or labs needed

GCS > 12GCS > 12

Oxygen to keep sat > 95%Oxygen to keep sat > 95%

Observe 4-6 hoursObserve 4-6 hours

Pulmonary exam abnormalPulmonary exam abnormal

Requires oxygenRequires oxygen

DeterioratesDeteriorates

Admit to Monitored bedAdmit to Monitored bed

GCS < 13GCS < 13

High flow oxygenHigh flow oxygen

Intubation for low PaO2Intubation for low PaO2

CXR, LabsCXR, Labs

Continuous cardiac monitoringContinuous cardiac monitoring

Frequent reassessmentsFrequent reassessments

SeizureSeizure

Dilutional hyponatremiaDilutional hyponatremia

Control seizuresControl seizures

Correct electrolytesCorrect electrolytes

Residual disorder uncommonResidual disorder uncommon

ED ArrestED Arrest

Warm water drowningWarm water drowning

Recovery doubtfulRecovery doubtful

Consider early discontinuation of effortsConsider early discontinuation of efforts

Risk profound neurological handicapsRisk profound neurological handicaps

Hospital ManagementHospital Management

SupportiveSupportive

Avoid ARDSAvoid ARDS

Pneumonia rarePneumonia rare

Dopamine, epinephrine dripsDopamine, epinephrine drips

48 hour window48 hour window

No benefitNo benefit

MannitolMannitol

Loop diureticsLoop diuretics

Hypertonic salineHypertonic saline

Fluid restrictionFluid restriction

HyperventilationHyperventilation

Controlled hypothermiaControlled hypothermia

Barbiturate comaBarbiturate coma

PrognosisPrognosis

No CPRNo CPR Full recovery within 48 hoursFull recovery within 48 hours May develop ARDSMay develop ARDS

Bystander CPRBystander CPR Steady recoverySteady recovery Steady declineSteady decline

ED CPRED CPR Very poor prognosisVery poor prognosis

Pediatric Warm Water DrowningPediatric Warm Water Drowning

500 victims500 victims

100% received ED CPR100% received ED CPR

84% died84% died

16% severe hypoxic encephalopathy16% severe hypoxic encephalopathy

Diving ReflexDiving Reflex

MammalsMammals

BradycardiaBradycardia

Peripheral VasoconstrictionPeripheral Vasoconstriction

Greatest in cold waterGreatest in cold water

Preserves oxygenPreserves oxygen

ICE water submersionICE water submersion

AsystoleAsystole

Children and AdultsChildren and Adults

Complete RecoveryComplete Recovery

RareRare

Resuscitate until normothermicResuscitate until normothermic

PreventionPrevention

InfantsInfants Parental vigilanceParental vigilance

ToddlerToddler Pool fencingPool fencing

Adolescent/Young AdultAdolescent/Young Adult Control Alcohol/Drug UseControl Alcohol/Drug Use Swimming lessonsSwimming lessons

ElderlyElderly Same as infant/toddlerSame as infant/toddler