DROWNING
SUBMERSION INJURIES
INTRODUCTION
Drowning accounts for at least 500,000 deaths / year
(worldwide).
US : +/- 4000 fatalities.
Nonfatal drowning statistics are more difficult to obtain.
Nonfatal drowning events may occur several hundred
times as frequently as reported drowning deaths.
INTRODUCTION
Nonfatal drowning : survival, at least temporarily, after
suffocation by submersion in a liquid medium, include the
loss of consciousness while submerged.
Since pulmonary complications may follow the aspiration of
water without the loss of consciousness,
Nonfatal drowning : survival, at least temporarily, after
aspiration of fluid into the lungs ("wet nonfatal
drowning") or after a period of asphyxia secondary to
laryngospasm ("dry nonfatal drowning")
INTRODUCTION
According to the Utstein guidelines
Drowning refers to: "a process resulting in primary
respiratory impairment from submersion or
immersion in a liquid medium”
Ambiguous or confusing terms such as "near-
drowning," "secondary drowning," and "wet
drowning" should not be used.
EPIDEMIOLOGY
Drowning :
common cause of accidental death (US)
an important cause of childhood fatalities
(worldwide).
highest rates : Low / middle-income countries.
EPIDEMIOLOGY
In US, drowning is
a major cause of accidental death among persons < 45 yo.
a leading cause in children < 5 yo (in states where
swimming pools or beaches are more accessible).
Males, African-Americans, children 1 - 5 yo, low-
socioeconomic status.
Summer months.
EPIDEMIOLOGY
Age distribution : bimodal.
1st peak : < 5 yo,
who are inadequately supervised (in swimming pools,
bathtubs, or around other liquid-filled containers);
+/- 7 % : related to child abuse or neglect.
2nd peak : males, 15 - 25 yo,
occur at rivers, lakes, and beaches.
RISK FACTORS
Inadequate adult supervision.
Inability to swim or overestimation of swimming capabilities.
Risk-taking behavior.
Use of alcohol and illicit drugs (more than 50 percent of adult drowning deaths are
believed to be alcohol-related).
Hypothermia, which can lead to rapid exhaustion or cardiac arrhythmias
Concomitant trauma, stroke, or myocardial infarction.
Seizure disorder or developmental/behavioral disorders in children
Undetected primary cardiac arrhythmia (may be a more common cause of drowning
than generally appreciated)
Hyperventilation prior to a shallow dive.
PATHOPHYSIOLOGY
Fatal and nonfatal drowning typically begins with a period of panic,
loss of the normal breathing pattern,
breath-holding,
air hunger,
a struggle by the victim to stay above the water.
Reflex inspiratory efforts,
leading to hypoxemia and either aspiration or reflex
laryngospasm that occurs when water contacts the lower
respiratory tract.
PATHOPHYSIOLOGY
Hypoxemia affects every organ system.
Morbidity and mortality related to cerebral hypoxia
END ORGAN EFFECTS
Hypoxemia produces tissue hypoxia,
affects virtually all tissues and organs within the body.
Pulmonary
Neurologic
Cardiovascular
Acid-base and electrolytes
Renal
Coagulation
PULMONARY EFFECTS
Fluid aspiration results in hypoxemia.
Salt water and fresh water wash out surfactant,
producing noncardiogenic pulmonary edema and
the ARDS.
Pulmonary insufficiency (shortness of breath, crackles,
and wheezing).
Chest xray or CT : normal or localized - diffuse
pulmonary edema.
NEUROLOGIC EFFECTS
Hypoxemia and ischemia cause neuronal damage
produce cerebral edema and elevations in
intracranial pressure.
CV EFFECTS
Arrhythmias secondary to hypothermia and hypoxemia.
ACID-BASE EFFECTS
Metabolic and/or respiratory acidosis.
Significant electrolyte imbalances : submerged in
unusual media, such as the Dead Sea,
hypernatremia,
hypermagnesemia, and
hypercalcemia
due to absorption of swallowed seawater.
RENAL EFFECTS
Renal failure (rare)
due to acute tubular necrosis (resulting from
hypoxemia, shock, hemoglobinuria, or myoglobinuria).
COAGULATION
EFFECTS
Hemolysis and coagulopathy (rare in nonfatal drowning)
MANAGEMENT
Rescue and immediate resuscitation improves the
outcome.
CPR is determined as soon as possible (without
compromising the safety of the rescuer or delaying the
removal of the victim from the water).
MANAGEMENT
Ventilation : most important initial treatment for victims of
submersion injury.
Rescue breathing should begin as soon as the rescuer reaches
shallow water or a stable surface.
Note : that the priorities of CPR in the drowning victim differ from
those in the typical adult cardiac arrest patient, which emphasize
immediate uninterrupted chest compressions.
If the patient does not respond to the delivery of two rescue breaths
—> immediately begin performing high-quality chest compressions.
CPR (including automated external defibrillator) is then performed
according to standard guidelines.
MANAGEMENT
Life-threatening arrhythmias : ACLS protocols.
High-flow oxygen-delivery : to ensure adequate
oxygenation of spontaneously breathing patients;
Intubation : in apneic patients and in respiratory
distress or unable to protect airway.
Rewarming hypothermic patients.
MANAGEMENT
ED MANAGEMENT :
Prehospital resuscitative efforts should be continued and the
airway secured.
CPAP / BPAP
frequent vital sign measurements and clinical reassessment,
monitoring :
continuous oxygen saturation, end-tidal CO (Capnography)
2
and cardiac telemetry.
blood glucose
MANAGEMENT
ED MANAGEMENT :
Trauma evaluation and appropriate imaging studies.
Wet clothing should be removed and rewarming.
Methods :
passive and active external rewarming (eg, application of warm
blankets, plumbed garments, heating pads, radiant heat, forced
warm air), and
active internal core rewarming (eg, warmed humidified oxygen
via tracheal tube, heated irrigation of peritoneal and pleural
cavities).
MANAGEMENT
Repeat chest radiographs only when indicated by signs
and symptoms of
increased respiratory distress, declining pulse
oximetry, or hypercarbia.
Bronchospasm : management is treated similarly to
acute asthma.
MANAGEMENT
Pts with hypothermia :
"cold diuresis" —> significant hypovolemia and
hypotension
because during the early phase of vasoconstriction,
blood moves to the core, causing central volume
receptors to sense fluid overload and resulting in
decreased antidiuretic hormone production.
MANAGEMENT
Poor prognosis :
Duration of submersion >5 minutes (most critical factor)
Time to effective BLS >10 minutes
Resuscitation duration >25 minutes
Age >14 years
GCS <5 (ie, comatose)
Persistent apnea and requirement of CPR in ED
Arterial blood pH <7.1 upon presentation
MANAGEMENT
Poor prognosis :
Duration of submersion >5 minutes (most critical factor)
Time to effective BLS >10 minutes
Resuscitation duration >25 minutes
Age >14 years
GCS <5 (ie, comatose)
Persistent apnea and requirement of CPR in ED
Arterial blood pH <7.1 upon presentation
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