Near Drowning

1. Near Drowning Resident Rounds June 26, 2003 Robbie N. Drummond

2. Not Waving but DrowningStevie Smith • Nobody heard him, the dead man, • But still he lay moaning: • I was much further out than you thought • And not waving but drowning. • Poor chap, he always loved larking • And now he's dead • It must have been too cold for him his heart gave way, • They said. • Oh, no no no, it was too cold always • (Still the dead one lay moaning) • I was much too far out all my life • And not waving but drowning.

3. IV. DEATH BY WATER (from the Wasteland, T.S. Eliot) • PHLEBAS the Phoenician, a fortnight dead, • Forgot the cry of gulls, and the deep seas swell • And the profit and loss. • A current under sea • Picked his bones in whispers.As he rose and fell • He passed the stages of his age and youth • Entering the whirlpool. • Gentile or Jew • O you who turn the wheel and look to windward, • Consider Phlebas, who was once handsome and tall as you.

4. The Tempest by Willy Boy the Spear Shaker Act I Scene ii • ARIEL sings] • Full fathom five thy father lies; • Of his bones are coral made; • Those are pearls that were his eyes: • Nothing of him that doth fade • But doth suffer a sea-change • Into something rich and strange. • Sea-nymphs hourly ring his knell • Hark! now I hear them,--Ding-dong, bell. • FERDINAND The ditty does remember my drown'd father.

5. YODA’s 7 QUESTIONS ABOUT DROWNING • There are a lot of terms to describe drowning how do I wade through them all? • What is the real difference between fresh and salt water drowning? • How common is drowning are there any preventative measures to be taken to avert death by water? • There is a drowning victim in the ED what are the factors that suggest he will survive? • What is the best approach to resuscitating a drowning victim? • What about the prophylaxis measures previously taken, steroids, hyper therapy, antibiotics....etc.? • Survivors of drownings usually are hypothermic what is the relation between hypothermia and drowning?

6. There are many terms to describe drowning how do I wade through them all? • gets complicated..... Drowning, near-drowning, drowning with/without aspiration, dry drowning, wet drowning, secondary drowning, submersion vs immersion, immersion syndrome, • ORLOWSKI feels too complicated was supposed to imply prognosis but does not • Drowning “ suffocation by immersion or submersion in any liquid medium, caused by the entrance of liquid in the airways that partially or fully compromises ventilation or oxygen exchange”

7. basic definitions • drowning death within 24 hours of submersion • near drowning death after 24 hours of submersion • secondary drowning death from a complication of submersion • one author secondary drowning cause of death not related to water (eg MI) • drowning with or without aspiration • immersion vs submersion partially vs totally covered • aspiration of other fluids bodily etc

8. wet vs dry drowning • 10% no fluid found in lungs • severe laryngospasm, hypoxia, convulsion and death • one author “dry drownings probably do not exist.... if there is no water in lungs victim probably not alive when entered water”..... A la Brian Jones of the Stones.... It was Mick and Keith, the glimmer twins, don’t you know it?

9. 13 % of all drownings happens after precipitating event • drugs 36% (usually alcohol) • convulsion 18 % • trauma 16 % • cardiopulmonary 14% • SCUBA 3 % • others 11 %

11. My mother told me to splash water on my face before..... • Immersion Syndrome • syncope provoked by arrhythmia • sudden contact with water at least 5 degrees less than body temperature • syncope loss of consciousness and secondary drowning • massive release of adrenaline • reduced by wetting face and head before entering water

12. How common is drowning are there any preventative measures to be taken to avert death by water? • 90 % of all drowning deaths occur within 10 meters of safety

13. Some watery numbers • 500,000 per year worldwide • third most common cause of unintentional death • 10 saves and five near drownings for every drowning • 1996 62,747 rescues • 55-60% less than 20 years of age • African-Americans two time rate of Caucasians • males five times as often as females • costs 6.5 billion buckaroos in US alone

14. bimodal distribution • toddlers less than 2 and teenage boys 10 - 19 years • teenager (boys) risk taking, alcohol factor 60% of time • bathtubs usual site under one year of age • many as a result of abuse • bucket- related deaths • older toddlers pools • children and adolescents fresh water

16. POOLS • 50, 000 new pools built every year in USA • 2.2 million residential pools • 2.3 million nonresidential pools already in existence • in temperate areas of USA 70 - 90 % of drowning occur in pools

17. PUBLIC HEALTH • proper pool fencing and supervision • training in swimming and water safety essential • not leaving child unattended near tub or pool • personal flotation devices while boating • proper training, SCUBA boating etc • solar blankets support weight of toy not children hides drowning child • citizens trained in CPR • avoidance of alcohol

19. PREVENTION • the key to minimizing morbidity is successful prevention • AAP 23 recommendations • swimming lessons a good idea • but sometimes children not aware of their skill level and • parents not cautious enough

20. RISK FACTORS FOR SUBMERSION ACCIDENTS • , seizures, trauma, Etoh, hyperventilation, • drugs of abuse, hot tubs, hypothermia, • cvs disease, child abuse, diabetes, suicide • inability to swim • 53% of individuals with a submersion incident over age 26 blood etoh >100 • 9% of suicides due to drowning • Time of day: toddler drowning : • meal preparation times early evenings

21. What is the real difference between fresh and salt water drowning? • animal models (ie threw man’s best friend in water to see what happens) • struggle small amounts fluid hypopharynx laryngospasm • swallowing water • laryngospasm abates aspiration large amounts water • vomiting aspiration of gastric contents • evolving hypoxemia , circulatory collapse • myocardial damage, and multiorgan failure • ischemic brain injury....death

22. the Pacific vs Georgian Bay • for many years suggested difference between fresh and salt water drowning • give dogs 44 ml /kg fresh water causes potassium disturbance • previous theory was fresh water more hypotonic • hemodilution hyper volemia, red cell rupture • dilution of pulmonary surfactant alveolar collapse • sea water hypovolemia, and increased electrolyte hemoconcentration • fluid movement from intravascular to alveoli

23. In reality.... • more than 11 ml per kg for change in blood volume • only 15% who die in the water aspirate more than this quantity most less than 4ml/kg • 22 ml/kg for changes in electrolytes • in a study by spilzman 1994 187 drowning victims had no electrolyte abnormality • seawater drowning does not cause hypovolemia • freshwater drowning does not cause hypervolemia, hemolysis, or hyperkalemia

24. no difference • from clinical point of view no difference fresh vs salt water • most immediate cause is hypoxia and metabolic acidosis • both produce surfactant destruction alveolitis, noncardiogenic pulmonary edema • disruption of gas exchange increased shunt leading to profound hypoxia • as little as 1 ml /kg aspiration profound alterations in gas exchange decreased compliance • cerebral hypoxia is the final common pathway • resp disturbance more on amount than type of water

25. 2 small points • sometimes physiologic changes many hours after insult • water may be contaminated with chemicals, bacteria, sand etc.

26. DEAD SEA

27. Dead Sea • unless you drown in the dead sea (Yagil et al arch In Med 1985) • one case hypercalcemia and hypermagnesemia

28. What is the best approach to resuscitating a drowning victim? • drowning victims present risk to rescuer • approach with caution or intermediate object • instinctive drowning response • drowning victims unable to call for help • upright position slapping or thrashing water • children 10 - 20 seconds • adult up to 60 seconds

29. CPR ASAP SVP • first description of CPR 1600’s : Paracelcus a Swiss physician inserting fireplace bellows in the victim’s mouth or nostrils • always remember underlying causes for drowning • caution re neck injuries • citizens trained in CPR • in water CPR usually ineffective and dangerous • delay in CPR prolongs hypoxia • because circumstance are never clear • resuscitation should always be initiated in the field

30. drowning victims swallow much more water than they inhale • no attempt to remove water from lung • great quantities of water in stomach likely to aspirate • Heimlich himself suggested his maneuver to expel water from lungs,,,, counterproductive • gastric acid aspiration from abdominal pressure • lots of fluid in stomach • up to 60 % of drowning victims vomit • right lateral decubitus head down ? Sellick’s maneuver • high risk for vomiting spontaneously or on resuscitation

31. There is a drowning victim in the ED what are the factors that suggest he will survive?

32. ORLOWSKI’s 5 unfavourable prognostic factors • age of 3 or less • submersion > 5 minutes • no attempts at resuscitation for 10 minutes • coma on admission to ED • severe acidosis pH <7.1 • lack of controlled studies which factors greatest impact <2.... 90 % recovery • >3.... 5 % likelihood of recovery

33. Check out the GCS • GCS adds predictability • 2-6 hours after if no improvement unlikely to improve • if some increase GCS 50% • if alertness normal sequelae limited

34. other factors • resuscitation > 25 minutes • asystole on arrival at hospital GCS < 5 • elevated ICP, coma or CPR needed in ED • some survival in some individuals with some or all of these factors • water temperature, duration and degree of hypothermia • the diving reflex, the victim’s age, water contamination, • duration of cardiac arrest • the speed and effectiveness of initial treatment cerebral resuscitation

35. success of resuscitation major determinant of outcome • prognosis response to serial neurologic exams • 3 point improvement on GCS on arrival to ICU portends • 100 % full recovery in pediatric population • conscious on arrival excellent chance of survival • CONN scale alert 100%’ • blunted mortality rate 10% • comatose greater than 35%

36. The Opposite of Drowning?

37. What is the best approach to resuscitating a drowning victim in ED? • continuous cardiac monitoring • observation for 4-6 hours if asymptomatic • serial ABG measurements (Arterial line) • oxygen therapy • NGT and FOLEY • ETT degree of respiratory distress pa o2 below 50 paco2 greater than 50%

38. Read my lips “it’s the anoxia, stupid!!!” • grading system from 1 to 7 based on need for aggressive airway intervention • grade 2 only by cannula, grade 4 mechanical • pneumothoraces usually as result of baro trauma • most significant implication is anoxic ischemic cerebral insult • most common cause of late death • every effort to maintain oxygenation and prevent cerebral edema

39. r/o other cause of injury • toxicological insult spinal injury • evaluate and treat associated conditions, • hypovolemia, hypothermia, hypoglycemia • careful neurological assessment and reassessment

40. both respiratory and metabolic acidosis • may still need fluid resuscitation despite pulmonary edema • shock is uncommon in drowning • do not use furosemide to treat pulmonary edema may need volume • in ICU many patients will need PEEP • ARDS common in drowning same management as any ARDS patient • delayed onset of pulmonary edema (up to 12 hrs)

41. PATHOPHYSIOLOGY • although some difference drowning is an asphyxia injury like like hanging, foreign body aspiration, apnea etc • noncardiac pulmonary edema, noncardiogenic pulmonary injury, surfactant loss, inflammatory contaminants, and cerebral hypoxia • global hypoxic ischemic event affecting brain, lungs, and heart • cardiovascular function usually preserved • aggressive pulmonary support is required to prevent long term sequelae of hypoxia • optimal treatment for anoxic brain injury remains unclear • no prognostic scale accurately predicts long term neurologic outcome

42. Consequences global hypoxia • cns dysfunction from initial hypoxic injury increased ICP edema • aggressive control of cerebral perfusion pressure • does not improve out come • CNS damage progresses after circulation reestablished • cardiac dysrhythmias : a result of hypoxemia/acidosis • low cardiac index elevated right and left heart filling pressures increased SVR • renal failure uncommon • coagulopathies esp DIC and hemolysis

43. What about the prophylaxis measures previously taken, steroids, hyper therapy, antibiotics....etc.? • prophylactic antibiotics of limited use • treat when infection • antibiotics only if grossly contaminated water • contributing to injury is aspiration of sand bacteria algae or particulate matter emesis and chemical irritant • corticosteroids of limited use

44. HYPER THERAPY • early theory (BOHN Critical care medicine 1986) • hyperhydration, hyperventilation, hyperpyrexia, hyper- excitability, hyperrigid • suggested use of diuretic, hypothermia, barbituates glucocorticoids barbituate coma, muscle paralysis and monitoring and treating of ICP • subsequent reviews failed to show improvement with these protocols • most centers no longer use hyper therapy • current approach supportive care

45. disposition • four groups • 1) no evidence of sig. submersion d/c’d quickly • cxray and abg unnecessary serial sats reassuring • pts without any symptoms and completely normal respiratory status may be discharged with instruction to return immediately if respiratory distress developed • 2) asymptomatic after sig. episode observed for four to six hours then d/c’d • 3) poor oxygenation mod hypoxemia admitted followed once o2 resolved ....home

46. ??? ICU • final group... Intubated: depends on neurological status • any respiratory complaints or symptoms, cxray abnormalities, demonstrated oxygen requirement monitored for 24 hours usually in ICU • any patient with LOC, cyanosis, or apnea, CPR or resuscitative efforts need to be monitored closely • GCS needs to be done sequentially

47. CXRAY • 20 % of severe drowning normal cxray • typical findings perihilar infiltrates, pulmonary edema

49. Pediatrics • peds use fairly aggressive PEEP protocol • increased risk of nosocomial infection • children larger surface area less fat more prone to hypothermia • hypothermia some degree of protection • rapid cooling necessary in icy water <5 deg to offer benefit • usually severe hypothermia increased mortality • large costs realistic goal re prognosis • families need time to adjust

50. POOR PROGNOSIS IF: • absence of cognitive function / recovery 48 -72 hours • seizures beyond 12 hours • despite early enthusiasm, ICP monitoring: no benefit • CT only helpful if ass’d with other injury • MRI day 1 and day 3 change helpful in predicting outcome • EEG often obscured by drugs and resuscitation • persistent flat tracing attenuated record without med or burst suppression poor prognosis • brainstem evoked potential: controversial many confounding factors • most useful for predicting outcome is repeated clinical neurological examination