1 / 34

Neardrowning: Prehospital and Emergency Department Management

Neardrowning: Prehospital and Emergency Department Management. James Hoekstra, MD, FACEP Ohio State University. Case Report: Neardrowning. 17 year old male ejected from a boat during a violent turn in a fresh water reservoir Pulled from the water by friends

maritzaa
Download Presentation

Neardrowning: Prehospital and Emergency Department Management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Neardrowning: Prehospital and Emergency Department Management James Hoekstra, MD, FACEP Ohio State University

  2. Case Report: Neardrowning • 17 year old male ejected from a boat during a violent turn in a fresh water reservoir • Pulled from the water by friends • Unconscious, not breathing at the scene • Given mouth to mouth • Total time submerged: 3-5 minutes • EMS arrival in 20 minutes

  3. Case Report: EMS • At EMS arrival, breathing but unconscious • BP 130/90, P 110, R 24, good BS • Obvious head injury with parietal scalp laceration, moving all fours to pain • Backboard and C-collar immobilization • O2 per face mask, monitor • Transport, IV established en route

  4. Case Report: ED Arrival • Airway: Guarded, alert but confused • Breathing: R 32, good BS, Pulse Ox 96% on 100% FM • Circulation: Good color, BP 140/100, P 130, pulses X 4 • Neuro: Alert but confused, purposeful X 4 • No signs of external trauma except scalp lac

  5. Critical Actions • IV X2, O2 FM, Monitor • Tetanus, Ancef • CXR, CS, Pelvis • ECG • Labs sent, ABG sent • Foley cath inserted • NG inserted • Secondary survey: No apparent trauma

  6. Laboratory Results • pH 7.30/pO2 72/pCO2 32/HCO3 16 • ECG: Sinus Tach, NAD • CS and pelvis films normal • WBC 14K, Hb 14, Hct 42 • Na 134, K 3.9, Cl 104, CO2 17, Glucose 133. Renal function normal • EtOH .130

  7. Clinical Course • CT head normal • CT abd normal • C, T, L spine films normal • Scalp wound closed in the ED • Sedated for combativeness with Midazolam • Admitted to SICU

  8. Clinical Course, Cont. • Ventilation and oxygenation deteriorates, requiring intubation and ventilation • PEEP at high levels • Barotrauma with bilateral chest tubes, sub Q air • Fever, purulent sputum, IV broad spectrum antibiotics instituted • Rocky course, SICU on vent for 3 weeks. • D/C after 5 weeks in the hospital

  9. Neardrowning • Nomenclature • Epidemiology • Pathophysiology • Prognostics • Prehospital Management • Hospital Management

  10. Nomenclature • Drowning • Neardrowning • Secondary Drowning • Wet drowning • Dry drowning • Immersion Syndrome

  11. Epidemiology • 7-8000 reported cases per year in US • 40% are children 0-5 years old • 1% of pediatric ICU admissions • Male predominance • Backyard pools • Lack of supervision, seizures

  12. Epidemiology • Adult drowning, third most common cause of accidental death • Alcohol, alcohol, alcohol • Boys 15-19 • Trauma, diving most common mechanism • 90% within 10 feet of safety • Swimming ability not a risk factor

  13. Pathophysiology of Drowning • Submersion • Panic and Flailing (if conscious) • Inhalation and aspiration or laryngospasm • Hypoxia • Cardiopulonary arrest

  14. Near Drowning Pathophysiology • Hypoxic episode interrupted with ROSC • End organ damage with • ARDS (often delayed) • Hypoxic encephalophy • Renal failure (ATN) • Pancreatic necrosis • DIC • Cardiac dysrrhythmias

  15. Fresh Water Inhalation (90%) • Hypotonic load to alveoli • Water absorbed into circulation • Surfactant washout • Alveolar cell damage • Chemical pneumonitis, pulmonary edema • Hypervolemia • Hyponatremia • Hemodilution • Hemolysis

  16. Salt Water Inhalation (10%) • Hypertonic load to alveoli • Protein rich effusion into alveoli • Surfactant damage, alveolar basement membrane damage • Alveolar cell damage • Chemical pneumonitis, pulmonary edema • Hypovolemia • Hypernatremia • Hemoconcentration

  17. Salt versus Fresh Water • Modell, series of 91 near drowning victims • No significant electrolyte abnormalities • No difference in treatment, but be vigil • Differences in bacteria, chemical composition (chlorine), and temperature of the aspirated water more significant • Conn: Animal model

  18. Hypothermia • Water conduction of heat • Pulmonary heat exchange • Cold water absorption • Temperature of water a factor in fresh water near drowning • Symptoms vary with degree of hypothermia • Is hypothermia destructive or protective?

  19. Prognostic Factors • Submersion Time? • Level of hypothermia? • CPR? • Mental Status? • Combinations?

  20. Submersion Time and Prognosis • Frates: No correlation in time of submersion and survival • Quan and Kinder: Duration of submersion >10 minutes predicts bad outcome (6/6) • Field resuscitation >25 minutes predicts bad outcome (17/17)

  21. CPR and Prognosis • 66 near drowning patients in warm water • 25% of victims who were under CPR with GCS of 3 in the ED survived intact, 50% died, 25% neurologically impaired • 91% of patients who were still GCS 3 in the ICU either died or were persistently vegetative state • Peterson: All who arrived under CPR died or were damaged

  22. Hypothermia and Prognosis • Many case reports of long submersion up to 45 minutes with survival in cold water • In warm water, hypothermia is an indication of prolonged submersion time, a bad prognostic factor

  23. Neurologic Status and Prognosis • Kemp and Sibert: 188 admissions, dilated pupils 6 hours after admission had poor outcome, reactive pupils on ED admission 33% recovered intact, 33% with neurologic impairment • Lavel and Shaw: 44 admissions: Nonreactive pupils and GCS <5 poor outcome • Dean: GCS <5, unreactive pupils, poor outcome

  24. Conn et al: Neurologic Classification and Prognosis • Classification based on 105 patients • A: Awake • B: Blunted • C: Comatose • C1: Decorticate • C2: Decerebrate • C3: Flaccid

  25. Other Predictors • Initial pH • Age • Cardiac standstill • Cardiotonic medications • Best Predictor: Resuscitation effectiveness determined 12-24 hours after admission

  26. Prehospital Management • ABC’s • Initiation of ventilation is the only way to interrupt the submersion time • C-Spine control, backboard • IV, O2, monitor, pulse ox • ACLS if needed, with attention to hypothermia concerns • Correction of acidosis • NO HEIMLICH

  27. Prehospital Management Cont. • Passive Rewarming • Rapid Transport • All neardrowning victims need evaluation at a medical facility • History is important

  28. ED Management • ABC’s, with C-spine control • IV, O2, Monitor, Pulse Ox • CXR • ABGs • Electrolytes • Trauma workup, primary and secondary assessment. • Treatment of Complications

  29. Hospital Management • Pulmonary Support • Rewarming • Cerebral Resuscitation

  30. Pulmonary Support • O2 • Intubation and Ventilation • PEEP • Steroids? • Antibiotics? • New ventilation techniques • ECMO • Liquid Ventilation • Surfactant Therapy

  31. Rewarming • Passive External • Active External (beware of afterdrop) • Active Internal • IV • Vent • NG/Bladder/Peritoneal • Bypass

  32. Cerebral Resuscitation • Frequent neurologic exams • ICP monitoring • Resuscitation techniques • Steroids/Mannitol • Barbiturates • Hypothermia • HYPER

  33. Conn et al: HYPER • Hyperhydration: diuretics and fluid restriction • Hyperventilation: pCO2 30-35 mmHg • Hyperpyrexia: hypothermia to 30 degrees C • Hyperexcitability: barbiturate coma • Hyperrigidity: paralysis • Effective in C2 and C1 patients, not C3 • Not supported elsewhere in the literature

  34. Conclusions • Neardrowning is a common cause of accidental death • Remember: • Initiate ventilation early • Don’t forget trauma as a cause • Aggressive treatment of complications: • Head, Lung, and Temperature

More Related