Neardrowning: Prehospital and Emergency Department Management James Hoekstra, MD, FACEP Ohio State University

Case Report: Neardrowning 17 year old male ejected from a boat during a violent turn in a fresh water reservoir Pulled from the water by friends Unconscious, not breathing at the scene Given mouth to mouth Total time submerged: 3-5 minutes EMS arrival in 20 minutes

Case Report: EMS At EMS arrival, breathing but unconscious BP 130/90, P 110, R 24, good BS Obvious head injury with parietal scalp laceration, moving all fours to pain Backboard and C-collar immobilization O2 per face mask, monitor Transport, IV established en route

Case Report: ED Arrival Airway: Guarded, alert but confused Breathing: R 32, good BS, Pulse Ox 96% on 100% FM Circulation: Good color, BP 140/100, P 130, pulses X 4 Neuro: Alert but confused, purposeful X 4 No signs of external trauma except scalp lac

Critical Actions IV X2, O2 FM, Monitor Tetanus, Ancef CXR, CS, Pelvis ECG Labs sent, ABG sent Foley cath inserted NG inserted Secondary survey: No apparent trauma

Laboratory Results pH 7.30/pO2 72/pCO2 32/HCO3 16 ECG: Sinus Tach, NAD CS and pelvis films normal WBC 14K, Hb 14, Hct 42 Na 134, K 3.9, Cl 104, CO2 17, Glucose 133. Renal function normal EtOH.130

Clinical Course CT head normal CT abd normal C, T, L spine films normal Scalp wound closed in the ED Sedated for combativeness with Midazolam Admitted to SICU

Clinical Course, Cont. Ventilation and oxygenation deteriorates, requiring intubation and ventilation PEEP at high levels Barotrauma with bilateral chest tubes, sub Q air Fever, purulent sputum, IV broad spectrum antibiotics instituted Rocky course, SICU on vent for 3 weeks. D/C after 5 weeks in the hospital

Neardrowning Nomenclature Epidemiology Pathophysiology Prognostics Prehospital Management Hospital Management

Nomenclature Drowning Neardrowning Secondary Drowning Wet drowning Dry drowning Immersion Syndrome

Epidemiology reported cases per year in US 40% are children 0-5 years old 1% of pediatric ICU admissions Male predominance Backyard pools Lack of supervision, seizures

Epidemiology Adult drowning, third most common cause of accidental death Alcohol, alcohol, alcohol Boys Trauma, diving most common mechanism 90% within 10 feet of safety Swimming ability not a risk factor

Pathophysiology of Drowning Submersion Panic and Flailing (if conscious) Inhalation and aspiration or laryngospasm Hypoxia Cardiopulonary arrest

Near Drowning Pathophysiology Hypoxic episode interrupted with ROSC End organ damage with –ARDS (often delayed) –Hypoxic encephalophy –Renal failure (ATN) –Pancreatic necrosis –DIC –Cardiac dysrrhythmias

Fresh Water Inhalation (90%) Hypotonic load to alveoli Water absorbed into circulation Surfactant washout Alveolar cell damage Chemical pneumonitis, pulmonary edema Hypervolemia Hyponatremia Hemodilution Hemolysis

Salt Water Inhalation (10%) Hypertonic load to alveoli Protein rich effusion into alveoli Surfactant damage, alveolar basement membrane damage Alveolar cell damage Chemical pneumonitis, pulmonary edema Hypovolemia Hypernatremia Hemoconcentration

Salt versus Fresh Water Modell, series of 91 near drowning victims No significant electrolyte abnormalities No difference in treatment, but be vigil Differences in bacteria, chemical composition (chlorine), and temperature of the aspirated water more significant Conn: Animal model

Hypothermia Water conduction of heat Pulmonary heat exchange Cold water absorption Temperature of water a factor in fresh water near drowning Symptoms vary with degree of hypothermia Is hypothermia destructive or protective?

Prognostic Factors Submersion Time? Level of hypothermia? CPR? Mental Status? Combinations?

Submersion Time and Prognosis Frates: No correlation in time of submersion and survival Quan and Kinder: Duration of submersion >10 minutes predicts bad outcome (6/6) Field resuscitation >25 minutes predicts bad outcome (17/17)

CPR and Prognosis 66 near drowning patients in warm water 25% of victims who were under CPR with GCS of 3 in the ED survived intact, 50% died, 25% neurologically impaired 91% of patients who were still GCS 3 in the ICU either died or were persistently vegetative state Peterson: All who arrived under CPR died or were damaged

Hypothermia and Prognosis Many case reports of long submersion up to 45 minutes with survival in cold water In warm water, hypothermia is an indication of prolonged submersion time, a bad prognostic factor

Neurologic Status and Prognosis Kemp and Sibert: 188 admissions, dilated pupils 6 hours after admission had poor outcome, reactive pupils on ED admission 33% recovered intact, 33% with neurologic impairment Lavel and Shaw: 44 admissions: Nonreactive pupils and GCS <5 poor outcome Dean: GCS <5, unreactive pupils, poor outcome

Conn et al: Neurologic Classification and Prognosis Classification based on 105 patients A: Awake B: Blunted C: Comatose C1: Decorticate C2: Decerebrate C3: Flaccid

Other Predictors Initial pH Age Cardiac standstill Cardiotonic medications Best Predictor: Resuscitation effectiveness determined hours after admission

Prehospital Management ABC’s Initiation of ventilation is the only way to interrupt the submersion time C-Spine control, backboard IV, O2, monitor, pulse ox ACLS if needed, with attention to hypothermia concerns Correction of acidosis NO HEIMLICH

Prehospital Management Cont. Passive Rewarming Rapid Transport All neardrowning victims need evaluation at a medical facility History is important

ED Management ABC’s, with C-spine control IV, O2, Monitor, Pulse Ox CXR ABGs Electrolytes Trauma workup, primary and secondary assessment. Treatment of Complications

Hospital Management Pulmonary Support Rewarming Cerebral Resuscitation

Pulmonary Support O2 Intubation and Ventilation PEEP Steroids? Antibiotics? New ventilation techniques ECMO Liquid Ventilation Surfactant Therapy

Rewarming Passive External Active External (beware of afterdrop) Active Internal –IV –Vent –NG/Bladder/Peritoneal –Bypass

Cerebral Resuscitation Frequent neurologic exams ICP monitoring Resuscitation techniques –Steroids/Mannitol –Barbiturates –Hypothermia –HYPER

Conn et al: HYPER Hyperhydration: diuretics and fluid restriction Hyperventilation: pCO mmHg Hyperpyrexia: hypothermia to 30 degrees C Hyperexcitability: barbiturate coma Hyperrigidity: paralysis Effective in C2 and C1 patients, not C3 Not supported elsewhere in the literature

Conclusions Neardrowning is a common cause of accidental death Remember: –Initiate ventilation early –Don’t forget trauma as a cause –Aggressive treatment of complications: Head, Lung, and Temperature