DROWNING

 

Definition/Etiology:

  1. Drowning = death from suffocation
     
  2. Near Drowning = survival (at least temporarily ). Aspiration of  3-4 ml/kg  is needed to cause near drowning,
     
  3. Secondary Drowning = death within minutes to days of initial survival. Most commonly is 2ry to ARDS.
     
  4. Immersion syndrome = death 2ry to arrhythmias induced by submersion probably 2ry to vagal stimulation
     
  5. "Dry" drowning = asphyxia  2ry to laryngospasm. Accounts for 10% of all the drownings.
     
  6. Hypothermia, alcohol and  drug use, seizure history are contributory  causes.
     
  7. Much emphasis was put on the difference between fresh and salty water aspiration. In reality most deaths occur  with minimal fluid aspiration, thus electrolyte changes are rare.

S & S:

  1. Pulmonary : ARDS - presents  with a wide range of symptoms: wheezing, ronchi, SOB. Initial Xray can  be positive in the asymptomatic  pt or negative in the symptomatic. ARDS also develops insidiously  over a few hrs. in pts  who  initially  looks well as in  secondary drowning. This is probably 2ry to protein and fluid influx as a consequence of surfactant loss.
     
  2. Neuro : The neurological damage is 2ry to hypoxia  resulting in cerebral anoxia and neural cell damage. Thus  O2 must be administered
     
  3. Blood volume and electrolyte : The changes detectable on CBC and SMA do not commonly occur in near drowning survivors. Aspiration of 11 ml/kg is needed  for blood volume to change. Aspiration of 22 ml/kg  is needed for electrolyte changes. Aspiration of  3-4 ml/kg  is needed to cause near drowning.
     
  4. Renal : Uncommon, but ATN can occur 2ry to hypoperfusion.
     
  5. Cardiac : arrhythmias 2ry to hypoxia and hypothermia.
     
  6. Trauma : C-spine and head trauma must be ruled out if mechanism  of near drowning is from diving or surfing

Treatment:

  1. Airway        }
     
  2. C-spine      }   Require  Immediate  Attention
     
  3. Breathing   }
     
  4. Circulation } - if Bradycardia and A.fib are  present  these are probably 2ry to hypothermia from cold water immersion and  immediate  treatment with medications is not the first line of treatment, but rather pt rewarming. Other arrhythmias like Asystole and V.fib require immediate intervention with CPR ( if the pt is monitored - see Hypothermia ACLS Protocol ).
     
  5. Coma Protocol - Thiamine 100 mg IM, D50 IV, Naloxone (Narcan)  0.4-2.0 mg IV/IM/SQ/ETT
     
  6. NaHCO3 - majority of victims  have lactic acidosis from hypoperfusion
     
  7. Postural Drainage - no convincing evidence of efficacy  with exception of Heimlich  maneuver to clear  a complete airway obstruction from water. This drainage should never be attempted prior to providing ventilation.
     
  8. Temperature Control
     
  9. Blood Test - routine plus CPK and drug screen.
     
  10. Antibiotics - prophylactic use is not supported.
     
  11. Hypoxic Cerebral Injury -treatment c/w:
     
    1. Hyperventilation and O2 supplementation
    2. Control of  hypoxic  seizures
    3. 30% head elevation.
       
  12. Symptomatic pts are admitted
     
  13. Asymptomatic patients are DC after 6-8 hr. of observation if Cxray and ABG are normal,  pt is reliable and  close monitor of  breathing is available.

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