Near Drowning

Resident Rounds

June 26, 2003

Robbie N. Drummond

Not Waving but Drowning Stevie Smith

Nobody heard him, the dead man,

But still he lay moaning:

I was much further out than you thought

And not waving but drowning.

Poor chap, he always loved larking

And now he's dead

It must have been too cold for him his heart gave way,

They said.

Oh, no no no, it was too cold always

(Still the dead one lay moaning)

I was much too far out all my life

And not waving but drowning.

IV. DEATH BY WATER (from the Wasteland, T.S. Eliot)

PHLEBAS the Phoenician, a fortnight dead,

Forgot the cry of gulls, and the deep seas swell

And the profit and loss.

A current under sea

Picked his bones in whispers.As he rose and fell

He passed the stages of his age and youth

Entering the whirlpool.

Gentile or Jew

O you who turn the wheel and look to windward,

Consider Phlebas, who was once handsome and tall as you.

The Tempest by Willy Boy the Spear Shaker Act I Scene ii

ARIEL sings]

Full fathom five thy father lies;

Of his bones are coral made;

Those are pearls that were his eyes:

Nothing of him that doth fade

But doth suffer a sea-change

Into something rich and strange.

Sea-nymphs hourly ring his knell

Hark! now I hear them,--Ding-dong, bell.

FERDINAND The ditty does remember my drown'd father.

YODA’s 7 QUESTIONS ABOUT DROWNING

There are a lot of terms to describe drowning how do I wade through them all?

What is the real difference between fresh and salt water drowning? How common is drowning are there any preventative measures to be

taken to avert death by water? There is a drowning victim in the ED what are the factors that suggest

he will survive? What is the best approach to resuscitating a drowning victim? What about the prophylaxis measures previously taken, steroids, hyper

therapy, antibiotics....etc.? Survivors of drownings usually are hypothermic what is the relation

between hypothermia and drowning?

There are many terms to describe drowning how do I wade through them all?

gets complicated..... Drowning, near-drowning, drowning with/without aspiration, dry drowning, wet drowning, secondary drowning, submersion vs immersion, immersion syndrome,

ORLOWSKI feels too complicated was supposed to imply prognosis but does not

Drowning “ suffocation by immersion or submersion in any liquid medium, caused by the entrance of liquid in the airways that partially or fully compromises ventilation or oxygen exchange”

basic definitions

drowning death within 24 hours of submersion near drowning death after 24 hours of submersion secondary drowning death from a complication of

submersion one author secondary drowning cause of death not related

to water (eg MI) drowning with or without aspiration immersion vs submersion partially vs totally covered aspiration of other fluids bodily etc

wet vs dry drowning

10% no fluid found in lungs severe laryngospasm, hypoxia, convulsion and death one author “dry drownings probably do not exist.... if there

is no water in lungs victim probably not alive when entered water”..... A la Brian Jones of the Stones.... It was Mick and Keith, the glimmer twins, don’t you know it?

13 % of all drownings happens after precipitating event

drugs 36% (usually alcohol) convulsion 18 % trauma 16 % cardiopulmonary 14% SCUBA 3 % others 11 %

My mother told me to splash water on my face before.....

Immersion Syndrome syncope provoked by arrhythmia sudden contact with water at least 5 degrees less than body

temperature syncope loss of consciousness and secondary drowning massive release of adrenaline reduced by wetting face and head before entering water

How common is drowning are there any preventative measures to be taken to avert death by water?

90 % of all drowning deaths occur within 10 meters of safety

Some watery numbers

500,000 per year worldwide third most common cause of unintentional death 10 saves and five near drownings for every drowning 1996 62,747 rescues 55-60% less than 20 years of age African-Americans two time rate of Caucasians males five times as often as females costs 6.5 billion buckaroos in US alone

bimodal distribution

toddlers less than 2 and teenage boys 10 - 19 years teenager (boys) risk taking, alcohol factor 60% of time bathtubs usual site under one year of age many as a result of abuse bucket- related deaths older toddlers pools children and adolescents fresh water

POOLS

50, 000 new pools built every year in USA 2.2 million residential pools 2.3 million nonresidential pools already in existence in temperate areas of USA 70 - 90 % of drowning occur in

pools

PUBLIC HEALTH

proper pool fencing and supervision training in swimming and water safety essential not leaving child unattended near tub or pool personal flotation devices while boating proper training, SCUBA boating etc solar blankets support weight of toy not children hides

drowning child citizens trained in CPR avoidance of alcohol

PREVENTION

the key to minimizing morbidity is successful prevention AAP 23 recommendations swimming lessons a good idea but sometimes children not aware of their skill level and parents not cautious enough

RISK FACTORS FOR SUBMERSION ACCIDENTS

, seizures, trauma, Etoh, hyperventilation, drugs of abuse, hot tubs, hypothermia, cvs disease, child abuse, diabetes, suicide inability to swim 53% of individuals with a submersion incident over age

26 blood etoh >100 9% of suicides due to drowning Time of day: toddler drowning : meal preparation times early evenings

What is the real difference between fresh and salt water drowning?

animal models (ie threw man’s best friend in water to see what happens)

struggle small amounts fluid hypopharynx laryngospasm swallowing water laryngospasm abates aspiration large amounts water vomiting aspiration of gastric contents evolving hypoxemia , circulatory collapse myocardial damage, and multiorgan failure ischemic brain injury....death

the Pacific vs Georgian Bay

for many years suggested difference between fresh and salt water drowning

give dogs 44 ml /kg fresh water causes potassium disturbance

previous theory was fresh water more hypotonic hemodilution hyper volemia, red cell rupture dilution of pulmonary surfactant alveolar collapse sea water hypovolemia, and increased electrolyte

hemoconcentration fluid movement from intravascular to alveoli

In reality....

more than 11 ml per kg for change in blood volume only 15% who die in the water aspirate more than this

quantity most less than 4ml/kg 22 ml/kg for changes in electrolytes in a study by spilzman 1994 187 drowning victims had no

electrolyte abnormality seawater drowning does not cause hypovolemia freshwater drowning does not cause hypervolemia,

hemolysis, or hyperkalemia

no difference

from clinical point of view no difference fresh vs salt water most immediate cause is hypoxia and metabolic acidosis both produce surfactant destruction alveolitis,

noncardiogenic pulmonary edema disruption of gas exchange increased shunt leading to

profound hypoxia as little as 1 ml /kg aspiration profound alterations in gas

exchange decreased compliance cerebral hypoxia is the final common pathway resp disturbance more on amount than type of water

2 small points

sometimes physiologic changes many hours after insult water may be contaminated with chemicals, bacteria, sand

etc.

DEAD SEA

Dead Sea

unless you drown in the dead sea (Yagil et al arch In Med 1985)

one case hypercalcemia and hypermagnesemia

What is the best approach to resuscitating a drowning victim?

drowning victims present risk to rescuer approach with caution or intermediate object instinctive drowning response drowning victims unable to call for help upright position slapping or thrashing water children 10 - 20 seconds adult up to 60 seconds

CPR ASAP SVP

first description of CPR 1600’s : Paracelcus a Swiss physician inserting fireplace bellows in the victim’s mouth or nostrils

always remember underlying causes for drowning caution re neck injuries citizens trained in CPR in water CPR usually ineffective and dangerous delay in CPR prolongs hypoxia because circumstance are never clear

resuscitation should always be initiated in the field

drowning victims swallow much more water than they inhale

no attempt to remove water from lung great quantities of water in stomach likely to aspirate Heimlich himself suggested his maneuver to expel water

from lungs,,,, counterproductive gastric acid aspiration from abdominal pressure lots of fluid in stomach up to 60 % of drowning victims vomit right lateral decubitus head down ? Sellick’s maneuver high risk for vomiting spontaneously or on resuscitation

There is a drowning victim in the ED what are the factors that suggest he will survive?

ORLOWSKI’s 5 unfavourable prognostic factors

age of 3 or less submersion > 5 minutes no attempts at resuscitation for 10 minutes coma on admission to ED severe acidosis pH <7.1

lack of controlled studies which factors greatest impact <2.... 90 % recovery

>3.... 5 % likelihood of recovery

Check out the GCS

GCS adds predictability 2-6 hours after if no improvement unlikely to improve if some increase GCS 50% if alertness normal sequelae limited

other factors

resuscitation > 25 minutes asystole on arrival at hospital GCS < 5 elevated ICP, coma or CPR needed in ED some survival in some individuals with some or all of these

factors water temperature, duration and degree of hypothermia the diving reflex, the victim’s age, water contamination, duration of cardiac arrest the speed and effectiveness of initial treatment cerebral

resuscitation

success of resuscitation major determinant of outcome

prognosis response to serial neurologic exams 3 point improvement on GCS on arrival to ICU portends 100 % full recovery in pediatric population

conscious on arrival excellent chance of survival

CONN scale alert 100%’ blunted mortality rate 10% comatose greater than 35%

The Opposite of Drowning?

What is the best approach to resuscitating a drowning victim in ED?

continuous cardiac monitoring observation for 4-6 hours if asymptomatic serial ABG measurements (Arterial line) oxygen therapy NGT and FOLEY ETT degree of respiratory distress pa o2 below 50 paco2

greater than 50%

Read my lips “it’s the anoxia, stupid!!!”

grading system from 1 to 7 based on need for aggressive airway intervention

grade 2 only by cannula, grade 4 mechanical pneumothoraces usually as result of baro trauma most significant implication is anoxic ischemic cerebral

insult most common cause of late death every effort to maintain oxygenation and prevent cerebral

edema

r/o other cause of injury

toxicological insult spinal injury evaluate and treat associated conditions, hypovolemia, hypothermia, hypoglycemia

careful neurological assessment and reassessment

both respiratory and metabolic acidosis

may still need fluid resuscitation despite pulmonary edema shock is uncommon in drowning do not use furosemide to treat pulmonary edema may need

volume in ICU many patients will need PEEP ARDS common in drowning same management as any

ARDS patient delayed onset of pulmonary edema (up to 12 hrs)

PATHOPHYSIOLOGY

although some difference drowning is an asphyxia injury like like hanging, foreign body aspiration, apnea etc

noncardiac pulmonary edema, noncardiogenic pulmonary injury, surfactant loss, inflammatory contaminants, and

cerebral hypoxia global hypoxic ischemic event affecting brain, lungs, and heart cardiovascular function usually preserved aggressive pulmonary support is required to prevent long term

sequelae of hypoxia optimal treatment for anoxic brain injury remains unclear no prognostic scale accurately predicts long term neurologic outcome

Consequences global hypoxia

cns dysfunction from initial hypoxic injury increased ICP edema

aggressive control of cerebral perfusion pressure does not improve out come

CNS damage progresses after circulation reestablished cardiac dysrhythmias : a result of hypoxemia/acidosis low cardiac index elevated right and left heart filling

pressures increased SVR renal failure uncommon coagulopathies esp DIC and hemolysis

What about the prophylaxis measures previously taken, steroids, hyper therapy, antibiotics....etc.?

prophylactic antibiotics of limited use treat when infection antibiotics only if grossly contaminated water

contributing to injury is aspiration of sand bacteria algae or particulate matter emesis and chemical irritant

corticosteroids of limited use

HYPER THERAPY

early theory (BOHN Critical care medicine 1986) hyperhydration, hyperventilation, hyperpyrexia, hyper-

excitability, hyperrigid suggested use of diuretic, hypothermia, barbituates

glucocorticoids barbituate coma, muscle paralysis and monitoring and treating of ICP

subsequent reviews failed to show improvement with these protocols

most centers no longer use hyper therapy current approach supportive care

disposition

four groups 1) no evidence of sig. submersion d/c’d quickly

cxray and abg unnecessary serial sats reassuring pts without any symptoms and completely normal respiratory

status may be discharged with instruction to return immediately if respiratory distress developed

2) asymptomatic after sig. episode observed for four to six hours then d/c’d

3) poor oxygenation mod hypoxemia admitted followed once o2 resolved ....home

??? ICU

final group... Intubated: depends on neurological status

any respiratory complaints or symptoms, cxray abnormalities, demonstrated oxygen requirement monitored for 24 hours usually in ICU

any patient with LOC, cyanosis, or apnea, CPR or resuscitative efforts need to be monitored closely

GCS needs to be done sequentially

CXRAY

20 % of severe drowning normal cxray

typical findings perihilar infiltrates, pulmonary edema

Pediatrics

peds use fairly aggressive PEEP protocol increased risk of nosocomial infection children larger surface area less fat more prone to

hypothermia hypothermia some degree of protection rapid cooling necessary in icy water <5 deg to offer benefit usually severe hypothermia increased mortality large costs realistic goal re prognosis families need time to adjust

POOR PROGNOSIS IF:

absence of cognitive function / recovery 48 -72 hours seizures beyond 12 hours despite early enthusiasm, ICP monitoring: no benefit CT only helpful if ass’d with other injury MRI day 1 and day 3 change helpful in predicting outcome EEG often obscured by drugs and resuscitation

persistent flat tracing attenuated record without med or burst suppression poor prognosis

brainstem evoked potential: controversial many confounding factors

most useful for predicting outcome is repeated clinical neurological examination

Survivors of drownings are often hypothermic what is the relation between hypothermia and drowning?

continue resuscitation till core temperature 30 -35degreesC one child recovered successfully after 66 minute

immersion in cold water hypothermic protection dependant on slowing cerebral

metabolism before irreversible damage works with sudden immersion in very icy water or in

victims above water cooling before immersion

HYPOTHERMIA

definition core temperature less than 35 degrees significant pathophysiology develops below 35 degrees primary direct exposure to cold secondary systemic disorders heat preservation shivering, autonomic and endocrinologic

responses.... adaptive behavioral responses

35-32-27....mild, moderate, severe

mild 32 -35 32 -35 shivering stops, hr and bp decline, oxygen consumption

declines depressed CNS increase metabolic rate & pulse , dysarthria,

amnesia, ataxia, apathy

moderate 27 - 32 decreased loc and vitals, shivering extinguished, arrhythmias, qt

prolonged, j wave (Osborne) cannot rewarm spontaneously cold diuresis

Severe Hypothermia

severe less than 27 degrees coma and areflexia with profoundly depressed vital signs co2 production decreases 50% for each 8 degrees fall in

temperature increase heat loss impaired thermoregulation extreme bradycardia spont VF or asystole coagulopathy prolonged clotting times and platelet

dysfunction

physiologic changes

protein binding increases temp drops drugs ineffective wait with monitoring 60 second before initiating CPR most recommend CPR with PEA even with profound

hypothermia pulse oximetry accurate in hypothermic patients caution irritating heart in central line insertion most rhythms revert spontaneously with rewarming most VF refractory until rewarmed three shocks trial if unsuccessful rewarm CPR attempt at

higher temperature

changes in hypothermia

tachycardia disproportionate to temperature suspect hypoglycemia hypovolemia or OD

hyperventilation suggests A CNS system lesion systemic acidosis DKA or lactic acidosis

cold induced rectus spasm and ileus may mask or mimic an acute abdomen

need core temperature anemia is masked because hematocrit increase 2% per 1

degree drop in temperature leukocytes sequestered

active rewarming

passive vs active warming passive noninvasive

involves simply covering the patient in a warm environment

active rewarming if cvs instability temperature less than 32.2

active core rewarming heated humidified air inhalation, heated infusion lavage, extracorporeal

rewarming

Invasive techniques

thorocostomy tube irrigation IV fluids 40- 42 degrees double catheter peritoneal lavage 2 liters of 40 -45 degrees NS suction after 20 minutes extracorporeal rewarming

cardiopulmonary bypass arteriovenous and venovenous rewarming hemodialysis lifesaving in cardiac arrest situations

caution:

drop in core temp after initiation of rewarming temperature equilibration circulatory return of cold peripheral blood to the core

overwhelms a depressed cvs system

vasoconstricted skin prone to burning caution with warming extremities

What is the Diving Reflex?

mammalian response protective bradycardia shunting blood to brain and heart victims age ration of body mass to surface area development of

hypothermia hypothermia more protective in children than the diving reflex water must be 10 degrees or colder sudden immersion in cold water can cause ventricular fibrillation controversy over diving reflex

breath holding intense vaso constriction bradycarda decreased Cardiac output and increased MAP selective vasoconstriction and heart and CNS perfused

breath holding reduced when children submerged in cold water

Answers to Yoda’s seven questions

drowning is a form of asphyxia main injury is anoxia and its consequences

there is no clinical difference between fresh and salt water drowning 90% of drowning occurs within 10 meters of safety prevention is the

key level of consciousness on presentation to the ED best prognostic

indicator followed by sequential neurologic assessments main features of management is aggressive respiratory support prophylaxis is not indicated the usual dicturm applies the patient is not dead dead till he is warm and

dead

Yoda’s real feeling about water Nothing in the world is more flexible and yielding than water. Yet when it attacks the firm and strong none can withstand it, because they have no way to change it. So the flexible overcome the adamant, the yielding overcome the forceful. Everyone knows this, but no one can do it. This is why the sages say those who can take on the disgrace of nations are leaders of lands; those who can take on the misfortune of nations are rulers of the world. True sayings seem paradoxical.

References

DROWNING Pediatric clinics of North America June 2001Orlowski et al

EMR June 1997Schwab et al Emergencies of Summer NEAR DROWNING Critical Care Clinics April199 Sachdeva

SUBMERSION AND ASPHYXIAL INJURIES Ibsen and Kock Critical Care medicine Nov 2002

TINTINELLI’s 2002 Rosen’s 2002 EMERGENCY MEDICINE SECRETS THIRD EDITION

Markovchick 2003+

the (deep) end