1. بسم الله الرحمن الرحیم

2. NEAR-DROWNING

3. DROWNING :submersion injuries that result in death in less than 24 h. NEAR-DROWNING : survival longer than 24 h after a submersion event. DEFINITION

4. EPIDEMIOLOGY In the U.S., drowning is the forth leading cause of accidental death overall. It’s the second cause of death in those under 15 years of age. Additional injuries or disorders that either precipitate or are associated with submersion events include: 1 ) spinal cord injuries 1 ) spinal cord injuries 2 ) hypothermia 2 ) hypothermia 3 ) panicking 3 ) panicking 4 ) syncope 4 ) syncope 5 ) seizures 5 ) seizures 6 ) other premorbid condition ( e.g., heart disease ) 6 ) other premorbid condition ( e.g., heart disease )

5. PREVENTION Child abuse should be considered with the victim is less than 6 months of age, or in toddlers with atypical presentations. Teen and young adult drowning may be reduced by the control of alcohol and illicit drug consumption. Drowning locations in elderly closely parallel locations of infant and toddler drowning.

6. PATHOPHYSIOLOGY After submersion, the degree of pulmonary, and in particular central nervous system (CNS) insult determines the ultimate outcome. Diving reflex ( i.e., bradycardia, apnea, peripheral vasoconstriction, and central shunting of blood flow) is protection mechanism. Diving reflex is stronger in infants < 6 months old, but the effects decrease with age. In fresh-water aspiration, there is transient hemodilution, and if large enough volumes are aspirated, significant hemolysis is possible. Rarely, DIC can be a complicating factor in near- drowning.

7. TREETMENT Prehospital care : - rapid, cautious rescue - rapid, cautious rescue - spinal precautions - spinal precautions - cardipulmonary resusciation - cardipulmonary resusciation - supplemental oxygen ( all patients ) - supplemental oxygen ( all patients ) - transport ( all patient ) - transport ( all patient ) Emergency Emergency department and hospital care

8. HOSPITAL CARE OF SUBMERSION VICTIMS PRESENTATION PRESENTATION GCS >= 13 GCS >= 13 cervical spine clear ______________________ Ancillary test only as indicated indicated_________________________ Respiratory Oxygen to Support keep Sao 2 > 95 % 95 % Monitor O 2 saturation PRESENTATION GCS < 13 _______________________Clear_______________________CXR-ECG-ABG-CBC-BS-PT/PTT Electrplytes-UA-CK-urine myoglobin- urine drug screen _____________________________ Oxygen to keep Sao 2 > 95% Intubation and positive-pressure ventilation as needed ( PEEP-CPAP ) _________________________________ Oxygen saturation-Acid base status Temperature-Volume status ( urine output, CVP

9. PROGNOSIS AND DISPOSITION Uncomplicated : 4 to 6 h observed. Complicated : frequently, neurologic and cardiovascular examinations are normal within 24 h of the submersion event. Victims who later die in hospital usually demonstrate deteriorating cardiovascular status. Victims undergoing ED CPR have a poor prognosis.