In light of this morning’s toilet-related malfunction and Noah’s Ark-like flooding of the PA Conference Room……here are a few quick-to-read pearls about the drowning patient.

 

Epidemiology

  • Leading cause of death worldwide among boys 5 to 15 years of age

Risk Factors

  • male sex (yeah, we do dumb things)
  • age < 14
  • alcohol use
  • low income
  • poor education
  • rural
  • lack of supervision
  • epilepsy (15-19x higher risk)

Definition

  • “Process of experiencing respiratory impairment from submersion/immersion in liquid” (WHO, 2002)

Process

  • Airway goes below surface (submersion) or water splashes over face (immersion) -> patient cannot keep airway clear -> water entering mouth is spat out or swallowed -> breath holding (~ 1 min) -> some water aspirated into airway -> coughing reflex -> laryngospasm -> aspiration continues -> hypoxemia -> loss of consciousness and apnea -> tachycardia to bradycardia to PEA to asystole
  • Water in alveoli causes surfactant dysfunction, atelectasis, V/Q mismatch, ARDS

Pre-Hospital Pearls

  • Cardiac arrest primarily due to lack of oxygen. Thus, start with 5 initial rescue breaths (water in airways can interfere with effective alveolar expansion), 30 compressions, then continue with 2-to-30 ratio. A-B-C, not C-A-B.
  • If unconscious, in-water resuscitation improves likelihood of favorable outcome
    • Ventilation alone, as compressions futile in deep water
  • With respiratory arrest, there is usually a response after a few rescue breaths
    • If no response, assume cardiac arrest and bring to dry land for CPR
      • While bringing to dry land, try to maintain vertical position with airway open to prevent vomiting and aspiration
  • If unconscious but breathing, put in lateral decubitus position

ED Pearls

  • Most critical prognosticator is duration of submersion
  • A-B-C, not C-A-B (as above).
  • Cardiac arrest usually due to hypoxemia. May correct with improved oxygenation.
  • Routine C-spine immobilization can interfere with airway management and is not recommended unless clinically indicated based on events.
  • Goal of hospital management: prevent secondary neurologic injuries due to ongoing ischemia, cerebral edema, hypoxemia, fluid and electrolyte imbalances, acidosis, and seizure activity
  • Early intubation and mechanical ventilation (ARDS guidelines, i.e. PEEP) if indicated
    • Indications: neurologic deterioration, need to protect airway, unable to maintain PaO2 >60 mmHg or O2 sat >90 despite high-flow O2, PaCO2 >50
    • Keep ventilated for at least 24 hrs before attempting to wean; minimize recurrence of pulmonary edema and reintubation
  • Permanent neurologic damage is the most worrisome outcome
    • Hypothermia may slow this process
  • Healthy individuals with spontaneous respirations, clear breath sounds, and an O2 sat >90% with no focal neurologic deficits may need only temporary supplemental O2 or no treatment at all prior to discharge
  • Volume of fluid aspirated in most immersions is only 3 mL/kg, not enough to cause significant hemodynamic and electrolyte abnormalities. In other words, saltwater versus freshwater immersion no longer considered significant.
  • MANAGEMENT ALGORITHM
  • Drowning
  • cpr drowning

Poor Prognosticators

  • Duration of submersion > 5 min
  • Time to BLS > 10 min
  • Resus duration > 25 min
  • Age > 14
  • GCS < 5
  • Persistent apnea and requirement of CPR in ED
  • ABG pH < 7.1 on presentation

 

References

Chandy D, Weinhouse G. Drowning (submersion injuries). UpToDate April 2015.

Meisenheimer E, Bevis Z, Tagawa C, Glorioso J. Drowning Injuries: An Update on Terminology, Environmental Factors and Management. Current Sports Medicine Reports. March/April 2016, 91-93.

Schmidt A, Sempsrott J, Havryliuk T, Semple-Hess J. Drowning in the Adult Population: Emergency Department Resuscitation and Treatment. Emerg Med Pract. 2015 May;17(5):1-20.

Szpilman D, et al. Treatment of Persons Who Have Drowned N Engl J Med 2012;366:2102-2110.