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DROWNING AND NEAR-DROWNING

DROWNING AND NEAR-DROWNING. Dr.Özgül Keskin Yeditepe University School of Medicine Department of Anesthesiology and Reanimation. It is one of Nature’s greatest ironies that man should spend the first nine months of his existence continously surrounded by water, but

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DROWNING AND NEAR-DROWNING

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  1. DROWNINGANDNEAR-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 hisexistence continously surrounded by water, but the rest of his life with an inherent fear of submersions B. A. GOODEN

  3. > 500 000 deaths/yearduetodrowning • Mostly 5-14 years of age • 4thfrequentcause of death in thesameage • Morefrequent in pediatricagegroup • Freshwaterdrowning > salt waterdrowning • Especially in <5 y agegroupdrowning in bathtubsarefrequent • Drowningaffectshealthypeople in youngandproductiveagegroup USA; leadingcauses of death 0-4 years-old 6th 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: Drowning is defined as death resulting from suffocation within 24 hours of submersion in a liquid medium Near-drowning: Near-drowning, as survival of (evenwith severe medicalthrapy) at least 24 hours after an episode of suffocation caused by submersion in a liquid medium

  6. Definitions Dry-drowning: Dueto a suddenimmersionintowater, largyngospasmleadingtoasphyxiaresultingwithalveoliwithoutwater Wet-drowning: Drowningduetowater in thealveoli Secondarydrowning: Anysecondarydisease (Heartdisease, epilepsy, alcoholuseetc) leadingtoloss of consciousness in water, therebydrowning

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

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

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

  12. Electrolyteimbalance • 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 and WARM WATER drownings are different Cold water has more survivors

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

  15. Treatment Drown not thyself to save a drowning man

  16. Treatment Resuscitation in thesetting of accident • A-B-C should be appliedMouth –to-mouthbreathingshould be started in water • No needforcardiacmassage in water, loss of time • HeimlichandPatricmaneuvers (?) • Subdiaphragmaticpressuremay be effectivefordrainingwaterfromthelungs • Theymaybothaspirateanddrinkwater in tostomachalso. Pressuremaycausemoreaspiration • Manualandmechanicalventilationwith ETT • Standart CPR • SpO2shouldtriedto be kept at 90%

  17. Treatment in ER & ICU RespiratorySystem • ETT andmechanicalventilationifneeded • Positiveendexpiratorypressure (PEEP) 4-6 cm H2O to 12-14 cmH2O • Aim is tomake SpO2 >90%, whilekeeping FiO2 < 50% • NG tube

  18. Treatment in ER & ICU CardiovascularSystem • Fluidreplacementwithappropriatesolution • Inotropicsupport • Treathypoglycemiaandhypocalcemiatotreatmycardialdepression Thermoregulation • Wetclothesshould be removed • Especially in childrenheatloss is veryfast • Heatthepatientslowlywithblanketsandlight • IV fluidsshould be heatedto 36-40 ̊C • O2 should be heatedandhumidified (HMEF-Heatedhumidifiers) • Peritonealorbladderlavage

  19. Treatment in ER & ICU NeurologicalSystem • GCS <8 orConn-Barkerclass C1 or C2 should be intubatedandmechanicallyventilated • GCS <3 orConn-Barkerclass C4 patientsshould not be resuscitated • Increased ICP leadstobadprognosisand can not be treatedifoccured

  20. Prognosis • Factors forgoodprognosis • Duration of stay in water <5 min • Immediate CPR • CPR duration <10 min • Spontaneous ECG rhytm on ER admission • GCS >5 on ER admission • Spontaneousmovementandheathybrainstemfunction in 24 hours • Factorsforpoorprognosis • Duration of stay in water >10 min • CPR start > 10 min • Cardiotonicdrugneed on ER admission • GCS <5 • No spontaneousmovementafter 24 hours

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