1. 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.

2. 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.

3. 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

4. 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

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

6. Epidemiology

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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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

23. 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

24. 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

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

26. 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

27. 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

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

29. 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

30. 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

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

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

35. 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

36. Outcomes
Death 30 – 50%

37. 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

38. 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

39. Prevention
Swimming partners
Flotation devices

40. 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.

41. 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

42. Prevention - Education
Educate children and parents about water safety

43. Doing Something Right