1. Drowning New Definitions and Protocols Charles Stewart MD, EMDM Director of Research University of Oklahoma Tulsa School of Community Medicine Oklahoma Institute for Disaster and Emergency Medicine

2. Drowning Much of our experience with the resuscitation of patients is a direct result of man’s ventures into the water.Much of our experience with the resuscitation of patients is a direct result of man’s ventures into the water.

3. Drowning DemographicsDemographics –6,000 - 8,000 deaths per year –The 3rd leading cause of accidental death in USA –The 2nd leading cause of death in children –25,000 rescues each summer on California beaches

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

5. Drowning We really don’t know how many ‘near’ drownings occur each year.We really don’t know how many ‘near’ drownings occur each year. –Death statistics are readily available –>15% of school children have at least one submersion incident per year. –With 7.4 per 100,000 reported mortality, that means at least ½ million per year in South Carolina alone!.

6. Near Drowning Statistical Risk FactorsStatistical Risk Factors –Predisposing Illnesses: Epilepsy, seizures –Trauma: Diving and boating accidents, falls –Mental impairment: Drugs and alcohol

7. Near Drowning Most common sites:Most common sites: –Fresh inland bodies of water LakesLakes RiversRivers QuarriesQuarries Residential swimming poolsResidential swimming pools

8. Predisposing Factors Coma, seizuresComa, seizures Alcohol/DrugsAlcohol/Drugs ExhaustionExhaustion HyperventilationHyperventilation Rapidly moving waterRapidly moving water

9. Predisposing Factors Poor swimming abilityPoor swimming ability ExhaustionExhaustion PanicPanic HypothermiaHypothermia TraumaTrauma

10. Near Drowning Murder ??? Suicide ???

11. Near Drowning Definitions Definitions were revised at 2002 World congress on Drowning in Amsterdam, Netherlands. They are now internationally accepted and more uniform

12. Near Drowning Survival beyond 24 hours after immersion. This definition is no longer used…

13. Drowning Submersion in a fluid resulting in immediate death or death with 24 hours Respiratory impairment from submersion in a liquid. May have outcome of death, morbidity, or no morbidity

14. Drowning The fluid does not have to be water

15. Drowning UnconsciousnessUnconsciousness –Due to : TraumaTrauma SeizureSeizure ComaComa Drug/Alcohol abuseDrug/Alcohol abuse

16. Drowning Pathophysiology 3 Major metabolic abnormalities3 Major metabolic abnormalities –Anoxia –Acidosis –Hypercapnia

17. Wet Drowning Approximately 90% of drowning victimsApproximately 90% of drowning victims –aspirate water –vomit –cough –gasp – flood lungs with water

18. Pathophysiology with aspiration HypoxemiaHypoxemia –Occurs whether or not patient aspirates –85-90% aspirate –10-15% DO NOT aspirate

19. Pathophysiology without aspiration Severe, persistent laryngospasmSevere, persistent laryngospasm Anoxic seizuresAnoxic seizures DeathDeath

20. Pathophysiology with aspiration HypoxemiaHypoxemia –Asphyxia starts the Hypoxia –Intrapulmonary shunting leads to further hypoxemia –Pulmonary damage continues the process

21. Does the type of aspirated water matter?

22. Pathophysiology Consequences of AspirationConsequences of Aspiration –Few survivors of drowning aspirate enough water to cause significant changes in either blood volume or serum electrolytes.

23. Pathophysiology Consequences of AspirationConsequences of Aspiration –2.2 cc/kgHypoxia –11 cc/kgBlood volume changes –22 cc/kgElectrolyte changes Average aspiration is only 2-4 cc/kgAverage aspiration is only 2-4 cc/kg

24. Pathophysiology with aspiration Pulmonary EdemaPulmonary Edema –Damage to Alveolar membrane –Damage to pulmonary microcirculation

26. Near Drowning Potential Fresh Water DamagePotential Fresh Water Damage –Hypoxia –Atelectasis Strips surfactant –Pulmonary Edema –Hypotonic –Hemolysis Lowered Na, Cl, and KLowered Na, Cl, and K

27. Potential Fresh Water Damage HypoxiaHypoxia AtelectasisAtelectasis Pathogenic bacteria and impurities lethalPathogenic bacteria and impurities lethal Produces greater long-term damage due to salt in pulmonary edemaProduces greater long-term damage due to salt in pulmonary edema

28. Drowning Potential Salt Water DamagePotential Salt Water Damage –Hypovolemia if large amounts swallowed –Hypertonic Elevation of Na, Cl and K, decrease blood volume Salt water is 2 times as lethalSalt water is 2 times as lethal

29. Drowning Final Pathway Pulmonary EdemaPulmonary Edema HypoxiaHypoxia

30. COLD WATER and WARM WATER drownings are different

31. Warm Water 20 o C and above20 o C and above 72 o F and above72 o F and above Lakes, ponds, quarriesLakes, ponds, quarries

32. Hot Water Body temperature and aboveBody temperature and above Hot tubs, bath tubs, hot springsHot tubs, bath tubs, hot springs

33. Warm Water Drownings 49 Warm Water Drownings in Children49 Warm Water Drownings in Children –29 died58% –13 neurological cripples27% –7 survived intact15%

34. Cold water has more survivors

35. Very Cold Water The definition is not easyThe definition is not easy –It is usually below 21 o C or (71 o F)

36. Hours Water Temperature 6 5 4 3 2 1 20304050 100% Lethal 50% unconscious Probable Drowning Safe -8-2410

37. Mammalian Diving Reflex Circulatory system shunts blood to the brain and heart from extremities, GI tract and skinCirculatory system shunts blood to the brain and heart from extremities, GI tract and skin Apnea and bradycardia follow, allowing prolonged submersionApnea and bradycardia follow, allowing prolonged submersion

38. Mammalian Diving Reflex Found in all mammalsFound in all mammals Heart Rate SlowsHeart Rate Slows Airway closesAirway closes Circulatory system shunts blood to brain and heart from extremities, GI tract and skinCirculatory system shunts blood to brain and heart from extremities, GI tract and skin Apnea and bradycardia follow, allowing prolonged submersionApnea and bradycardia follow, allowing prolonged submersion

39. Mammalian Diving Reflex Mammalian Diving Reflex in HumansMammalian Diving Reflex in Humans –Not very active –Probably not the mechanism for survival in prolonged submersions in children

40. Immersion syndrome Sudden exposure to very cold water.Sudden exposure to very cold water. Probably vagal dysrhythmiaProbably vagal dysrhythmia –Asystole –Ventricular fibrillation –Alcohol and intoxicants are predisposition

41. Immersion Hypothermia A special case….

42. Cold water immersion Survival Times - Persons of Average BuildSurvival Times - Persons of Average Build Water Temperature Survival TimeWater Temperature Survival Time 0 Deg C 45 minutes0 Deg C 45 minutes 9.5 deg C 2 to 3 hours9.5 deg C 2 to 3 hours 11 deg C 4 hours11 deg C 4 hours 14 deg C 6 hours14 deg C 6 hours 18 deg C 10 hours18 deg C 10 hours

43. Immersion hypothermia HuddleHuddle HELPHELP

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

45. Field Management

46. Drown not thyself to save a drowning man Old Proverb

47. Rescue Most people drown within 10 to 30 feet of safety.Most people drown within 10 to 30 feet of safety. –Reach –Throw –Row –Go? American Red Cross

48. Scene Assessment Type of incident?Type of incident? Duration of submersion?Duration of submersion? Type and temperature of water?Type and temperature of water? Duration of on scene CPR?Duration of on scene CPR? Prior health of patient?Prior health of patient? Drug and Alcohol use?Drug and Alcohol use?

49. Near Drowning Watch for trauma in rapidly moving waterWatch for trauma in rapidly moving water

50. Resuscitation

51. #1 Restore Ventilation !!!

52. CPR Cardiopulmonary ResuscitationCardiopulmonary Resuscitation –The immediate actions of the Primary Responder significantly affects the outcome of the near drowning victim

53. Field Management In near drownings that involve falls, moving water, boating, and surfing accidents. Always take C-spine precautions

54. The Heimlich Maneuver is unproved in near drownings

55. Emergency Department Management

56. Intubate Secures airwaySecures airway Protects against aspirationProtects against aspiration Allows suction of secretionsAllows suction of secretions Better ventilationBetter ventilation

57. Suction Suction equipment must be availableSuction equipment must be available Many patients will vomitMany patients will vomit Many will have heavy secretions form pulmonary edemaMany will have heavy secretions form pulmonary edema

58. Emergency Department Management Cardiac monitoring needed for all patientsCardiac monitoring needed for all patients Acidosis and Hypoxia will decrease the fibrillation thresholdAcidosis and Hypoxia will decrease the fibrillation threshold

59. Emergency Department Management Core body temperature should be measuredCore body temperature should be measured Keep patient dryKeep patient dry

60. History of Patient Obtain Medical History ASAPObtain Medical History ASAP AgeAge Pre-existing diseasesPre-existing diseases Physical conditionPhysical condition MedicationMedication

61. Near Drowning In near drowning victims suspect:In near drowning victims suspect: –Child abuse –Suicide –Attempted murder –Cervical spine trauma –Seizures –Drug/Alcohol abuse

62. Emergency Department Management Reassess ABC’s and vital signs frequentlyReassess ABC’s and vital signs frequently Include Neuro checksInclude Neuro checks

63. Neurological deficit should not be assumed to be anoxic untilNeurological deficit should not be assumed to be anoxic until –C-spine –Intracranial Injury –Toxic encephalopathy Have been ruled outHave been ruled out Emergency Department Management

64. Laboratory Arterial blood gasesArterial blood gases ElectrolytesElectrolytes BUN/ CreatinineBUN/ Creatinine Platelets/ PT & PTT/ CBCPlatelets/ PT & PTT/ CBC Serum & Urine HemoglobinSerum & Urine Hemoglobin

65. Clinical Manifestations Radiographic ChangesRadiographic Changes –Non-cardiac pulmonary edema with normal heart size –Perihilar pattern –Seen in 1/3 to 2/3 of patients initially

66. Adjunctive Therapy

67. Hypoxia Respiratory Management ObjectiveRespiratory Management Objective –Try to achieve a Pa O 2 of 70-100 mm Hg –70% will require more aggressive therapy

68. PEEP Indicated when pO 2 50Indicated when pO 2 50 Try to keep the pO 2 at 75-90Try to keep the pO 2 at 75-90 This prevents pulmonary edema and ARDS ??? (acute respiratory distress syndrome)This prevents pulmonary edema and ARDS ??? (acute respiratory distress syndrome)

69. Hypoxia BronchospasmBronchospasm Treat with:Treat with: –A) Nebulized Agents –B) Theophylline –C) Consider steroids

70. Steroids As always.... controversial

71. Infection Prophylactic AntibioticsProphylactic Antibiotics –Not usually indicated –Septic tank? –Daily gram stains –Treat the proper bug

72. Experimental Therapies ? Controlled hypothermia? Controlled hypothermia ? Calcium channel blockers? Calcium channel blockers ? Barbiturate coma therapy? Barbiturate coma therapy ? Hyperbaric oxygenation? Hyperbaric oxygenation ? Hyperventilation? Hyperventilation

73. Hospital Management ResuscitationResuscitation Cerebral resuscitationCerebral resuscitation –HYPER regimen advocated in comatose children ??? Utility??? Utility

74. Disposition All patients with submersion injuries should be admittedAll patients with submersion injuries should be admitted High incidence of delayed complicationsHigh incidence of delayed complications

75. Patients should be admitted and observed... But for how long?

76. Disposition WARD BED - Asymptomatic with normal vital signs, CXR, and ABGWARD BED - Asymptomatic with normal vital signs, CXR, and ABG ICU - Symptomatic or abnormal vital signs, CXR, or ABGICU - Symptomatic or abnormal vital signs, CXR, or ABG

77. Prognosis

78. Survival depends upon a variety of interrelated factorsSurvival depends upon a variety of interrelated factors –Age –Underlying disease –Water type and temperature –Duration of submersion –Degree of hypothermia

79. Clinical Manifestations Neurological DamageNeurological Damage Flaccid is BAD!Flaccid is BAD!

80. Bad Prognostic Factors Older ageOlder age Warm waterWarm water Spinal cord damageSpinal cord damage Inadequate CPRInadequate CPR Decorticate / DecerebrateDecorticate / Decerebrate UnconsciousUnconscious Septic tankSeptic tank

81. Good Prognostic Factors Older child or young adultOlder child or young adult Cold waterCold water Adequate CPR/on scene ACLS/BLSAdequate CPR/on scene ACLS/BLS ConsciousConscious Short submersionShort submersion HealthyHealthy

82. Warm Water Submersion In warm water submersionIn warm water submersion –Submersion > 5 minutes –Fixed and dilated pupils (in the ED) –No CPR for 10 minutes or more –pH less than 7.1 on arrival at hospital –Need for in hospital resuscitation or ventilation Severe neurologic impairment or mortality is likelySevere neurologic impairment or mortality is likely

83. Check the K! Potassium of > 10 is uniformly associated with mortality…Potassium of > 10 is uniformly associated with mortality… –OK to call the arrest at this point.

84. Prevention

85. FencesFences Self-locking gatesSelf-locking gates Immersion alarmsImmersion alarms Keep pool fullKeep pool full

86. Prevention Decrease intoxicants around the pool!Decrease intoxicants around the pool!

87. Prevention Proper protective gearProper protective gear –survival suit –Flotation device Cold water trainingCold water training

88. Prevention Supervise patients with seizuresSupervise patients with seizures Other handicaps?Other handicaps?

89. Prevention Prevention TipsPrevention Tips –Swimming lessons –Appropriate people to watch children –Teach children to obey the swimming pool rules

90. Prevention Prevention tipsPrevention tips –Don’t mix alcohol and drugs with swimming activities –Do not overexert –Avoid dangerous situations –Buddy swim

91. Pitfalls Low oxygen saturation???Low oxygen saturation??? –Calls for significant monitoring – can decompensate quickly Head trauma and drowning???Head trauma and drowning??? Look for cervical spine traumaLook for cervical spine trauma Hot water drowningHot water drowning Much quicker lethality…lower survivalMuch quicker lethality…lower survival

92. Pitfalls Cold water drowning???Cold water drowning??? –Don’t give up quickly – longer survival High potassium???High potassium??? –OK to stop CPR Septic tank drowningSeptic tank drowning –Massive bacterial contamination

93. Summary

94. Drowning Claims > 8,000 death/year

95. Drowning Claims >50,000 deaths/year

96. Prevention