DROWNING

Definition:
• According to Utstein guidelines last updated 2015

Drowning is defined as a process resulting in primary respiratory impairment

from submersion or immersion in a liquid medium.

The Utstein guidelines further suggest that ambiguous or confusing terms such
as "near-drowning," "secondary drowning," and "wet drowning" should not be
used.

Drowning outcomes are classified as either drowning with mortality, drowning

with morbidity, or drowning without morbidity
SALT WATER V/S FRESH WATER DROWNING
Distinction between salt water and fresh water drowning is no longer
considered important.

Both types of nonfatal drowning result in decreased lung compliance,

ventilation-perfusion mismatching, and intrapulmonary shunting, leading to
hypoxemia that causes diffuse organ dysfunction.

The temperature of the water and the presence of contaminants may affect
patient outcomes
Common Questions and Confusions ??!!
Should the Heimlich maneuver be a routine part of resuscitation ?

Should patients without symptoms after submersion be taken to an ED and

admitted ?

Should patients arriving in the ED in cardiac arrest continue to have

resuscitation attempted ?

Does ICP monitoring do any good ?

Does surfactant administration help ?

Risk factors:
The following factors increase the risk of drowning

• Inadequate adult supervision.

• Inability to swim or overestimation of swimming capabilities.
• Risk-taking behavior.
• Use of alcohol and illicit drugs.
• Hypothermia, which can lead to rapid exhaustion or cardiac arrhythmias.
• Concomitant trauma, stroke, or myocardial infarction.
• Seizure disorder or developmental/behavioral disorders in children.
• Undetected primary cardiac arrhythmia
• Hyperventilation prior to a shallow dive
Pathophysiology:
Submersion: airway drops below surface of water

Period of Panic: victim struggles and attempts to resurface

Breath hold: voluntary attempt to protect airway

Reflex inspiratory effort: involuntary attempt to inhale oxygen

Hypoxia: by means of either aspiration or reflex laryngospasm

Organ Damage :Hypoxemia in turn affects every organ system, with the major
component of morbidity and mortality being related to cerebral hypoxia
END ORGAN EFFECTS:
Pulmonary : Non cardiogenic pulmonary edema, ARDS

Neurological : Seizures, Raised ICP, Neuronal damage, cerebral edema.

Cardiovascular : Arrythmias

Renal : Acute tubular necrosis , Renal failure

Acid-base and electrolytes : Respiratory & Metabolic Acidosis

Coagulation : Hemolysis, Coagulopathy, DIC.

MANAGEMENT :
Management of drowning victims can be divided into three phases:

• Prehospital care,

• Emergency department (ED) care, and

• Inpatient care.
PRE HOSPITAL CARE :
Rescue and immediate resuscitation by bystanders definitely improves the outcome.

The need for CPR is determined as soon as possible without compromising the safety
of the rescuer or delaying the removal of the victim from the water.

Ventilation is the most important initial treatment in submersion injury and rescue
breathing should begin as soon as rescuer reaches shallow water or a stable surface

Pulses may be very weak and difficult to palpate in the hypothermic patient with sinus
bradycardia or atrial fibrillation; a careful search for pulses should be performed for at
least one minute before initiating chest compressions in the hypothermic patient
because these arrhythmias require no immediate treatment
PRE HOSPITAL CARE :
If the patient does not respond to the delivery of two rescue breaths that make the
chest rise, the rescuer should immediately begin performing high-quality chest
compressions once the absence of a pulse is established in the hypothermic patient.

Attempts at rewarming hypothermic patients with a core temperature <33ºC should

be initiated, either by passive or active means as available. Remove wet clothes.

The Heimlich maneuver or other postural drainage techniques to remove water from
the lungs are of no proven value and may even induce emesis with subsequent
aspiration.

Cervical spinal cord injury is uncommon in nonfatal drowning victims. Routine cervical
spine immobilization can interfere with essential airway management and is not
recommended
EMERGENCY DEPARTMENT MANAGEMENT :
Prehospital resuscitative efforts should be continued and the airway secured as
indicated.

If tracheal intubation is performed, an orogastric tube should be placed to

relieve gastric distension, which occurs from passive passage of fluid.

In symptomatic patients who do not require immediate intubation,

supplemental oxygen should be provided to maintain the SpO2 above 94
percent.

In addition, noninvasive positive pressure ventilation via CPAP or BIPAP can

improve oxygenation and decrease ventilation-perfusion mismatch
INPATIENT MANAGEMENT :
Symptomatic patients require hospitalization for supportive care and treatment
of organ-specific complications

Hypotension :
Persons with hypothermia can have significant hypovolemia and hypotension
due to a "cold diuresis.“

Optimal fluid replacement and inotropic support.

Respiratory failure or infection:
Bronchospasm is often seen in nonfatal drowning victims, and management is similar
to acute asthma; most cases rapidly improve with inhaled beta-agonists.

No evidence to support the routine use of glucocorticoids or prophylactic antibiotics

Antibiotics should be used only in cases of clinical pulmonary infection or if the victim
was submerged in grossly contaminated water

Mechanical ventilatory strategies are similar to those employed in other types of

acute lung injury.

No high-quality evidence that pulmonary function improves with surfactant therapy

Neurologic injuries :
The goal of hospital management is to prevent secondary neurologic injuries
due to ongoing ischemia, cerebral edema, hypoxemia, fluid and electrolyte
imbalances, acidosis, and seizure activity.

Useful treatments may include the following:

• Head of the bed should be elevated to 30 degrees if potential cervical spine

injuries have been excluded.

• Diuretics can be used to avoid hypervolemia

Neurologic injuries :
• Hyperventilation may be used acutely as a temporizing measure to reduce
intracranial pressure by vasoconstriction and decreasing intracranial blood volume.

• Seizure activity increases cerebral oxygen consumption and blood flow, should be
aggressively controlled. Non-sedating anticonvulsants (e.g, phenytoin) are preferred.

• Both hypoglycemia and hyperglycemia may be harmful to the brain, and euglycemia
should be meticulously maintained.

• The appropriate use of therapeutic (induced) hypothermia in the postresuscitation

period following nonfatal drowning remains unclear. Normothermia is desirable
Guidelines for treating cold-water drowning :
• Patients with severe hypothermia may appear dead because of profound
bradycardia and vasoconstriction.

• Resuscitation should continue while aggressive attempts are made to restore

normal body temperature.

• Do not stop resuscitation of a patient until their core temperature is at least

30 degrees Celsius.
Guidelines for treating cold-water drowning :

Miracle

Matthew Granger

14 months old
20-40 minutes
Guidelines for treating warm-water drowning :
• Patients arriving at the emergency department in cardiopulmonary arrest
after a warm-water submersion have a dismal prognosis.

• The benefits of resuscitative efforts should be continuously reassessed in

such situations
QUESTIONS??