Drowning David Slocum MD Albany Medical Center

Miracles Matthew Granger 14 month old 14 month old minutes minutes

Vocabulary Drowning – death within 24 hours Near-drowning – survival past 24 hours

Who? Usually young, healthy individuals

2006 Drowning U.S.A. – 5000 died Worldwide – over 100,000 died

Epidemiology 500,000 submersion events annually 2nd cause of death – children under 15 Injury ranges Transient Transient Profound neurological deficit Profound neurological deficit

Three Peaks ToddlersAdolescentsElderly

Toddlers ToiletsBathtubsBuckets

Coastal Areas Swimming pools more likely

Adolescents Stupidity

Young Adults Alcohol 40% adult drownings 40% adult drownings 75% boat drownings 75% boat drownings

Elderly

Complicating Factors Spinal cord injury HypothermiaPanickingSyncopeSeizures

Pathophysiology Central Nervous System Injury Pulmonary Injury

Dry-drowning 10-20% of submersions LaryngospasmHypoxia Loss of consciousness

Wet-drowning Aspiration of water Dilution of surfactant Diminished gas transfer Atelectasis Ventilation perfusion mismatch

Pulmonary Injury Contaminated foreign material Particulate matter BacteriaVomitus Chemical irritants

Prognosis Submersion time Physiological scoring systems

Two extremes Fair cardiovascular and neurological function Minimal disability Minimal disability Unstable cardiovascular function and coma Poorly Poorly Hypoxic CNS injury Hypoxic CNS injury

End Organ Damage Renal injury Hypoxia Hypoxia Myoglobinuria Myoglobinuria Hemoglobinuria HemoglobinuriaHematologic Hemolysis Hemolysis DIC DIC

Treatment

Prehospital Care Resuscitation Time optimizes outcome Time optimizes outcome Removal from water C-spine protection C-spine protection CPR ASAP

Airway Breathing High flow oxygen by facemask High flow oxygen by facemask Not Breathing Bag valve mask Bag valve mask Endotracheal tube Endotracheal tubeUnconscious Protect from aspiration

Who to transport? Amnesia Loss or depressed consciousness Period of apnea Period of artificial respirations Even if asymptomatic

Don’t Forget Warm patient Hypothermia HypothermiaMonitor IV access Warm isotonic fluids Warm isotonic fluids

Summary Rapid, cautious rescue Spine precautions Cardiopulmonary resuscitation Supplemental Oxygen Transport

ED Treatment Continue EMS care Airway Airway Oxygen Oxygen Ventilation Ventilation Warmed fluids Warmed fluids Warming adjunts Warming adjunts Treat associated injuries Treat associated injuries

GCS > 12 Oxygen to keep sat > 95% Observe 4-6 hours Pulmonary exam normal Saturation normal Discharge home No xray or labs needed

GCS > 12 Oxygen to keep sat > 95% Observe 4-6 hours Pulmonary exam abnormal Requires oxygen Deteriorates Admit to Monitored bed

GCS < 13 High flow oxygen Intubation for low PaO2 CXR, Labs Continuous cardiac monitoring Frequent reassessments

Seizure Dilutional hyponatremia Control seizures Correct electrolytes Residual disorder uncommon

ED Arrest Warm water drowning Recovery doubtful Consider early discontinuation of efforts Risk profound neurological handicaps

Hospital Management Supportive Avoid ARDS Pneumonia rare Dopamine, epinephrine drips 48 hour window

No benefit Mannitol Loop diuretics Hypertonic saline Fluid restriction Hyperventilation Controlled hypothermia Barbiturate coma

Prognosis No CPR Full recovery within 48 hours Full recovery within 48 hours May develop ARDS May develop ARDS Bystander CPR Steady recovery Steady recovery Steady decline Steady decline ED CPR Very poor prognosis Very poor prognosis

Pediatric Warm Water Drowning 500 victims 100% received ED CPR 84% died 16% severe hypoxic encephalopathy

Diving Reflex MammalsBradycardia Peripheral Vasoconstriction Greatest in cold water Preserves oxygen

ICE water submersion Asystole Children and Adults Complete Recovery Rare Resuscitate until normothermic

Prevention Infants Parental vigilance Parental vigilanceToddler Pool fencing Pool fencing Adolescent/Young Adult Control Alcohol/Drug Use Control Alcohol/Drug Use Swimming lessons Swimming lessonsElderly Same as infant/toddler Same as infant/toddler