Thanks to our PEM fellow Dr. Michelle Vasquez for a great morning report today!
Some questions that came up afterwards:
Is there a difference in drowning with salt vs freshwater?
-turns out that while there are blood and electrolyte shifts, the amount of water needed to induce a clinically significant difference between the two types of water is so much that the pt has essentially suffered a fatal drowning, and therefore the difference does not change management.
UpToDate states “Aspiration of more than 11 mL/kg of body weight must occur before blood volume changes occur, and more than 22 mL/kg before electrolyte changes take place” but non fatal drowning usually is more on the lines of 3-4mL/kg.
When are antibiotics indicated in drowning?
No great evidence for antibiotics in drowning unless water is grossly contaminated. However if pt develops a pneumonia afterwards, make sure to cover for water-borne pathogens like Pseudomonas.
In the awake but symptomatic patient, what are indications for intubation?
•Signs of neurologic deterioration or inability to protect the airway
•Inability to maintain a PaO2 above 60 mmHg or SpO2 above 90 percent despite high-flow O2
•PaCO2 above 50 mmHg
Consider using bipap on patients who don’t meet the above criteria for immediate intubation, but are symptomatic