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(Near) Drownings

Tuesday, September 18, 2012 - Grand ROUNDS Presentation
by

Courtney Woods

on 20 November 2014

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Transcript of (Near) Drownings

Courtney Woods, MD PGY1
Emergency Medicine
Emory University SOM

Drownings and Near Drowning
Review epidemiology of Drowning & Near Drowning
Discuss Pathophysiology
Discuss patient presentation
Discuss Initial ED Management
Discuss key players to involve
Discuss final Disposition

Objectives
"When you're drowning, you don't say 'I would be incredibly pleased if someone would have the foresight to notice me drowning and come and help me,' you just scream."
John Lennon
Epidemiology
Pathophysiology
Involved Systems

2nd leading cause of death: child <4yrs
6th leading cause accidental death
more common in rural and southern areas
Bimodal age distribution
boys 4x > girls (submersion)
boys 12x > girls (boating)
girls > boys (bathtub)
Definition: process resulting in primary respiratory impairment from submersion in liquid medium
Involuntary Laryngospasm
Involuntary Gasp
Inability to Oxygenate
Liquid in Oropharphynx
Laryngospasm Release
Initial Breath Holding
Parasympathetic
Response
CO2 retention
O2 Depletion
Hyperventilation
Liquid Aspiration
Further Hypoxemia
Pulmonary Effects
1-3 mL/kg fluid: impaired gas exchange
Pulmonary vasoconstriction/hypertension
Fresh Water
HypOtonic
Disrupts Surfactant
Salt Water
HypERtonic
Surfactant washout
Fluid-induced Bronchospasm
Aspiration Vomitous
Postobstructive Pulmonary Edema
Hypoxic Neuronal Injury
ARDS
Cardiovascular Effects
PERMANENT
2 mins - LOC
4-6 mins - Irreversible brain damage
tissue hypoxia & ischemia
Secondary Injury
Reperfusion, Sustained Acidosis, Cerebral Edema, Hyperglycemia, Release Excitatory Neurotransmitters, Seizures, Hypotension, Impaired cerebral autoregulation
Autonomic Instability (Diencephalic/Hypothalamic Storm)
Seizures
CNS Effects
Call from EMS - ETA 20 minutes
Case Presentation
4-year-old white male weighing 20 kilos was called in by EMS over the radio after being found down in a lake. The child was in good health until he fell into a fresh water lake while bird counting with his father. He was unaccounted for approx. 15-20 minutes until his body was found floating face down in the water. He was immediately pulled out and basic life support was started.
What needs to be done in preparation for this patient in the ED?

How will he be initially stabilized and managed?

What should you be most concerned about?

Who else needs to be involved in his care?

What will be his likely disposition?
Manage hypoxemia
continuous pulse ox
ABG
C-Spine
POCT glucose
CBC, CMP (w/ LFTs)
serial creatinine*
Lactate
Coags
UA
ETOH
UDS
Trops
WORK UP
CXR
CT
c-spine
non-contrast Head
EKG
LABS
Imaging
ABG: 7.04 / 84 / 36 / 19 /78%
How would you interpret this ABG?
What is the Acid-Base Disturbance?
What's up with the metabolic acidosis?
Uncompensated mixed respiratory & metabolic acidosis
Monitors
Swanz-ganz catheter
CO
ICP monitor
Foley
Urine output
Return to Case:
What to Get Ready in the ED
Pediatric Resuscitation Equimpment:
(Prepare for possible intubation)
Pediatric Crash Cart
Warmed Blankets
Heated IV Fluids
ABG Kit
Renal Failure
Lactic Acidosis
ED Treatment
Primary GOALS:
Resuscitation (ABCs, IV, O2, Monitor)
Reversal of Respiratory Failure
Measure of Success:
Correction of Hypoxemia
Correction of Acidosis
GCS (frequent rechecks!)
C-Spine Precautions
100% O2
PO2 <80mmHg (can be 60-70mmHg in Adult)
Failure of CPAP or BiPAP
Only in alert & cooperative
Altered Level of Consciousness
A-a gradient
Require more than 15L on nonrebreather
Respiratory failure
CO2 >45mmHg
Indications to Intubate
Interstitial fluid shifts
increase lung volumes
increase diameter of small airways
improve alveolar ventilation
(Lil' bo) PEEP
20ml/kg rapid volume expansion
Inotropes
Hypothermia
Fix acidosis with O2 and volume
Rescucitaion
NG Tube
Bronchoscopy
Surfactant replacement?
Other Interventions
Therapeutic Hypothermia...
Does the Patient Really Need Rewarming?
Good (RARE)
sudden, rapid cooling
Bad (Common)
Gradual, slow
Who needs to stay? (Admits)
Who needs to "kinda" stay? (CDU)
Who can bounce?
Final Disposition
Moderate hypoxemia
Intubated
Neurologic Insult
90% w/ blunted mental status recover
Patients arriving comatose
34% die
10-23% severe neuro deficits
STAY
Mild hypoxemia
Symptoms improved in ED
NO ABG abnormalities
No pulse oximetry abnormalitis
Normal CXR
"Kinda" Stay
After 6-8 hours in ED
Airtight history
No Injury
No Mental Status Changes
No evidence Bronchospasm
cough, SOB, hypoxia, tachypnea
Normal ABG & Pulse Ox

EXPLICIT DISCHARGE INSTRUCTIONS & FOLLOW-UP
Return to ED for
dyspnea, cough, fever
F/u with PMD in 1-2 days
Bounce
CDU Admissions
Admissons
Discharge Home
Summary
“He was swimming in a sea of other people’s expectations. Men had drowned in seas like that.”
Robert Jordan, New Spring
SUMMARY
Health, United States 1996-97 and Injury Chartbook. DHHS Publication No (PHS) 96-1232. US Department of Health and Human Services. Hyattsville, Md: National Center for Health Statistics;. 1997.

Papa L, Hoelle R, Idris A. Systematic review of definitions for drowning incidents. Resuscitation. Jun 2005;65(3):255-64. Medline.

van Beeck EF, Branche CM, Szpilman D, Modell JH, Bierens JJ. A new definition of drowning: towards documentation and prevention of a global public health problem. Bull World Health Organ. Nov 2005;83(11):853-6. Medline. Full Text.

Orlowski JP. Drowning, near-drowning, and ice-water submersions. Pediatr Clin North Am. Feb 1987;34(1):75-92. Medline.

Suominen P, Baillie C, Korpela R, Rautanen S, Ranta S, Olkkola KT. Impact of age, submersion time and water temperature on outcome in near-drowning. Resuscitation. Mar 2002;52(3):247-54. Medline.

Garzoni C, Garbino J. Long-term risk of atypical fungal infection after near-drowning episodes. Pediatrics. Feb 2007;119(2):417; author reply 417-8. Medline.

Lunetta P, Modell JH, Sajantila A. What is the incidence and significance of "dry-lungs" in bodies found in water?. Am J Forensic Med Pathol. Dec 2004;25(4):291-301. Medline.

Citro R, Previtali M, Bossone E. Tako-tsubo cardiomyopathy and drowning syndrome: is there a link?. Chest. Aug 2008;134(2):469. Medline.

Choi G, Kopplin LJ, Tester DJ, Will ML, Haglund CM, Ackerman MJ. Spectrum and frequency of cardiac channel defects in swimming-triggered arrhythmia syndromes. Circulation. Oct 12 2004;110(15):2119-24. Medline.

Cortez KJ, Roilides E, Quiroz-Telles F, Meletiadis J, Antachopoulos C, Knudsen T, et al. Infections caused by Scedosporium spp. Clin Microbiol Rev. Jan 2008;21(1):157-97. Medline. Full Text.

Leechawengwongs M, Milindankura S, Liengudom A, Chanakul K, Viranuvatti K, Clongsusuek P. Multiple Scedosporium apiospermum brain abscesses after near-drowning successfully treated with surgery and long-term voriconazole: a case report. Mycoses. Nov 2007;50(6):512-6. Medline.

Mesfin FB, Tobin E, Adamo MA, Dirisio D. Fungal vertebral osteomyelitis due to Scedosporium apiospermum after near-drowning. J Neurosurg Spine. Jul 2008;9(1):58-61. Medline.
References
Pathophysiology
WET DROWNING
DRY DROWNING
Most common: 80-90%
Aspiration of H2O
Dilution of Surfactant
Atelectasis
V/Q mismatch
Shunting
Uncommon: 10%
Laryngospasm
Hypoxia
LOC
Dry Drowning
Usually TRANSIENT
Hypovolemia
Hypotension
Myocardial Dysfunction
Ventricular Dysrhythmias
PEA
Asystole

NOTE: Primary Arrythmias may be Inciting Event
eg. long QT syndrome
PREVENTION is key!
Hypoxemia and Acidosis
C-spine precautions
Monitor while warming
Frequent neuro checks & re-assessment
Resucitate with
QUESTIONS?
Consults
Neurosurgery, Orthopedics &Trauma
Intensivist
Cardiovascular:
bypass for rewarming
ECMO
Neurology: persistent neuro deficits and seizures
Cardiology: dysrhythmias or myocardial dysfunction
Infectious Disease

Long term:
PT/OT/Rehab
YES! Hypothermia exacerbates bradycardia, acidosis & hypoxemia
Full transcript