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DROWNING

DROWNING. Dr.Özgül Keskin Yeditepe University School of Medicine Department of Anesthesiology and Reanimation. > 500 000 deaths / year due to drowning Mostly 5-14 years of age 4 th frequent cause of death in the same age More frequent in pediatric age group

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DROWNING

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  1. DROWNING Dr.Özgül Keskin Yeditepe University School of Medicine Department of Anesthesiology and Reanimation

  2. > 500 000 deaths/yearduetodrowning • Mostly 5-14 years of age • 4thfrequentcause of death in thesameage • Morefrequent in pediatricagegroup • Freshwaterdrowning > salt waterdrowning (?) ( Boğulma vakalarında suyun tuz içeriği sonucu etkilememektedir) • Especially in <5 y agegroupdrowning in bathtubsarefrequent • Drowningaffectshealthypeople in youngandproductiveagegroup

  3. Statistical Risk Factors • Age: Pediatricage • Location: Pools, bathtubs, lakes, rivers • Sex: Male 3:1 • Time of year: Warm months

  4. Definitions Drowning: Drowning is defined as death resulting from suffocation within 24 hours of submersion in a liquid medium 2005 DSÖ **(Sıvı ortama batma/dalma sonucu gelişen solunumsal bozulma) Near-drowning:?? Near-drowning, as survival of (evenwith severe medicalthrapy) at least 24 hours after an episode of suffocation caused by submersion in a liquid medium

  5. Definitions Dry-drowning:?? Dueto a suddenimmersionintowater, largyngospasmleadingtoasphyxiaresultingwithalveoliwithoutwater Wet-drowning:?? Drowningduetowater in thealveoli Secondarydrowning: Anysecondarydisease (Heartdisease, epilepsy, alcoholuseetc) leadingtoloss of consciousness in water, therebydrowning

  6. Definitions ImmersionSyndrome: The immersion syndrome is syncope provoked by bradycardia, tachycardia, or arrhythmia precipitated by sudden contact with water at a temperature of at least 5°C less than body temperature. It can happen, therefore, in water as warm as 31°C

  7. Chain of events Immersion in water Breath holding voluntarily and with panic Struggle of the victim Unvoluntarily point of cession (vazgeçme noktası) Aspiration of water and/or laryngospasm Cardiac arrest due to on-going hypoxia Hypoxic damage of brain Cytotoxic cerebral odema Increased intracranial pressure, decreased cerebral blood flow Herniation and death

  8. Pathophysiology (Pulmonary) Immersion in water Breath holding Aspiration of water Laryngospasm Alveolar hypoxia & hypercapnia ARDS Surfactant loss Left ventricular afterload Pulmonary edema Pulmonary hypertension Systemic hypoxemia and hypercapnia Cardiac depression Asistoli

  9. HİPOKSİ • HİPOTERMİ • ASİDOZ

  10. FreshWaterAspiration Fresh water aspiration Water Hypotonic pass into capillary easily Hemolysis Pulmonary surfactant dissolution Alveolar collaps Atelectasis V/Q mismatch HYPOXEMIA

  11. Salt WaterAspiration Salt water aspiration Water Hypotonic pass into alveoli easily Hemoconsantration Water in the alveoli HYPOXEMIA

  12. Electrolyteimbalance • Consequences of Aspiration • 2.2 cc/kg Hypoxia • 11 cc/kg Blood volume changes • 22 cc/kg Electrolyte changes • Average aspiration is only 2-4 cc/kg

  13. COLD WATER and WARM WATER drownings are different Cold water has more survivors

  14. Submersion victims aren’t dead until they are WARM and DEAD (30 C)

  15. Treatment Drown not thyself to save a drowning man

  16. Treatment Resuscitation in thesetting of accident • A-B-C should be appliedMouth –to-mouthbreathingshould be started in water • No needforcardiacmassage in water, loss of time • HeimlichandPatricmaneuvers (?) • Subdiaphragmaticpressuremay be effectivefordrainingwaterfromthelungs • Theymaybothaspirateanddrinkwater in tostomachalso. Pressuremaycausemoreaspiration • Manualandmechanicalventilationwith ETT • Standart CPR • SpO2shouldtriedto be kept at 90% • Cervicalinjury (%0.5)

  17. Vakayı getiren ekibe sormamız gerekenler! • Su altında kalma süresi • Suyun ısısı ve temizliği hakkında bilgi • Travma hikayesi/şüphesi varmı? • Alanda CPR uygulandı mı? Süresi ve kim tarafından? • Kazazedenin vücut ısısı? • Boğulma sebebi? (İlaç veya alkol intoksikasyonu, kardiyak arrest, uzun QT sendromu, suisid, pediatrik vakalarda istismar ve ihmal olasılığı düşünülmelidir)

  18. Treatment in ER & ICU Respiratory System • Hafif semptomu olan bazı hastalar hızla kötüleşebilir • Artmış solunum hızı, ronküs, ral ve wheezing; solunumsal kötüleşme açısından uyarıcı olmalıdır • Gastrik içeriğin aspirasyonu (ARDS, enfeksiyon) • Nörolojik açıdan (değişken), KIBAS bulguları geç ortaya çıkabilir • ETT and mechanical ventilation if needed • Aim is to make SpO2 >90% • NG tube

  19. TETKİK • Kardiak monitorizasyon ve EKG • Pulse oksimetre, kapnografi, arter kan gazı • Kan glukozu, kreatinin, elektrolitler • Rektal vücut ısısı • Tam kan sayımı (Lökositoz dışında normaldir) • Toksikoloji paneli • Böbrek ve karaciğer fonksiyon testleri (koagülasyon testleri) • Akciğer grafisi, travma varlığında CT

  20. Treatment in ER & ICU CardiovascularSystem • Fluidreplacementwithappropriatesolution • Inotropicsupport • Treathypoglycemiaandhypocalcemiatotreatmycardialdepression Thermoregulation • Wetclothesshould be removed • Especially in childrenheatloss is veryfast • Heatthepatientslowlywithblanketsandlight • IV fluidsshould be heatedto 36-40 ̊C • O2 should be heatedandhumidified (HMEF-Heatedhumidifiers) • (Komatöz hasta 34 derecenin üzerinde ısıtılmamalıdır)

  21. Treatment in ER & ICU NeurologicalSystem • GCS <8 should be intubatedandmechanicallyventilated • Increased ICP leadstobadprognosisand can not be treatedifoccured • CPR vücut sıcaklığı 32-35 C olana dek devam etmelidir

  22. TABURCULUK • GKS 15, spontan solunumu olan, vitalleri ve saturasyonu normal, hipotermisi olmayan hastalar, destek oksijen tedavisi ve sürekli monitorizasyon ile 4-6 saat gözlemlenerek taburcu edilebilir. • Taburcu edilen hasta ve yakını gecikmiş pulmoner komplikasyonlar konusunda bilgilendirilmelidir. • Semptomatik hastalar yatırılmalıdır. • Apne, hipoksi veya bilinç kaybı öyküsü olanlar, ritim bozukluğu saptanan ve anormal akciğer grafi bulgusu olanlar yatış gerektirir.

  23. Prognosis • Factors forgoodprognosis • Duration of stay in water <5 min • Immediate CPR • CPR duration <10 min • Spontaneous ECG rhytm on ER admission • GCS >5 on ER admission • Spontaneousmovementandheathybrainstemfunction in 24 hours • Factorsforpoorprognosis • Duration of stay in water >10 min • CPR start > 10 min • Cardiotonicdrugneed on ER admission • GCS <5 • No spontaneousmovementafter 24 hours

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