1. DROWNING AND NEAR-DROWNING
Dr.Özgül Keskin
Yeditepe University School of Medicine
Department of Anesthesiology and Reanimation

2. It is one of Nature’s greatest ironies that man should spend the first nine months of his existence continously surrounded by water, but the rest of his life with an inherent fear of submersions
B. A. GOODEN

3. USA; leading causes of death 0-4 years-old 6th 5-14 years-0ld 4th
> deaths/year due to drowning
Mostly years of age
4th frequent cause of death in the same age
More frequent in pediatric age group
Fresh water drowning > salt water drowning
Especially in <5 y age group drowning in bathtubs are frequent
Drowning affects healthy people in young and productive age group
USA; leading causes of death
0-4 years-old th
5-14 years-0ld 4th

4. Statistical Risk Factors
Age: Youth 40% under 4 years old
Location: Pools, bathtubs, lakes, rivers
Sex: Male 3:1
Time of year: Warm months

5. Definitions Drowning: Near-drowning:
Drowning is defined as death resulting from suffocation within 24 hours of submersion in a liquid medium
Near-drowning:
Near-drowning, as survival of (even with severe medical thrapy) at least 24 hours after an episode of suffocation caused by submersion in a liquid medium

6. Definitions Dry-drowning: Wet-drowning: Secondary drowning:
Due to a sudden immersion into water, largyngospasm leading to asphyxia resulting with alveoli without water
Wet-drowning:
Drowning due to water in the alveoli
Secondary drowning:
Any secondary disease (Heart disease, epilepsy, alcohol use etc) leading to loss of consciousness in water, thereby drowning

7. Definitions Immersion Syndrome:
The immersion syndrome (also called the immediate disappearance syndrome)
is syncope provoked by bradycardia, tachycardia, or arrhythmia precipitated by sudden contact with water at a temperature of at least 5°C less than body temperature. It can happen, therefore, in water as warm as 31°C

8. Chain of events Immersion in water
Breath holding voluntarily and with panic
Struggle of the victim
Unvoluntarily point of cession (vazgeçme noktası)
Aspiration of water and/or laryngospasm
Cardiac arrest due to on-going hypoxia
Hypoxic damage of brain
Cytotoxic cerebral odema
Increased intracranial pressure, decreased cerebral blood flow
Herniation and death

9. Pulmonary hypertension
Pathophysiology (Pulmonary)
Immersion in water
Breath holding
Aspiration of water
Laryngospasm
Alveolar hypoxia
& hypercapnia
ARDS
Surfactant loss
Left ventricular afterload
Pulmonary hypertension
Pulmonary edema
Systemic hypoxemia and hypercapnia
Cardiac depression
Asistoli

10. Fresh Water Aspiration
Hypotonic
pass into capillary easily
Hemolysis
Pulmonary surfactant dissolution
Alveolar collaps
Atelectasis
V/Q mismatch
HYPOXEMIA

11. pass into alveoli easily
Salt Water Aspiration
Salt water aspiration
Water
Hypotonic
pass into alveoli easily
Hemoconsantration
Water in the alveoli
HYPOXEMIA

12. Electrolyte imbalance
Consequences of Aspiration
2.2 cc/kg Hypoxia
11 cc/kg Blood volume changes
22 cc/kg Electrolyte changes
Average aspiration is only 2-4 cc/kg

13. Cold water has more survivors
and
WARM WATER
drownings are different
Cold water has more survivors

14. Submersion victims
aren’t dead until
they are WARM and DEAD

15. Drown not thyself to save a drowning man
Treatment
Drown not thyself to save a drowning man

16. Treatment Resuscitation in the setting of accident
A-B-C should be applied Mouth –to-mouth breathing should be started in water
No need for cardiac massage in water, loss of time
Heimlich and Patric maneuvers (?)
Subdiaphragmatic pressure may be effective for draining water from the lungs
They may both aspirate and drink water in to stomach also. Pressure may cause more aspiration
Manual and mechanical ventilation with ETT
Standart CPR
SpO2 should tried to be kept at 90%

17. Treatment in ER & ICU Respiratory System
ETT and mechanical ventilation if needed
Positive end expiratory pressure (PEEP) 4-6 cm H2O to cmH2O
Aim is to make SpO2 >90%, while keeping FiO2 < 50%
NG tube

18. Treatment in ER & ICU Cardiovascular System Thermoregulation
Fluid replacement with appropriate solution
Inotropic support
Treat hypoglycemia and hypocalcemia to treat mycardial depression
Thermoregulation
Wet clothes should be removed
Especially in children heat loss is very fast
Heat the patient slowly with blankets and light
IV fluids should be heated to ̊C
O2 should be heated and humidified (HMEF-Heated humidifiers)
Peritoneal or bladder lavage

19. Treatment in ER & ICU Neurological System
GCS <8 or Conn-Barker class C1 or C2 should be intubated and mechanically ventilated
GCS <3 or Conn-Barker class C4 patients should not be resuscitated
Increased ICP leads to bad prognosis and can not be treated if occured

20. Prognosis Factors for good prognosis Factors for poor prognosis
Duration of stay in water <5 min
Immediate CPR
CPR duration <10 min
Spontaneous ECG rhytm on ER admission
GCS >5 on ER admission
Spontaneous movement and heathy brain stem function in 24 hours
Factors for poor prognosis
Duration of stay in water >10 min
CPR start > 10 min
Cardiotonic drug need on ER admission
GCS <5
No spontaneous movement after 24 hours