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Drowning

Drowning. David Slocum MD Albany Medical Center. Miracles. Matthew Granger 14 month old 20-40 minutes. Vocabulary. Drowning – death within 24 hours Near-drowning – survival past 24 hours. Who?. Usually young, healthy individuals. 2006 Drowning. U.S.A. – 5000 died

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Drowning

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  1. Drowning David Slocum MD Albany Medical Center

  2. Miracles • Matthew Granger • 14 month old • 20-40 minutes

  3. Vocabulary • Drowning – death within 24 hours • Near-drowning – survival past 24 hours

  4. Who? • Usually young, healthy individuals

  5. 2006 Drowning • U.S.A. – 5000 died • Worldwide – over 100,000 died

  6. Epidemiology • 500,000 submersion events annually • 2nd cause of death – children under 15 • Injury ranges • Transient • Profound neurological deficit

  7. Three Peaks • Toddlers • Adolescents • Elderly

  8. Toddlers • Toilets • Bathtubs • Buckets

  9. Coastal Areas • Swimming pools more likely

  10. Adolescents • Stupidity

  11. Young Adults • Alcohol • 40% adult drownings • 75% boat drownings

  12. Elderly

  13. Complicating Factors • Spinal cord injury • Hypothermia • Panicking • Syncope • Seizures

  14. Pathophysiology • Central Nervous System Injury • Pulmonary Injury

  15. Dry-drowning • 10-20% of submersions • Laryngospasm • Hypoxia • Loss of consciousness

  16. Wet-drowning • Aspiration of water • Dilution of surfactant • Diminished gas transfer • Atelectasis • Ventilation perfusion mismatch

  17. Pulmonary Injury • Contaminated foreign material • Particulate matter • Bacteria • Vomitus • Chemical irritants

  18. Prognosis • Submersion time • Physiological scoring systems

  19. Two extremes • Fair cardiovascular and neurological function • Minimal disability • Unstable cardiovascular function and coma • Poorly • Hypoxic CNS injury

  20. End Organ Damage • Renal injury • Hypoxia • Myoglobinuria • Hemoglobinuria • Hematologic • Hemolysis • DIC

  21. Treatment

  22. Prehospital Care • Resuscitation • Time optimizes outcome • Removal from water • C-spine protection • CPR ASAP

  23. Airway • Breathing • High flow oxygen by facemask • Not Breathing • Bag valve mask • Endotracheal tube • Unconscious • Protect from aspiration

  24. Who to transport? • Amnesia • Loss or depressed consciousness • Period of apnea • Period of artificial respirations • Even if asymptomatic

  25. Don’t Forget • Warm patient • Hypothermia • Monitor • IV access • Warm isotonic fluids

  26. Summary • Rapid, cautious rescue • Spine precautions • Cardiopulmonary resuscitation • Supplemental Oxygen • Transport

  27. ED Treatment • Continue EMS care • Airway • Oxygen • Ventilation • Warmed fluids • Warming adjunts • Treat associated injuries

  28. GCS > 12 • Oxygen to keep sat > 95% • Observe 4-6 hours • Pulmonary exam normal • Saturation normal • Discharge home • No xray or labs needed

  29. GCS > 12 • Oxygen to keep sat > 95% • Observe 4-6 hours • Pulmonary exam abnormal • Requires oxygen • Deteriorates • Admit to Monitored bed

  30. GCS < 13 • High flow oxygen • Intubation for low PaO2 • CXR, Labs • Continuous cardiac monitoring • Frequent reassessments

  31. Seizure • Dilutional hyponatremia • Control seizures • Correct electrolytes • Residual disorder uncommon

  32. ED Arrest • Warm water drowning • Recovery doubtful • Consider early discontinuation of efforts • Risk profound neurological handicaps

  33. Hospital Management • Supportive • Avoid ARDS • Pneumonia rare • Dopamine, epinephrine drips • 48 hour window

  34. No benefit • Mannitol • Loop diuretics • Hypertonic saline • Fluid restriction • Hyperventilation • Controlled hypothermia • Barbiturate coma

  35. Prognosis • No CPR • Full recovery within 48 hours • May develop ARDS • Bystander CPR • Steady recovery • Steady decline • ED CPR • Very poor prognosis

  36. Pediatric Warm Water Drowning • 500 victims • 100% received ED CPR • 84% died • 16% severe hypoxic encephalopathy

  37. Diving Reflex • Mammals • Bradycardia • Peripheral Vasoconstriction • Greatest in cold water • Preserves oxygen

  38. ICE water submersion • Asystole • Children and Adults • Complete Recovery • Rare • Resuscitate until normothermic

  39. Prevention • Infants • Parental vigilance • Toddler • Pool fencing • Adolescent/Young Adult • Control Alcohol/Drug Use • Swimming lessons • Elderly • Same as infant/toddler

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