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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