David A. Rodeberg, M.D. Chief Pediatric Surgery ECU UHS Drowning and Near-drowning: just when you thought it was safe to go into the water David A. Rodeberg, M.D. Chief Pediatric Surgery ECU UHS I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in our presentation.

I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in our presentation.

Definition How many shades of blue are there? Drowning – suffocation and death from submersion in liquid medium Near-drowning – not death, also called submerson injury Immersion syndrome – drown due to cardiac death (vagal in cold water) Hyperventilation drowning – hypocarbia and hypoxemia

Definitions Wet drowning – water or other debris is aspirated 80 – 90% of autopsies Dry drowning – no water Laryngospasm persists till death 10 – 20% Supports active inhalation of water into lungs as causal in drowning

Epidemiology Second leading cause of accidental death in children < 14 yrs 1200 - 1400 pediatric drownings/yr 2800 pediatric ED visits for near-drowning/yr < 5 yrs old accounts for 70% Due to underreporting could be 2-20X

Epidemiology

Epidemiology Age Males Bimodal: 0-4 and 15-19 yrs Females: 0-4 yrs African-Americans 1.7 fold higher for adolescents

Epidemiology Mechanism of Drowning Age dependent < 1 yr Drown in bathtubs, buckets or toilets Lack of supervision or abuse < 5 cm of water Bath seat is not drown proof Buckets 3-5 gallon

Epidemiology Mechanism of Drowning Age dependent 1-5 yrs Swimming pools 60-90% occur residential 90% occur in-ground pools Unsupervised < 5 min Hot tubs

Epidemiology Mechanism of Drowning Age dependent Adolescents Rivers, lakes, canals 50% involve drugs or EtOH Risk taking behavior Overestimate abilities

Epidemiology The risk of drowning vs near drowning is higher in lakes than bathtubs or pools Difficulty rescuing in open water Absence of supervision Use of EtOH More common in summer and weekends

Risk Factors Near-Drowning Inability or overestimation of swimming abilities Risk taking behavior EtOH and drug use Inadequate adult supervision Hypothermia Concomitant trauma Undetected primary cardiac arrhythmia Hyperventilation prior to dive

Epidemiology Risk of drowning is increased in some medical conditions Epilepsy Mentally retarded Poorly controlled Recent med change Prolonged QT syndrome swimming in very cold water arrhythmias

Clinical Stages of drowning Breath holding, Panic, Air hunger Attempts to surface Reflex inspiratory efforts Leads to aspiration or laryngospasm Many young children drown silently

Pathophysiology Pulmonary problems are the most common and severe Basic pathology is hypoxia - ischemia

Pulmonary Pathophysiology Intra-pulmonary shunting is the primary pulmonary physiologic problem Causes oxygenation and ventilation insufficiency Due to Bronchospasm Atelectasis Aspirated material Infectious or chemical pneumonitis ARDS and edema 12 hrs to 3 days later

Pulmonary Pathophysiology Patients may have symptoms initially and other develop after several hours Atelectasis caused by Bronchial obstruction Decreased surfactant Inactivated with water Damaged alveoli do not produce

Neurologic Severe neurologic sequelae 10 – 20% of near drownings Principle determinant of outcome Duration and severity of hypoxia/ischemia Neuronal damage Secondary insult Edema » increased ICP peaks about 24 hrs

Cardiovascular Dysrhythmias and cardiac dysfunction Sinus brady > a-fib > v-fib > asystole Sinus brady and a-fib do not require intervention since they usually perfuse Due to Hypoxemia Acidosis Hypothermia Electrolyte abnormalities

Cardiovascular Hypotension Carbon dioxide retention Blood loss Hypothermia Decreased ADH due to peripheral vasoconstriction in hypothermia Pulmonary edema Hypovolemia due to cold diuresis (ADH) Hypoxic cardiomyopathy

Fluids and Electrolytes Previous thought that fresh water vs salt had an effect greatly overrated Must aspirate > 11 ml/kg for fluid shifts > 22 ml/kg for electrolyte changes Clinically important fluid and electrolyte changes in < 15% of patients

Others H/H changes reflect other trauma Metabolic acidosis Acute tubular necrosis Due to hypoxemia and ischemia DIC

Pre-Hospital Treatment Rescue the victim ASAP Initiate rescue breathing during rescue if possible Cervical spine immobilization High impact event or shallow dive External thrust to clear water Usually able to ventilate, if not check for obstruction Intubate

Pre-Hospital Treatment Cardiovascular collapse after submersion Pressure from water causes 32 – 66% increase in cardiac output When removed from the water BP drops Therefore remove victims in supine position

ED ABC…. Standard protocol except Due to hypothermia pulses may be difficult to palpate Defibrillation is ineffective if the myocardium is cold

ED C-spine 11 of 2244 patients had injury All open bodies of water Signs of significant injuries High impact injuries Diving, boats or falls All GCS < 9 at scene All > 15 yrs Routine immobilization in collar may not be warranted

ED Monitors Cardiac O2 saturation Urine output Studies obtained when indicated by suspicion CXR, ABG, CBC, electrolytes, EKG, drug screen CXR may initially be normal then worsen with edema or ARDS

Interventions Pulmonary Hemoptysis, rales, edema or fluffy infiltrate on CXR or hypoxia All indications of aspiration

Interventions Pulmonary Supplemental oxygen May be needed for 48 – 72 hrs Time for surfactant to reconstitute No benefit to exogenous surfactant Bronchospasm Nebulized beta agonists Bronchoscopy to remove FB or debris

Interventions Pulmonary Further deterioration may require CPAP to decrease atelectasis and shunting Mechanical ventilation ECMO - case reports Prophylactic antibiotics or steroids unless water grossly contaminated

Hypothermia Not dead till your warm and dead!!!! Wet clothing should be removed Warm blankets applied In ED become more aggressive Hot air Warm fluid lavage ECMO Not dead till your warm and dead!!!!

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Interventions Neurologic Minimized initial time of asphyxia Prevent secondary brain injury Elevate head of bed Prevent ischemia, hypoxemia, acidosis, euglycemia and siezure

Interventions Infection Probably not common May include unique organisms such as aspergillosis, leptospirosis or psuedomonas, proteus, aeromonas

Observation Completely asymptomatic patients Normal vitals, oxygen sat, PE, CXR Observe for 6 – 8 hrs in the ED All others admitted for 24 hr observation

Outcomes Death 30 – 50%

Outcomes Survive neurologically intact 40 – 60% Question incidence less severe neurologic problems Survive with severe neurologic sequelae 10% Major determinants of outcome Duration of LOC and initial GCS Lack of spontaneous purposeful mvement by 24 hrs bad prognosis

Prevention 90% of victims are within 10 yrds of safety when they drown Restrict access Complete inclosure of the pool by fence Reduces drownings by 50% Pool covers and motion alarms are not as effective Nearby phone

Prevention Swimming partners Flotation devices

Prevention Never leave small children unattended around any body of water (pool, bathtub, lake, etc.). Take small children with you. Be aware of streams, creeks, ponds, ditches, etc. that may be located on or near your property. Be aware that standing water left in buckets, wading pools, bathtubs, toilets, etc. can be dangerous to toddlers. Learn CPR especially if you own a pool or live near the water. Encourage older children and adolescents to learn how to swim, but remember even good swimmers can drown. Swimming lessons are no substitute for supervision of young children in and around water and no one should ever swim alone. Teach children and adolescents to avoid conditions or situations which could create the potential for danger. Encourage adolescents to avoid drinking alcoholic beverages. Approved personal floatation devices (PFDS) should be worn by all passengers in powered and unpowered watercraft, or by anyone who is unable to swim or unsure of their swimming abilities when in and around water. "Water Wings" are not a dependable flotation device and are no substitute for adult supervision of small children in and around water. Swimming pools should be enclosed by a 4-sided fence that is at least 5 feet high and separates the pool area from the house. The fence gate should have a self-closing, self-latching mechanism, which is located on the side of the gate closest to the pool and out of reach of small children. Reaching and/or throwing aids should be readily available.

Prevention - Education Most drownings do not receive CPR until EMS arrives Therefore increased teaching CPR Learn to swim early Swimming must still be supervised No guarantee

Prevention - Education Educate children and parents about water safety

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