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Neardrowning: Prehospital and Emergency Department
Management
James Hoekstra, MD, FACEP
Ohio State University
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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
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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
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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
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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
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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
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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
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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
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Neardrowning
• Nomenclature
• Epidemiology
• Pathophysiology
• Prognostics
• Prehospital Management
• Hospital Management
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Nomenclature
• Drowning
• Neardrowning
• Secondary Drowning
• Wet drowning
• Dry drowning
• Immersion Syndrome
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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
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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
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Pathophysiology of Drowning
• Submersion
• Panic and Flailing (if conscious)
• Inhalation and aspiration or laryngospasm
• Hypoxia
• Cardiopulonary arrest
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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
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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
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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
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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
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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?
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Prognostic Factors
• Submersion Time?
• Level of hypothermia?
• CPR?
• Mental Status?
• Combinations?
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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)
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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
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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
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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
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Conn et al: Neurologic Classification and Prognosis
• Classification based on 105 patients
• A: Awake
• B: Blunted
• C: Comatose
• C1: Decorticate
• C2: Decerebrate
• C3: Flaccid
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Other Predictors
• Initial pH
• Age
• Cardiac standstill
• Cardiotonic medications
• Best Predictor: Resuscitation effectiveness determined 12-24 hours after admission
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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
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Prehospital Management Cont.
• Passive Rewarming
• Rapid Transport
• All neardrowning victims need evaluation at a medical facility
• History is important
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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
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Hospital Management
• Pulmonary Support
• Rewarming
• Cerebral Resuscitation
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Pulmonary Support• O2
• Intubation and Ventilation
• PEEP
• Steroids?
• Antibiotics?
• New ventilation techniques
• ECMO
• Liquid Ventilation
• Surfactant Therapy
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Rewarming
• Passive External
• Active External (beware of afterdrop)
• Active Internal– IV– Vent– NG/Bladder/Peritoneal– Bypass
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Cerebral Resuscitation
• Frequent neurologic exams
• ICP monitoring
• Resuscitation techniques– Steroids/Mannitol– Barbiturates– Hypothermia– HYPER
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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
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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