3 Drowning

Question 1

Incidence drowning

Answer 1

worldwide, leading cause of injury death among children <15 years of age

incidence has 3 peaks:
<5 y/o (highest)
15-24 y/o
elderly

US: 2nd leading cause of unintentional death from birth to 19 y/o

Question 2

diving reflex

Answer 2

parasympathetic activation:

• bradycardia
• apnea
• peripheral vasoconstriction

however, in most cases, this is overwhelmed by the stimulation of the sympathetic nervous system, yielding no meaningful protectkon

Question 3

remarks on cold water submersion

Answer 3

cerebral protection most likely results from rapid CNS cooling before significant hypoxic damage occurs

Complete or near-complete neurologic recovery after asystole has been reported in both children and adults after drowning in icy water, although such occurrences are rare.

Question 4

prehospital care for drowning: who should be transported to an ED for evaluation

Answer 4

all patients with Amnesia for the drowning event,
Altered and loss of consciousness, or
an observed period of Apnea, as well as
those who require a period of Artificial ventilation
even if they are Asymptomatic

or based on figure 215-1: “Transport All patients (?)

Question 5

gcs level that can be observed and discharged after 4-6 hours if with normal pulmonary PE and SpO2 ≥95%?

Answer 5

GCS ≥13

Question 6

What to do for patients with GCS ≥13 and SpO2 ≥95%

Answer 6

Clear cervical spine
Monitor oxygen saturations
Ancillary tests (usually not indicated)
Observe 4-6 hours

Question 7

What will be the approach for patients who initially arrived GCS ≥13 with SpO2 of ≥95%, but with eventual desaturation or development of abnormal physical exam (rales, rhonci, wheezing, retractions, etc.)?

Answer 7

Approach as if GCS <13

Question 8

what to do if GCS <13

Answer 8

Clear cervical spine
ABC
Dx:
- blood:
CK, ABG, Troponin I
CBC, electrolytes, glucose
- urine: urinalysis, urine myoglobin, urine drug screen
- CXR

Monitor
1. Volume status (e.g., UO, CVP)
2. Acid-base status
3. Temperature

Question 9

Remarks onn cervical injury in drowning

Answer 9

Cervical injury is rare without a history of diving or associated trauma.

Because of this, routine cervical immobilization and CT of the brain are not necessary

But do cervical spine precautions if injury is suspected or unknown

Question 10

factors associated with poor resuscitation prognosis in near-drowning

Answer 10

need for bystander CPR at scene
CPR in the ED
asystole at scene or in ED after warming

Question 11

Cervical spine injury is rare (0.5%) in drowning unless there is history of

Answer 11

diving,
falling from a significant height,
or motorized vehicular crash

Question 12

Upon the patient’s arrival at the ED, what shall you do?

Answer 12

Assess and secure the airway,
provide oxygen,
determine core temperature,
and assist ventilation as necessary.

Question 13

Remarks on low-risk drowning patients who can be discharged

Answer 13

If after 4-6 hours of observation, the pulmonary examination does not reveal rales, rhonchi, wheezes, or retractions,

and arterial oxygen stauration on room air remains ≥95%, the patient can be safely discharged home.
*If deterioration is going to occur, it will do so within the 4- to 6-hour observation period.

Laboratory studies and radiographs are unnecessary and are not predictive of discharge.

Question 14

If deterioration is going toccur, it will do so within

Answer 14

the 4- to 6- hours observation period

Question 15

often the most objective measure of the degree of anoxic or ischemic insult

Answer 15

The extent of required resuscitation
because submersion duration is frequently unknown or only estimated

Question 16

Remarks on asystolic patients

Answer 16

For asystolic victims of drowning with short submersion duration (i.e., a few minutes)ª and short transport times who receive CPR en route, a vigourous resuscitation attempt is reasonable.

Conversely, because of the poorporgnosis for intact neurologic survival, ED resuscitation attempts can reasonably be withheld from asystolic victims of drowning with longer submersion and transport times.

ª<5 mins

Question 17

For patients who have been resuscitated from cardiac arrest, the hemodynamic response to exogenously administered epinephrine is frequently short-lived, and most will require

Answer 17

continuous infusion of dopamine or epinephrine in the ED or ICU

Question 18

Hemodynamic recovery, when it occurs, can be expected within

Answer 18

48 hours
Patients demonstrating no hhemodynamic recovery after 48 hours may slowly improve over the first week but are more likely to have long-term neurologic damage

Question 19

Electrolyte abnormalities are seldom significant and are usually transient unless…

Answer 19

…there is significnat:
hypoxia,
CNS depression,
renal injury from hemoglobinuria, or
myoglobinuria

Question 20

DIC in drowning usually occurs following

Answer 20

severe hypoxic insult

Question 21

Prophylactic antibiotics in drowning

Answer 21

Although aspiration is common, prophylactic antibiotics have not been shown to improve outcome and may be associated with resistant infections

Question 22

serious thought should be given to discontinuing resuscitation efforts if…

Answer 22

…the patient is normothermic upon arrival in the ED and in cardiopulmonary arrest or asystole because recovery without profound neurologic complications is rare

Question 23

Hospital management of drowning victims is

Answer 23

largely supportive

Question 24

Remarks on “brain resuscitation” after significant “warm” water drowning

Answer 24

Efforts to control cerebral edema, including the use of mannitol, loop diuretics, HTS, fluid restricdtion, and mechanical ventilation, have not shown benefit

Question 25

If the victim did not require CPR at scene or ED, complete recovery is expected within

Answer 25

**48 hours** *A small fraction of patients with significant aspiration may develop severe, even life-threatening ARDS.*

Question 26

a near-universal sign of poor prognosis in drowning patients

Answer 26

**Asystole**, whether noted at the scene or in the ED, in both adult and pediatric drowning injury

Question 27

Results of the study "Association of water temperature and submersion duration and drowning outcome" by Quan and collegaues in 2014

Answer 27

*A large series of 1377 open-water drowning vicitmes found* *_no intact survivors_* *amoung the group submerged for more than* ***_15 minutes_***, *whether in warm or cold water, and there were* *_no survivors_* *of submersion greater than* *_60 minutes_*