Neardrowning: Prehospital and Emergency Department Management

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