RT 7 near drowning
general management of near drowning: first responder
Remove the person from the water Call for help CPR The victim's wet clothing should immediately be removed and replaced with warm, dry coverings
drowning in children
2nd leading cause of death
infants and drowning
55% infant deaths occur in bathtub
men and drowning
78% of all male deaths in US
second phase of near drowning
As oxygen tension in blood drops further, laryngospasm releases, • victim gasps, hyperventilates, possibly aspirating variable amounts of liquid •leads to further hypoxemia
clinical manifestations of near wet drowning
Atelectasis Alveolar consolidation Increased alveolar-capillary membrane thickness Bronchospasm Excessive bronchial secretions
initial treatment for near drowning
BLS / activation of EMS • CPR (airway, breathing, circulation) • Pulse check for up to 1 minute for cold water incident • Avoidance of Heimlich maneuver unless airway obstruction present • Rewarming (blankets, lavage, hemodialysis) • Specific treatment tied to scoring system/ categories (awake, blunted, comatose)
central nervous system effects in children
CNS injury remains major determinant of subsequent survival & long-term morbidity in cases of drowning. • Two minutes after immersion, child will lose consciousness. • Irreversible brain damage usually occurs after 4-6 minutes. • Most children who survive are discovered within 2 minutes of submersion. • Most children who die are found after 10 minutes.
immediate intervention/rescue (DRABC)
Danger Response Airway Breathing Circulation
prevention of drowning
Direct supervision of children • Continuous surveillance = PAY Attention @ ALL Times!!! • Swimming ability/survival skills • Control of alcohol use • Training in CPR • Presence of lifeguards • Proper use of life jackets
prevention of submersion injury - human factors
Direct supervision of children • Continuous surveillance = PAY Attention @ ALL Times!!! • Swimming ability/survival skills • Control of alcohol use • Training in CPR • Presence of lifeguards • Proper use of life jackets
frequent comorbidities resulting from near drowning
Disseminated intravascular coagulation (DIC), hepatic & renal insufficiency, metabolic acidosis, & GI injuries
prevention - site factors
Draining unnecessary water accumulation - EVERYWHERE! • Installation of isolation fencing • Use of pool alarms & covers • Self-closing/self-latching gates • Electronic surveillance • Installation of poolside phones
pathophysiology depends on
Fresh water vs. salt water • Wet drowning • Dry drowning • Neurological insult • Pulmonary insult • Hemodynamic/electrolyte effects
in cases of obvious death due to drowning, the following are present:
Normothermia with asystole • Apnea • Rigor mortis • Dependent lividity • No apparent CNS function
epidemiology of near drowning
One of major causes of accidental pediatric death • Most common in low- or middle-income areas • In adults, drowning is generally associated with alcohol & drug abuse • From 2005-2014 in the US, there were an average of 3,536 fatal deaths due to drownings annually • Almost 700 were children younger than 14 years of age
ECMO may be considered for near drowning in the following circumstances
Respiratory compromise resulting from lack of response to conventional mechanical ventilation or high-frequency ventilation • A reasonable probability of patient recovering neurologic function • Persistent hypothermia from cold-water drowning
contributing factors to near drowning
Sociodemographic / socioeconomic • Temporal & geographic • Location & circumstances • Lapses in adult supervision • Alcohol • Swimming ability • Underlying medical conditions
poor prognostic indicators
Submersion duration > 25 minutes • Resuscitation time > 25 minutes • Ventricular tachycardia or fibrillation on initial ECG • Fixed & dilated pupils on initial evaluation • Severe acidosis (arterial < 7.0) • Apnea, • Absent heartbeat
signs & symptoms of CNS injury
Tachycardia • Hypertension • Tachypnea • Diaphoresis • Agitation • Muscle rigidity
pulmonary effects of near drowning
The target organ of submersion injury is lung. • Aspiration of as little as 1-3 mL/kg of fluid leads to significantly impaired gas exchange. • Injury to other systems is largely secondary to hypoxia & ischemic acidosis • Fluid-induced bronchospasm also may contribute to hypoxia. • The distinction between fluid types is academic & primarily of epidemiologic importance, • initial treatments are similar.
two classifications of near drowning
asymptomatic & symptomatic
drowning may be further classified as
cold-water or warm water injury
definition of drowning
death with 24 hours of submersion
ABG in near drowning
early and advance stages acute ventilatory failure with hypoxemia acute respiratory acidosis decreased pH, PaO2, SaO2/SpO2 increased PaCO2, HCO3 (normal)
immediate threats of drowning
effects on CNS & CV systems
additional classifications of of near drowning
freshwater vs saltwater natural bodies of water vs man made
ECG monitoring in near drowning indicated
if rewarming is necessary dysrhythmias are common when rewarming patients who suffer cold-water immersion injuries
oxygenation indices in near drowning
increased Qs/QT, O2ER decreased DO2, SvO2 normal VO2
two reflexes comprise the pathophysiologic mechanisms of drowning
inhalation of fluid causes irritation & cough response, resulting in fluid being either swallowed or inhaled
Post-obstructive pulmonary edema follows
laryngeal spasm * hypoxic neuronal injury with resultant neurogenic pulmonary edema play a role (?)
drowning in toddlers
leading cause of death
long-term infectious complications primarily related to whether victims was submersed in
natural or man-made body of water
routine antibiotic prophylaxis is
not indicated unless patient was submerged in grossly contaminated water or sewage
high risk of death in submersion injury exists secondary to
subsequent development of adult respiratory distress syndrome (ARDS)
deaths from drowning in backyard pools, spas, hot tubs
67%
immersion syndrome
A form of cold injury resulting from prolonged immersion in cold water. Long-term constriction of the blood vessels results in tissue damage from deprivation of oxygen and nutrition. Permanent loss of sensation and abnormal sensitivity to cold result. In the most severe cases GANGRENE occurs. Also known as trench foot.
near drowning
A victim survives a liquid submersion, at least temporarily (>24 hrs)
classification based on
ABC: Alert (high recovery) Blunted (some risk, high chance of recovery) Comatose (high risk, 50/50 chance)
patients in cardiopulmonary arrest exhibit the following symptoms:
Apnea • Asystole (55%), • ventricular tachycardia/fibrillation (29%) • bradycardia (16%) • Immersion syndrome
treatment in near drowning
Extracorporeal membrane oxygenation (ECMO) has been shown to be beneficial in selected patients. • ECMO may be considered in following circumstances: • Respiratory compromise resulting from lack of response to conventional mechanical ventilation or high-frequency ventilation • A reasonable probability of patient recovering neurologic function • Persistent hypothermia from cold-water drowning • Frequent neurologic assessment should occur
wet drowning: inhalation of salt water
Hypertonic fluid inhalation causes water to move from circulation into lungs • Sustained edema & prolonged shunt • Causes direct damage to alveolar-capillary membrane • Exacerbates lung injury • Rapid loss of circulating volume into alveolar space across injured alveolar-capillary membrane • Causes hemoconcentration, hypernatremia, & hypoalbuminemia • Vascular collapse & hypovolemic shock
prevention in submersion injury
In most instances, drowning & near drowning can be prevented with simple safety measures & common sense. • Most children younger than 5 years enter a swimming pool directly adjacent to their home or one with inadequate fencing or unlatched gates or doors. • Most children who drown in pools are: • found silently floating with no screaming or splashing having been noted • were last seen in the home • were missing at least 5 minutes • were in the care of one or both parents at the time of the drowning • Parents who own pools or who take their children to pools are encouraged to learn CPR.
regardless of the type of fluid aspirated
Intravascular volume depletion is common, secondary to pulmonary edema & intracompartmental fluid shifts,
anatomic alterations of the lungs in near drowning
Laryngospasm Interstitial edema -Including engorgement of the perivascular and peribronchial spaces, alveolar walls, and interstitial spaces Decreased pulmonary surfactant with increased surface tension of alveolar fluid Frothy white and pink secretions throughout the tracheobronchial tree Alveolar shrinkage and atelectasis Alveolar consolidation Bronchospasm
wet drowning: inhalation of fresh water
Rapidly depletes alveolar surfactant • Acute neurogenic pulmonary edema due to cerebral hypoxia has been shown to worsen alveolar flooding • Electrolyte imbalance • Hypernatremia can lead to seizures • Diluted plasma causes water to rapidly enter into erythrocytes by osmosis • Causes hemolysis • Hyperkalemia & hyponatremia can cause ventricular fibrillation • Liberation of hemoglobin into the plasma can precipitate acute renal failure
history data collection of near drowning patient
Submersion time • Type of fluid/water • Presence of vital signs upon removal • Time from submersion & initiation of CPR • Whether CPR performed immediately • Duration of CPR before return of vital signs • Temperature of water • Age • Other circumstances related to incident
signs & symptoms of CNS injury include
Tachycardia • Hypertension • Tachypnea • Diaphoresis • Agitation • Muscle rigidity
warm-water drowning
occurs at water temperature of 20C or higher
hypothermia
profoundly decreases cerebral metabolic rate • neuroprotective effects seem to occur only if hypothermia occurs at the time of submersion • only if very rapid cooling occurs in water with temperature of less than 5°C (eg, if the individual broke through ice into water).
classic image of victim helplessly gasping & thrashing in water is
rarely reported
most acidosis after near drowning is
reversed after correction of volume depletion & oxygenation
dysrhythmias are common when
rewarming patients who suffer cold-water immersion injuries
the degree of CNS injury depends on
severity & duration of hypoxia post-hypoxic cerebral hypoperfusion may occur long-term effects of cerebral hypoxia, including vegetative survival, are most devastating
the terms wet drowning, dry drowning, active or passive drowning, near-drowning, secondary drowning, & silent drowning
should be discarded
corticosteroids in the management of submersion injuries
shown to be of no benefit
definition of near drowning
the process of experiencing respiratory impairment (Suffocation & death) from submersion/immersion in liquid
initial assessment: patients in cardiopulmonary arrest exhibit the following symptoms
• Apnea • Asystole (55%), • ventricular tachycardia/fibrillation (29%) • bradycardia (16%) • Immersion syndrome
treatment of near drowning first responders
Optimal prehospital care is significant determinant of outcome in management of immersion victims worldwide • Victim should be removed from water at earliest opportunity. • Rescue breathing should be performed while individual is still in water • chest compressions are inadequate because of buoyancy issues. • Patient should be removed from water with attention to cervical spine precautions. • When possible, individual should be lifted out in prone position.
radiologic findings in near drowning
fluffy infiltrates
Glasgow coma scale (GCS)
3 categories: eye opening (1-4) best verbal response (1-5) best motor response (1-5) 3 lowest score possible 7 or less indicates coma 14 indicated full consciousness
initial phase of near drowning
After initial breath holding, victim's airway lies below liquid's surface, • involuntary period of laryngospasm is triggered by presence of liquid in oropharynx or larynx. • At this time, victim is unable to breathe in air, • causing oxygen depletion & carbon dioxide retention.
sequence of events in drowning
After initial breath holding, victim's airway lies below liquid's surface, • involuntary period of laryngospasm is triggered by presence of liquid in oropharynx or larynx. • At this time, victim is unable to breathe in air, • causing oxygen depletion & carbon dioxide retention.
symptomatic near drowning
Altered vital signs (eg, hypothermia, tachycardia or bradycardia) • Tachypnea, dyspnea, or hypoxia: • If dyspnea occurs, no matter how slight, the patient is considered symptomatic • Metabolic acidosis (may exist in asymptomatic patients as well) • Altered level of consciousness, neurologic deficit • Cough • Wheezing • Hypothermia • Vomiting, diarrhea, or both • Anxious appearance
physical examination
Apnea Vital signs Increased • Respiratory rate (tachypnea) • Heart rate (pulse) • Blood pressure Cyanosis Cough and sputum production Frothy, pink, stable bubbles Pallor (extreme paleness) Chest assessment findings Crackles
chest radiography
Aspiration • pulmonary edema • segmental atelectasis suggestive of presence of foreign bodies (eg, silt or sand aspiration)
postsubmersion neurological classification system
Based on initial level of consciousness • A: Alert • B: Blunted • C: Comatose • All category A's survived without complications • 90% of category B's survived with complete recovery • 10% died • 55% of category C's completely recovered • 34% died • 10% had permanent neurological sequelae
Orlowski scoring system
Based on: • Age < 3 years • Duration of submersion > 5 minutes • Resuscitation attempts delayed > 10 minutes after incident • Presence of coma on arrival to ED • Arterial pH < 7.1 • Two or fewer reflect 90% good recovery • Only 5% with 3 or more
cardiovascular effects in near drowning
Hypovolemia is primarily due to fluid losses from increased capillary permeability. • Profound hypotension may occur during & after initial resuscitation period, • especially when rewarming is accompanied by vasodilatation. Pulmonary hypertension may result from release of pulmonary inflammatory mediators, • increasing right ventricular afterload • decreasing both pulmonary perfusion & left ventricular preload.
oxygen therapy in near drowning
Immediately place patient on 100% oxygen by mask. • The degree of hypoxemia may be difficult to determine on clinical observation. • Use HFNC or continuous positive airway pressure (CPAP) for continued hypoxemia. • If not available, consider early intubation with appropriate levels of PEEP. • Higher pressures may be required for ventilation because of poor compliance resulting from pulmonary edema.
near drowning first responder
Optimal prehospital care is significant determinant of outcome in management of immersion victims worldwide • Victim should be removed from water at earliest opportunity. • Rescue breathing should be performed while individual is still in water • chest compressions are inadequate because of buoyancy issues. • Patient should be removed from water with attention to cervical spine precautions. • When possible, individual should be lifted out in prone position. Follow classical Airway-Breathing-Circulation approach • CPR should be started immediately as indicated • Prone position preferred • Temperature monitoring • Airway clearance therapy • Mud, dirt, foreign matter • Mechanical ventilation • Almost every patient will develop ARDS
sequence of events in near drowning
Panic & immediate struggle • Suspension of movement • Violent struggle • Convulsions • Death
drowning or near drowning sequence
Panic and violent struggle to return to the surface Period of calmness and apnea Swallowing of large amounts of fluid, followed by vomiting Gasping inspirations and aspiration Convulsions Coma Death
prognosis in submersion injury
Patients who are alert or only mildly obtunded at presentation have an excellent chance for full recovery. • Patients who are comatose, those receiving CPR at presentation to emergency department (ED), or those who have fixed & dilated pupils with no spontaneous respirations have a poor prognosis. • The neuroprotective effects of cold-water drowning are poorly understood. • Intact survival of comatose patients after cold-water submersion is still quite uncommon.
prognosis of near drowning
Patients who are alert or only mildly obtunded at presentation have an excellent chance for full recovery. • Patients who are comatose, those receiving CPR at presentation to emergency department (ED), or those who have fixed & dilated pupils with no spontaneous respirations have a poor prognosis. • The neuroprotective effects of cold-water drowning are poorly understood. • Intact survival of comatose patients after cold-water submersion is still quite uncommon.
Guidelines for treating cold-water drowning
Patients with severe hypothermia may appear dead because of profound bradycardia & vasoconstriction. • Resuscitation should continue while aggressive attempts are made to restore normal body temperature. • A primitive mammalian diving reflex may be responsible for survival after extended immersion in cold water. • phenomenon that occurs in mammals when they are submerged in cool water below 21 ° C (or 70 °F), in which body's natural cardiovascular responses are altered to maintain cerebral & cardiac blood flow.
treatment for cold-water drowning
Patients with severe hypothermia may appear dead because of profound bradycardia & vasoconstriction. • Resuscitation should continue while aggressive attempts are made to restore normal body temperature. • A primitive mammalian diving reflex may be responsible for survival after extended immersion in cold water. • phenomenon that occurs in mammals when they are submerged in cool water below 21 ° C (or 70 °F), in which body's natural cardiovascular responses are altered to maintain cerebral & cardiac blood flow. • Core rewarming with: • warmed oxygen • continuous bladder lavage with fluid at 40°C • intravenous (IV) infusion of isotonic fluids at 40°C was initiated during resuscitation • Warm peritoneal lavage has been used for core rewarming in patients with severe hypothermia. • A heated humidity unit on ventilator has been used to warm inspired air. Use of permissive hypercapnia to decrease barotrauma in many patients with ARDS may not be appropriate in this setting of hypoxic ischemic CNS injury monitor closely for bacterial & fungal infection prophylactic antibiotics not recommended unless clear sign of infection (not common in early stage)
cardiovascular effects of near drowning
Pulmonary hypertension may result from release of pulmonary inflammatory mediators, • increasing right ventricular afterload • decreasing both pulmonary perfusion & left ventricular preload.
conclusion
RT is key player in resuscitation/recovery • Multiple definitions, ultimately entails suffocation by immersion • Etiologies extensive, yet most cases preventable • Pathophysiologically have neurologic, pulmonary, & hemodynamic/electrolyte effects • Clinical outcomes tied to scoring scales • Rapid recognition key to treatment success • CPR is cornerstone of treatment
near drowning summary
RT is key player in resuscitation/recovery • Multiple definitions, ultimately entails suffocation by immersion • Etiologies extensive, yet most cases preventable • Pathophysiologically have neurologic, pulmonary, & hemodynamic/electrolyte effects • Clinical outcomes tied to scoring scales • Rapid recognition key to treatment success • CPR is cornerstone of treatment
inhalation of fresh water
Rapidly depletes alveolar surfactant • Acute neurogenic pulmonary edema due to cerebral hypoxia has been shown to worsen alveolar flooding • Electrolyte imbalance • Hypernatremia can lead to seizures • Diluted plasma causes water to rapidly enter into erythrocytes by osmosis • Causes hemolysis • Hyperkalemia & hyponatremia can cause ventricular fibrillation • Liberation of hemoglobin into the plasma can precipitate acute renal failure
important history & physical data in assessment and treatment
Submersion time • Type of fluid/water • Presence of vital signs upon removal • Time from submersion & initiation of CPR • Whether CPR performed immediately • Duration of CPR before return of vital signs • Temperature of water • Age • Other circumstances related to incident
other system effects of near drowning
The clinical course may be complicated by multiorgan system failure (MSOF) resulting from prolonged hypoxia, acidosis, rhabdolyolysis (muscle cell breakdown) acute tubular necrosis (ATN), or treatment modalities. • Disseminated intravascular coagulation (DIC), hepatic & renal insufficiency, metabolic acidosis, & GI injuries are also frequent comorbidities.
general management of near drowning at the hospital
Virtually every near drowning victim suffers from hypoxemia, hypercapnia, and acidosis A chest radiograph Intubation and mechanical ventilation should be performed • Immediately for any victim with no spontaneous ventilations and for victims who are breathing spontaneously • If patient is unable to maintain a PaO2 of 60 mm Hg with an FIO2 of 0.50 or lower Warm patient
pneumonia in cold water submersion injury
a rare consequence and is more common with submersion in stagnant warm & fresh water -use of prophylactic antimicrobial therapy has not proven to be of any benefit
multi-organ system failure (MSOF) after near drowning
a result of prolonged hypoxia, acidosis, rhabdolyolysis (muscle cell breakdown), acute tubular necrosis (ATN), or treatment modalities
near drowning has a high association with
alcohol use/abuse
destruction of surfactant produces
alveolar instability, atelectasis, & decreased compliance, which produces marked ventilation/perfusion (V/Q) mismatching
chest radiography in near drowning may detect evidence of
aspiration pulmonary edema segmental atelectasis suggestive of presence of foreign bodies (silt or sand aspiration)
wet drowning
aspiration of fluid, The glottis relaxes and allows water to flood the tracheobronchial tree and alveoli
near drowning can occur in
bathtub, bucket, toilet, swimming pool
infants most often drown in
bathtubs or buckets of water most with <5 min
Glasgow coma score in near drowning
best response determined then given a numerically-assigned value • 3 categories: • eye opening (1-4) • best verbal response (1-5) • best motor response (1-5) • Score of 3 is lowest possible; • score of 7 or < indicates coma • score of 14 indicates full consciousness
intracranial pressure monitoring in near drowning is used in patients with
brain injury or mass lesions (hematomas)
asymptomatic near drowning
brief, witnesses submersions with immediate resuscitation
immediate threats of near drowning include effects on
central nervous system & cardiovascular systems
cold-induced bronchorrhea or irritation of tracheobronchial tree by inhaled water or particulate material can produce
cough & bronchospasm -manage these aggressively because they may worsen hypoxia drug of choice is inhaled beta-agonsit bronchodilator
DLCO in near wet drowing
decreased
PFT findings in moderate to Severe near wet drowning
decreased FVC, normal or decreased FEV1, FEF25-75, FEF50,FEF200-1200, PEFR, MVV normal or increased FEV1/FVC ratio
outcome of near drowning
delayed morbidity, delayed or rapid death, or life without morbidity
monitor closely for bacterial & fungal infections in submersion injury
evidence is insufficient to support use of prophylactic antibiotics
sudden, severe cardiovascular collapse in otherwise healthy patients with brief witness immersion may be result of
existing cardiac conduction defects & may not represent secondary effects of immersion injury
pathophysiology of near drowning stages
fresh water vs/ salt water wet drowning dry drowning neurological insult pulmonary insult hemodynamic/electrolyte effects
Acute respiratory distress syndrome (ARDS) in near drowning survivors
from altered surfactant effect & neurogenic pulmonary edema commonly complicates drowning in survivors
mechanism for the dive reflex
has been postulated to be reflex inhibition of respiratory center (apnea), bradycardia, & vasoconstriction of nonessential capillary beds triggered by sensory stimulus of cold water touching face. • These responses preserve circulation to heart & brain • conserve oxygen & prolong survival • Sudden temperature drop may depress cellular metabolism significantly, limiting the harmful effects of hypoxia & metabolic acidosis
Extracorporeal membrane oxygenation (ECMO) for near drowning
has been shown to be beneficial in selected patients
PEEP in near drowning
has been shown to improve ventilation patterns in noncompliant lung in several ways: • Shifting interstitial pulmonary water into capillaries • Increasing lung volume via prevention of expiratory airway collapse • Providing better alveolar ventilation & decreasing capillary blood flow • Increasing diameter of both small & large airways to improve distribution of ventilation
surfactant therapy for near drowning
has been utilized in patients in setting of respiratory failure associated with drowning, with improvement in ventilation, oxygenation, & fluid leak
therapeutic hypothermia
highly effective in reducing ischemic brain injury • improves oxygen supply to ischemic brain areas • decreases cerebral metabolic demand • decreases increased intracranial pressure
freshwater is considerably
hypotonic relative to plasma & causes disruption of alveolar surfactant
as much as 75% of blood flow may circulate through
hypoventilated lungs
chemical pneumonitis more common
if submersion occurs in chlorinated pool or in bucket of cleaning product
initial management of near drowning should emphasize
immediate resuscitation & treatment of respiratory failure.
saltwater (hyperosmolar)
increases osmotic gradient & draws fluid into alveoli • Dilutes surfactant (surfactant washout) • Protein-rich fluid then exudates rapidly into alveoli & pulmonary interstitium. • Compliance is reduced after alveolar-capillary basement membrane is damaged directly • Shunting occurs. • Results in rapid induction of significant hypoxia
pathophysiology of near drowning
involuntary gasp --->aspiration of water into the hypopharynx-->laryngospasm (parasympathetically medicated)--->both dry/wet-->cerebral hypoxia/acidosis/cardiac arrest-->brain injury/brain death dry refers to drowning secondary to airway wet refers to drowning secondary to aspiration as well as passive collection of fluid into the airway
morbidity & death from drowning are caused primarily by
laryngospasm & pulmonary injury, resulting hypoxemia & acidosis, & their effects on brain & other organ systems.
watch for evidence of pneumonia & CNS infection in submersion therapy
later in treatment uncommon infections may present late & unusually prophylactic antimicrobial therapy has not proven beneficial
initial assessment
level of consciousness presence of pulse respiration
initial assessment in near drowning
level of consciousness presence of pulse respiration
key to drowning management
management of hypoxemia Obtain ABG levels in all patients with any history of submersion injury. • ABG analysis is most reliable clinical parameter in patients who are asymptomatic or mildly symptomatic. • ABG analysis should include co-oximetry to detect methemoglobinemia & carboxyhemoglobinemia. • Obtain blood for a rapid glucose determination, complete blood count (CBC), electrolyte levels, lactate level, & coagulation profile.
ice-cold water drowning
may be initially protective (especially in children), but prolonged immersions can nullify the effect of temperature on survivability
treatment of cold water drowning
monitor ECG & rewarming
lung volume and capacity in moderate to severe near wet drowning
normal or decreased VT, decreased IRV, ERV, RV, VC,IC,FRC,TLC, normal RV/TLC ratio
saltwater (hypersomolar) increases
osmotic gradient & draws fluid into alveoli dilute surfactant (surfactant washout) Protein-rich fluid then exudates rapidly into alveoli & pulmonary interstitium. • Compliance is reduced after alveolar-capillary basement membrane is damaged directly • Shunting occurs. • Results in rapid induction of significant hypoxia
chemical pneumonitis is more common sequela then
pneumonia, especially if submersion occurs in chlorinated pool or in bucket containing cleaning product
near drowning new classification (definition)
process resulting in primary respiratory impairment from submersion in a liquid medium -implicit in this definition is that liquid-air interface is present at entrance to victim's airway which prevents individual from breathing oxygen
most critical actions in immediate management of drowning victims include
prompt correction of hypoxemia & acidosis
the most critical actions in immediate management of drowning victims include
prompt correction of hypoxemia & acidosis
pneumonia is uncommon early in course of treatment so
prophylactic antimicrobial therapy has not been proven to be beneficial
in near drowning fresh water moves
rapidly across alveolar-capillary membrane into microcirculation
pneumonia & near drowning
rare consequence of submersion injury & is more common with submersion in stagnant warm & fresh water
drowning may be secondary to
seizures cardiac arrhythmias alcohol and drug ingestion apnea suicide head or spine trauma hypothermia syncope hyperventilation hypoglycemia
definition of cold shock
series of cardio-respiratory response causes by sudden immersion of cold water
although initial treatment of submersion victims is not affected by type of water
serum electrolyte derangements may be related to salinity of water
nonfatal drowning injuries can cause
severe brain damage that may result in long-term disabilities
drowning usually occurs
silently & rapidly motionless individual floating in water or quietly disappearing from the surface is more typical
drowning usually occurs
silently & rapidly motionless, floating in water, quietly disappearing beneath the surface
dive reflex
the body's physiological response to submersion in cold water and includes selectively shutting down parts of the body in order to conserve energy for survival.
dry drowning
the glottis spasms (laryngospasm) and prevents water from passing into the lungs The lungs of dry drowning victims are usually normal
as fluid enters the alveoli in drowning
the pathophysiologic processes responsible for noncardiogenic pulmonary edema begins
primary CNS injury is initially associated with
tissue hypoxia & ischemia
bronchoscopy in near drowning may be needed
to remove foreign material - aspirated debris or vomitus plugs from airway
A Swan-Ganz catheter for monitoring cardiac output & related hemodynamic parameters useful in near drowning patients with
unstable cardiovascular status • those who require multiple inotropic & vasoactive medication requirements.
what treatment may not be appropriate in the hypoxic ischemic CNS injury of submersion?
use of permissive hypercapnia to decrease barotrauma in many patients with ARDS
because pneumonia is uncommon early in course of treatment of submersion injuries
use of prophylactic antimicrobial therapy has not proven to be beneficial
fluid aspirated into lungs produces
vagally mediated pulmonary vasoconstriction & hypertension
clinical presentations of people who experience submersion injuries
vary widely
core rewarming for cold-water drowning
warmed oxygen • continuous bladder lavage with fluid at 40°C • intravenous (IV) infusion of isotonic fluids at 40°C was initiated during resuscitation • Warm peritoneal lavage has been used for core rewarming in patients with severe hypothermia. • A heated humidity unit on ventilator has been used to warm inspired air
cold-water drowning occurs at
water temperatures < 20C
scoring system used in near drowning patients
•Glasgow coma scale • PRISM score (Pediatric Risk of Mortality Score, based on Orlowski Score) •Orlowski score (Post-submersion neurological classification system)