Drowning

• Drowning defined as: death secondary to asphyxia and

within 24 hours of submersion which may be immediate or follow resuscitation

• Submersion injury: Survival after more than 24 hr is termed

regardless the victim later dies or recovers

Epidemiology

Age 1-toddler age<5 yr 2-in 15-19 years old.• Male predominant in All

ages .• Male/ Female • 2:1 in toddlers 10:1 in teenager

• The site of drowning ,most common depending on age.

Relevant factors:• Water Tonicity• Time submersion • water Temperature• symptoms associated injuries .• Undetected primary cardiac

arrhythmia( long QT)• response to initial CPR

Drowning begin with: 1. Panic, breath holding, ear

hunger2. reflex inspiratory and

aspiration. 3. laryngospasm that leads to

hypoxemia4. hyperventilation followed by

voluntary apnea .

Pathophysiology

• Asphyxia may occur with:1. pulmonary aspiration (wet drowning).

2. laryngospasm (10-20%) until cardic arrest )dry drowning)

Anoxic-ischemic injury

• All organs may injured from hypoxia and ischemia .

• CNS injury (ICP ,cerebral edema) The most frequent cause of

mortality and long- term morbidity

Anoxic-ischemic injury

• Pulmonary:

wash out surfactant

Pulmonary edema, ARDS

• Cardiovascular:

Arrhythmia( hypothermia ,hypoxemia)

• Acid-base

• Electrolytes

Anoxic-ischemic injury

• Renal

ATN (hypoxemia,shock, hemoglobinuria)

• Gasterointestinal hepatic trasaminases and serum

pancratic enzymes are often acutely elevated

Aspiration and pulmonary injury

• Pulmonary aspiration occurs in the great majority of submersion .

Pneumonia may result from :• gastric contents• water salinity • pathogenic organisms• toxic chemical

Fluid and electrolyte alteration

• The great majority of submersion do not aspirate large volumes of fluid to result in significant electrolyte disturbances.

• Sea water• Fresh water

Hypothermia• Moderate hypothermia T(32-35) increase oxygen consumption.

• Below T 32: (sever hypothermia) shivering ceases and

cellular metabolic rate decreases

• Deep coma with fixed and dilated pupils and absent reflexes at T (25-29) may give the false appearance of death

Lab & imaging studies

• ABG • CBC ,Electrolytes ,U/A• Chet x Ray - cervical spine X Ray

• non contrast head CT scan???

Imaging

• Head CT scan is not helpful unless :

1. Suspicion of associated trauma injury

2. to rule out other possible causes of coma

• MRI may detect change associated with hypoxic- ischemic injuries

Clinical Manifestation

• Victims in cardiac arrest require aggressive and prolong

CPR.

Pre hospital treatment

• Careful search for pulses.

If pulses presented :• Chest compression withhold

Sinus bradicardia and atrial fibrillation require no immediate treatment

Treatment

• Initial resuscitation:

• CPR• air way should be clear

• Abdominal thrust should not be used

• Cervical spine should be protected

Emergency unit management

• All pediatrics should be observed for at least 8-12 hr even they are asymtomatic on presentation.

• Serial monitoring of repeated careful pulmunary and neurologic assessment.

• Chest X RAY

Emergency unit management

Patients discharge after 8-12 hours if no evidence of :

• significant injury • bronchospasm • tachypnea • inadequate oxigenation

hospitalized Children

• Supplement O2• NaHCO3• diuretic for pulmonary edema .• broncodilators for brochospasme .• Antibiotic for contaminated water.• Anticonvolsion treatment for seizure

Treatment

• NG tube• ECG monitoring for diagnosis and

treatment of arrhythmia.• Hypothermia treatment

passive,active • If a child is hypoglycemic

0/5-1g/kg dextrose

ETT is needed if…

1. apnea ,cyanosis .2. hypoventilation.3. hemodynamic istability.4. protect air way in patient with

depressed Mental

Treatment (con)

• A few patients develop require mechanical ventilation.

for at least 24-48 hours.

• evaluated of oxigenation with ABG

• Rewarming effort should be continued until T is at least 32-34c (passive, active)

• Patients should closely evaluated for The neurological status

• Neurologic examination during the first 24-72hr are the best prognostic of CNS outcome.

Prognosis (continue)

1.Overall about 75% of pediatric submersion victims survive.

• Good recovery did not occur in: Abnormal brainstem function

• Absence of purposeful movement at 24 hr

Poor prognosis

1. Submersion duration>10 minute

2. Age <3 years3. CPR>25minutes4. patient core<T33c 5. GCS<56. persistent apnea that CPR is

need in an ED.

prognosis

• PH<7.1

• Water temperature >10 c

• Children who remain comatose 24 hr after initiating resuscitation

Treatment discontinue

• submersion victim in non-icy water that remain systole

• despite 30-45 min of aggressive CPR