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Drowning and Submersion injury

Drowning and Submersion injury. Drowning. Drowning defined as: death secondary to asphyxia and within 24 hours of submersion which may be immediate or follow resuscitation Submersion injury:

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Drowning and Submersion injury

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  1. Drowning and Submersion injury

  2. Drowning • Drowning defined as: death secondary to asphyxia and within 24 hours of submersion which may be immediate or follow resuscitation • Submersion injury: Survival after more than 24 hr is termed regardless the victim later dies or recovers

  3. Epidemiology Age 1-toddler age<5 yr 2-in 15-19 years old. • Male predominant in All ages . • Male/ Female • 2:1 in toddlers 10:1 in teenager • The site of drowning ,most common depending on age.

  4. Relevant factors: • Water Tonicity • Time submersion • water Temperature • symptoms associated injuries . • Undetected primary cardiac arrhythmia( long QT) • response to initial CPR

  5. Drowning begin with: • Panic, breath holding, ear hunger • reflex inspiratory and aspiration. • laryngospasmthat leads to hypoxemia • hyperventilation followed by voluntary apnea .

  6. Pathophysiology • Asphyxia may occur with: • pulmonary aspiration (wet drowning). 2. laryngospasm (10-20%) until cardic arrest )dry drowning)

  7. Anoxic-ischemic injury • All organs may injured from hypoxia and ischemia . • CNS injury (ICP ,cerebral edema) The most frequent cause of mortality and long- term morbidity

  8. Anoxic-ischemic injury • Pulmonary: wash out surfactant Pulmonary edema, ARDS • Cardiovascular: Arrhythmia( hypothermia ,hypoxemia) • Acid-base • Electrolytes

  9. Anoxic-ischemic injury • Renal ATN (hypoxemia,shock, hemoglobinuria) • Gasterointestinal hepatic trasaminases and serum pancratic enzymes are often acutely elevated

  10. Aspiration and pulmonary injury • Pulmonary aspiration occurs in the great majority of submersion . Pneumonia may result from : • gastric contents • water salinity • pathogenic organisms • toxic chemical

  11. Fluid and electrolyte alteration • The great majority of submersion do not aspirate large volumes of fluid to result insignificant electrolyte disturbances. • Sea water • Fresh water

  12. Hypothermia • Moderate hypothermia T(32-35) increase oxygen consumption. • Below T 32: (sever hypothermia) shivering ceases and cellular metabolic rate decreases • Deep coma with fixed and dilated pupils and absent reflexes at T (25-29) may give the false appearance of death

  13. Lab & imaging studies • ABG • CBC ,Electrolytes ,U/A • Chet x Ray - cervical spine X Ray • non contrast head CT scan???

  14. Imaging • Head CT scan is not helpful unless : • Suspicion of associated trauma injury • to rule out other possible causes of coma • MRI may detect change associated with hypoxic- ischemic injuries

  15. Clinical Manifestation • Victims in cardiac arrest require aggressive and prolong CPR.

  16. Pre hospital treatment • Careful search for pulses. If pulses presented : • Chest compression withhold Sinus bradicardia and atrial fibrillation require no immediate treatment

  17. Treatment • Initial resuscitation: • CPR • air way should be clear • Abdominal thrust should not be used • Cervical spine should be protected

  18. Emergency unit management • All pediatrics should be observed for at least 8-12 hr even they are asymtomatic on presentation. • Serial monitoring of repeated careful pulmunary and neurologic assessment. • Chest X RAY

  19. Emergency unit management Patients discharge after 8-12 hours if no evidence of : • significant injury • bronchospasm • tachypnea • inadequate oxigenation

  20. hospitalizedChildren • Supplement O2 • NaHCO3 • diuretic for pulmonary edema . • broncodilators for brochospasme . • Antibiotic for contaminated water. • Anticonvolsion treatment for seizure

  21. Treatment • NG tube • ECG monitoring for diagnosis and treatment of arrhythmia. • Hypothermia treatment passive,active • If a child is hypoglycemic 0/5-1g/kg dextrose

  22. ETT is needed if… • apnea ,cyanosis . • hypoventilation. • hemodynamic istability. • protect air way in patient with depressed Mental

  23. Treatment (con) • A few patients develop require mechanical ventilation. for at least 24-48 hours. • evaluated of oxigenation with ABG • Rewarming effort should be continued until T is at least32-34c (passive, active)

  24. Patients should closely evaluated for The neurological status • Neurologic examination during the first 24-72hr are the best prognostic of CNS outcome.

  25. Prognosis (continue) • Overall about 75% of pediatric submersion victims survive. • Good recovery did not occur in: Abnormal brainstem function • Absence of purposeful movement at 24 hr

  26. Poor prognosis • Submersion duration>10 minute • Age <3 years • CPR>25minutes • patient core<T33c • GCS<5 • persistent apnea that CPR is need in an ED.

  27. prognosis • PH<7.1 • Water temperature >10 c • Children who remain comatose 24 hr after initiating resuscitation

  28. Treatment discontinue • submersion victim in non-icy water that remain systole • despite 30-45 min of aggressive CPR

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