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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. Drowning.

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drowning new definitions and protocols

DrowningNew Definitions and Protocols

Charles Stewart MD, EMDM

Director of ResearchUniversity of Oklahoma

Tulsa School of Community MedicineOklahoma Institute for Disaster and Emergency Medicine

drowning
Drowning

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

drowning1
Drowning
  • Demographics
    • 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
drowning2
Drowning
  • Statistical Risk Factors
    • Age: Youth 40% under 4 years old
    • Location: Pools, bathtubs, lakes, rivers
    • Sex: Male 3:1
    • Time of year: Warm months
drowning3
Drowning
  • 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!.
near drowning
Near Drowning
  • Statistical Risk Factors
    • Predisposing Illnesses: Epilepsy, seizures
    • Trauma: Diving and boating accidents, falls
    • Mental impairment: Drugs and alcohol
near drowning1
Near Drowning
  • Most common sites:
    • Fresh inland bodies of water
      • Lakes
      • Rivers
      • Quarries
      • Residential swimming pools
predisposing factors
Predisposing Factors
  • Coma, seizures
  • Alcohol/Drugs
  • Exhaustion
  • Hyperventilation
  • Rapidly moving water
predisposing factors1
Predisposing Factors
  • Poor swimming ability
  • Exhaustion
  • Panic
  • Hypothermia
  • Trauma
near drowning2

Near Drowning

Murder ???

Suicide ???

near drowning3

Near Drowning

Definitions

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

near drowning4

Near Drowning

Survival beyond 24 hours after immersion.

This definition is no longer used…

drowning4

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

drowning5

Drowning

The fluid does not have to be water

drowning6
Drowning
  • Unconsciousness
    • Due to :
      • Trauma
      • Seizure
      • Coma
      • Drug/Alcohol abuse
drowning pathophysiology
Drowning Pathophysiology
  • 3 Major metabolic abnormalities
    • Anoxia
    • Acidosis
    • Hypercapnia
wet drowning
Wet Drowning
  • Approximately 90% of drowning victims
    • aspirate water
    • vomit
    • cough
    • gasp
    • flood lungs with water
pathophysiology with aspiration
Pathophysiology withaspiration
  • Hypoxemia
    • Occurs whether or not patient aspirates
    • 85-90% aspirate
    • 10-15% DO NOT aspirate
pathophysiology without aspiration
Pathophysiology withoutaspiration
  • Severe, persistent laryngospasm
  • Anoxic seizures
  • Death
pathophysiology with aspiration1
Pathophysiology withaspiration
  • Hypoxemia
    • Asphyxia starts the Hypoxia
    • Intrapulmonary shunting leads to further hypoxemia
    • Pulmonary damage continues the process
does the type of aspirated water matter
Does the type of

aspirated water matter?

pathophysiology
Pathophysiology
  • Consequences of Aspiration
    • Few survivors of drowning aspirate enough water to cause significant changes in either blood volume or serum electrolytes.
pathophysiology1
Pathophysiology
  • 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
pathophysiology with aspiration2
Pathophysiology withaspiration
  • Pulmonary Edema
    • Damage to Alveolar membrane
    • Damage to pulmonary microcirculation
salt vs fresh there are real differences
Salt

vs

Fresh

There are REAL differences

near drowning5
Near Drowning
  • Potential Fresh Water Damage
    • Hypoxia
    • Atelectasis Strips surfactant
    • Pulmonary Edema
    • Hypotonic
    • Hemolysis
      • Lowered Na, Cl, and K
potential fresh water damage
Potential Fresh Water Damage
  • Hypoxia
  • Atelectasis
  • Pathogenic bacteria and impurities lethal
  • Produces greater long-term damage due to salt in pulmonary edema
drowning7
Drowning
  • Potential Salt Water Damage
    • Hypovolemia if large amounts swallowed
    • Hypertonic Elevation of Na, Cl and K, decrease blood volume
  • Salt water is 2 times as lethal
drowning final pathway
Drowning Final Pathway
  • Pulmonary Edema
  • Hypoxia
cold water and warm water drownings are different
COLD WATER

and

WARM WATER

drownings are different

warm water
Warm Water
  • 20oC and above
  • 72oF and above
  • Lakes, ponds, quarries
hot water
Hot Water
  • Body temperature and above
  • Hot tubs, bath tubs, hot springs
warm water drownings
Warm Water Drownings
  • 49 Warm Water Drownings in Children
    • 29 died 58%
    • 13 neurological cripples 27%
    • 7 survived intact 15%
very cold water
Very Cold Water
  • The definition is not easy
    • It is usually below 21oC or (71oF)
slide36

6

5

100% Lethal

50%

unconscious

4

Hours

3

Probable

Drowning

2

Safe

1

20

30

40

50

-8

-2

4

10

Water Temperature

mammalian diving reflex
Mammalian Diving Reflex
  • Circulatory system shunts blood to the brain and heart from extremities, GI tract and skin
  • Apnea and bradycardia follow, allowing prolonged submersion
mammalian diving reflex1
Mammalian Diving Reflex
  • Found in all mammals
  • Heart Rate Slows
  • Airway closes
  • Circulatory system shunts blood to brain and heart from extremities, GI tract and skin
  • Apnea and bradycardia follow, allowing prolonged submersion
mammalian diving reflex2
Mammalian Diving Reflex
  • Mammalian Diving Reflex in Humans
    • Not very active
    • Probably not the mechanism for survival in prolonged submersions in children
immersion syndrome
Immersion syndrome
  • Sudden exposure to very cold water.
  • Probably vagal dysrhythmia
    • Asystole
    • Ventricular fibrillation
    • Alcohol and intoxicants are predisposition
immersion hypothermia

Immersion Hypothermia

A special case….

cold water immersion
Cold water immersion

Survival Times - Persons of Average Build

Water Temperature Survival Time

0 Deg C 45 minutes

9.5 deg C 2 to 3 hours

11 deg C 4 hours

14 deg C 6 hours

18 deg C 10 hours

submersion victims aren t dead until they are warm and dead
Submersion victims

aren’t dead until

they are WARM and DEAD

rescue
Rescue
  • Most people drown within 10 to 30 feet of safety.
    • Reach
    • Throw
    • Row
    • Go?

American Red Cross

scene assessment
Scene Assessment
  • Type of incident?
  • Duration of submersion?
  • Type and temperature of water?
  • Duration of on scene CPR?
  • Prior health of patient?
  • Drug and Alcohol use?
near drowning6
Near Drowning
  • Watch for trauma in rapidly moving water
slide52
CPR
  • Cardiopulmonary Resuscitation
    • The immediate actions of the Primary Responder significantly affects the outcome of the near drowning victim
field management1

Field Management

In near drownings that involve falls, moving water, boating, and surfing accidents.

Always take C-spine precautions

the heimlich maneuver is unproved in near drownings
The Heimlich Maneuver

is unproved in near drownings

intubate
Intubate
  • Secures airway
  • Protects against aspiration
  • Allows suction of secretions
  • Better ventilation
suction
Suction
  • Suction equipment must be available
  • Many patients will vomit
  • Many will have heavy secretions form pulmonary edema
emergency department management1
Emergency Department Management
  • Cardiac monitoring needed for all patients
  • Acidosis and Hypoxia will decrease the fibrillation threshold
emergency department management2
Emergency Department Management
  • Core body temperature should be measured
  • Keep patient dry
history of patient
History of Patient
  • Obtain Medical History ASAP
  • Age
  • Pre-existing diseases
  • Physical condition
  • Medication
near drowning7
Near Drowning
  • In near drowning victims suspect:
    • Child abuse
    • Suicide
    • Attempted murder
    • Cervical spine trauma
    • Seizures
    • Drug/Alcohol abuse
emergency department management3
Emergency Department Management
  • Reassess ABC’s and vital signs frequently
  • Include Neuro checks
emergency department management4
Emergency Department Management
  • Neurological deficit should not be assumed to be anoxic until
    • C-spine
    • Intracranial Injury
    • Toxic encephalopathy
  • Have been ruled out
laboratory
Laboratory
  • Arterial blood gases
  • Electrolytes
  • BUN/ Creatinine
  • Platelets/ PT & PTT/ CBC
  • Serum & Urine Hemoglobin
clinical manifestations
Clinical Manifestations
  • Radiographic Changes
    • Non-cardiac pulmonary edema with normal heart size
    • Perihilar pattern
    • Seen in 1/3 to 2/3 of patients initially
hypoxia
Hypoxia
  • Respiratory Management Objective
    • Try to achieve a Pa O2 of 70-100 mm Hg
    • 70% will require more aggressive therapy
slide68
PEEP
  • Indicated when pO2 < 60 and FIO2 > 50
  • Try to keep the pO2 at 75-90
  • This prevents pulmonary edema and ARDS ??? (acute respiratory distress syndrome)
hypoxia1
Hypoxia
  • Bronchospasm
  • Treat with:
    • A) Nebulized Agents
    • B) Theophylline
    • C) Consider steroids
steroids

Steroids

As always .... controversial

infection
Infection
  • Prophylactic Antibiotics
    • Not usually indicated
    • Septic tank?
    • Daily gram stains
    • Treat the proper bug
experimental therapies
Experimental Therapies
  • ? Controlled hypothermia
  • ? Calcium channel blockers
  • ? Barbiturate coma therapy
  • ? Hyperbaric oxygenation
  • ? Hyperventilation
hospital management
Hospital Management
  • Resuscitation
  • Cerebral resuscitation
    • HYPER regimen advocated in comatose children
  • ??? Utility
disposition
Disposition
  • All patients with submersion injuries should be admitted
  • High incidence of delayed complications
patients should be admitted and observed but for how long
Patients should be admitted

and observed ...

But for how long?

disposition1
Disposition
  • WARD BED - Asymptomatic with normal vital signs, CXR, and ABG
  • ICU - Symptomatic or abnormal vital signs, CXR, or ABG
prognosis1
Prognosis
  • Survival depends upon a variety of interrelated factors
    • Age
    • Underlying disease
    • Water type and temperature
    • Duration of submersion
    • Degree of hypothermia
clinical manifestations1
Clinical Manifestations
  • Neurological Damage
  • Flaccid is BAD!
bad prognostic factors
Bad Prognostic Factors
  • Older age
  • Warm water
  • Spinal cord damage
  • Inadequate CPR
  • Decorticate / Decerebrate
  • Unconscious
  • Septic tank
good prognostic factors
Good Prognostic Factors
  • Older child or young adult
  • Cold water
  • Adequate CPR/on scene ACLS/BLS
  • Conscious
  • Short submersion
  • Healthy
warm water submersion
Warm Water Submersion
  • In 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 likely
check the k
Check the K!
  • Potassium of > 10 is uniformly associated with mortality…
    • OK to call the arrest at this point.
prevention

Prevention

Prevention

Prevention

Prevention

Prevention

prevention1
Prevention
  • Fences
  • Self-locking gates
  • Immersion alarms
  • Keep pool full
prevention2
Prevention
  • Decrease intoxicants around the pool!
prevention3
Prevention
  • Proper protective gear
    • survival suit
    • Flotation device
  • Cold water training
prevention4
Prevention
  • Supervise patients with seizures
  • Other handicaps?
prevention5
Prevention
  • Prevention Tips
    • Swimming lessons
    • Appropriate people to watch children
    • Teach children to obey the swimming pool rules
prevention6
Prevention
  • Prevention tips
    • Don’t mix alcohol and drugs with swimming activities
    • Do not overexert
    • Avoid dangerous situations
    • Buddy swim
pitfalls
Pitfalls
  • Low oxygen saturation???
    • Calls for significant monitoring – can decompensate quickly
  • Head trauma and drowning???
      • Look for cervical spine trauma
  • Hot water drowning
      • Much quicker lethality…lower survival
pitfalls1
Pitfalls
  • Cold water drowning???
    • Don’t give up quickly – longer survival
  • High potassium???
    • OK to stop CPR
  • Septic tank drowning
    • Massive bacterial contamination
drowning claims
Drowning Claims

> 8,000 death/year

drowning claims1
Drowning Claims

>50,000 deaths/year

prevention7

Prevention

Prevention

Prevention