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Transcript of (Near) Drownings
Emory University SOM
Drownings and Near Drowning
Review epidemiology of Drowning & Near Drowning
Discuss patient presentation
Discuss Initial ED Management
Discuss key players to involve
Discuss final Disposition
"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."
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
Inability to Oxygenate
Liquid in Oropharphynx
Initial Breath Holding
1-3 mL/kg fluid: impaired gas exchange
Postobstructive Pulmonary Edema
Hypoxic Neuronal Injury
2 mins - LOC
4-6 mins - Irreversible brain damage
tissue hypoxia & ischemia
Reperfusion, Sustained Acidosis, Cerebral Edema, Hyperglycemia, Release Excitatory Neurotransmitters, Seizures, Hypotension, Impaired cerebral autoregulation
Autonomic Instability (Diencephalic/Hypothalamic Storm)
Call from EMS - ETA 20 minutes
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?
continuous pulse ox
CBC, CMP (w/ LFTs)
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
Return to Case:
What to Get Ready in the ED
Pediatric Resuscitation Equimpment:
(Prepare for possible intubation)
Pediatric Crash Cart
Heated IV Fluids
Resuscitation (ABCs, IV, O2, Monitor)
Reversal of Respiratory Failure
Measure of Success:
Correction of Hypoxemia
Correction of Acidosis
GCS (frequent rechecks!)
PO2 <80mmHg (can be 60-70mmHg in Adult)
Failure of CPAP or BiPAP
Only in alert & cooperative
Altered Level of Consciousness
Require more than 15L on nonrebreather
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
Fix acidosis with O2 and volume
Does the Patient Really Need Rewarming?
sudden, rapid cooling
Who needs to stay? (Admits)
Who needs to "kinda" stay? (CDU)
Who can bounce?
90% w/ blunted mental status recover
Patients arriving comatose
10-23% severe neuro deficits
Symptoms improved in ED
NO ABG abnormalities
No pulse oximetry abnormalitis
After 6-8 hours in ED
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
“He was swimming in a sea of other people’s expectations. Men had drowned in seas like that.”
Robert Jordan, New Spring
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Most common: 80-90%
Aspiration of H2O
Dilution of Surfactant
NOTE: Primary Arrythmias may be Inciting Event
eg. long QT syndrome
PREVENTION is key!
Hypoxemia and Acidosis
Monitor while warming
Frequent neuro checks & re-assessment
Neurosurgery, Orthopedics &Trauma
bypass for rewarming
Neurology: persistent neuro deficits and seizures
Cardiology: dysrhythmias or myocardial dysfunction
YES! Hypothermia exacerbates bradycardia, acidosis & hypoxemia