DROWNINGDROWNING

Review articleThe New England Journal of Medicine

Current ConceptsDavid Szpilman, M.D., Joost J.L.M. Bierens, M.D.,

Ph.D.,Anthony J. Handley, M.D., and James P. Orlowski, M.D.

n engl j med 366;22 nejm.2102 org may 31, 2012

DEFINITION DEFINITION (What) (What) ??

• Process of experiencing respiratory Process of experiencing respiratory impairment from submersion or impairment from submersion or immersion in liquid (immersion in liquid (WHO in 2002)WHO in 2002)– Submersion: person airways goes below Submersion: person airways goes below

surface of liquidsurface of liquid– Immersion: water splashes over the Immersion: water splashes over the

faceface

• Non Fatal Drowning: process of drowning is Non Fatal Drowning: process of drowning is interrupted if the person rescuedinterrupted if the person rescued

• Fatal Drowning: person dies at any time as a Fatal Drowning: person dies at any time as a result of drowningresult of drowning

* Any incident of submersion/immersion without * Any incident of submersion/immersion without respiratory impairment consider water rescue not respiratory impairment consider water rescue not drowning.drowning.

* No longer term use: near drowning, dry or wet * No longer term use: near drowning, dry or wet drowning, secondary drowning , active and passive drowning, secondary drowning , active and passive drowning, delayed onset respiratory distressdrowning, delayed onset respiratory distress

Who is Affected?Who is Affected?

Risk Factors:Risk Factors:• Male sexMale sex• Age < 14 yearsAge < 14 years• Alcohol useAlcohol use• Low incomeLow income• Poor educationPoor education• Rural residencyRural residency• Aquatic exposureAquatic exposure• Risk behaviourRisk behaviour• Lack of supervisionLack of supervision

* Statistics (worldwide) * Statistics (worldwide) show among boys 5-14 show among boys 5-14 years years

• In the United States, In the United States, drowning is the second drowning is the second leading cause of injury-leading cause of injury-related death among related death among children 1 to 4 years of children 1 to 4 years of age, with a death rate of 3 age, with a death rate of 3 per 100,000per 100,000

• Thailand, the death rate among 2-year-old children is 107 per 100,000

Pathophysiology…Pathophysiology…(how ??)(how ??)

1.1.Pulmonary InjuryPulmonary Injury

– Water in the alveoli causes surfactant dysfunction and washout. Water in the alveoli causes surfactant dysfunction and washout. Aspiration of salt water and aspiration of fresh water cause Aspiration of salt water and aspiration of fresh water cause similar degrees of injury although with differences in osmotic similar degrees of injury although with differences in osmotic gradients.gradients.

– the effect of the osmotic gradient on the very delicate alveolar–the effect of the osmotic gradient on the very delicate alveolar–capillary membrane disrupts the integrity of the membrane, capillary membrane disrupts the integrity of the membrane, increases its permeability, and exacerbates fluid, plasma, and increases its permeability, and exacerbates fluid, plasma, and electrolyte shifts.electrolyte shifts.

– The clinical picture of the damage caused to the alveolar–The clinical picture of the damage caused to the alveolar–capillary membrane is a massive, often bloodstained, capillary membrane is a massive, often bloodstained, pulmonary edema that decreases the exchange of oxygen and pulmonary edema that decreases the exchange of oxygen and carbon dioxide.carbon dioxide.

– The combined effects of fluids in the lungs, loss of surfactant, The combined effects of fluids in the lungs, loss of surfactant, and increased permeability of the alveolar–capillary membrane and increased permeability of the alveolar–capillary membrane result in decreased lung compliance, increased regions of very result in decreased lung compliance, increased regions of very low or zero ventilation to perfusion in the lungs, atelectasis, low or zero ventilation to perfusion in the lungs, atelectasis, and bronchospasm.and bronchospasm.

2.2. Central nervous injuryCentral nervous injury– If cardiopulmonary resuscitation (CPR) is required, If cardiopulmonary resuscitation (CPR) is required,

the risk of neurologic damage is similar to that in the risk of neurologic damage is similar to that in other instances of cardiac arrest.other instances of cardiac arrest.

* hypothermia associated with drowning can provide * hypothermia associated with drowning can provide a protective mechanism that allows persons to a protective mechanism that allows persons to survive prolonged submersion episodes.survive prolonged submersion episodes.

– Hypothermia can reduce the consumption of Hypothermia can reduce the consumption of oxygen in the brain, delaying cellular anoxia and oxygen in the brain, delaying cellular anoxia and ATP depletion.ATP depletion.

– Hypothermia reduces the electrical and metabolic Hypothermia reduces the electrical and metabolic activity of the brain in a temperature dependent activity of the brain in a temperature dependent fashion. fashion.

– The rate of cerebral oxygen consumption is The rate of cerebral oxygen consumption is reduced by approximately 5% for each reduction of reduced by approximately 5% for each reduction of 1°C in temperature within the range of 37°C to 1°C in temperature within the range of 37°C to 20°C20°C

TREATMENTTREATMENT

• Pre hospital carePre hospital care• Care In EDCare In ED• Care In ICUCare In ICU

TreatmentTreatment

• Prehospital carePrehospital care– to alert advanced-life-support teams as soon as to alert advanced-life-support teams as soon as

possible.possible.– ResuscitationResuscitation

* Cardiac arrest from drowning is due primarily to * Cardiac arrest from drowning is due primarily to lack of oxygen. For this reason, it is important that lack of oxygen. For this reason, it is important that CPR follow the traditional airway–breathing–CPR follow the traditional airway–breathing–circulation (ABC) sequence, rather than the circulation (ABC) sequence, rather than the circulation–airway–breathing (CAB) sequence.circulation–airway–breathing (CAB) sequence.

• starting with five initial rescue breaths, followed by starting with five initial rescue breaths, followed by 30 chest compressions, and continuing with two 30 chest compressions, and continuing with two rescue breaths and 30 compressions until signs of rescue breaths and 30 compressions until signs of life reappear.life reappear.

- Airway- Airway– Breathing: Breathing: maintain adequate oxygenation maintain adequate oxygenation

through an abnormally high respiratory rate through an abnormally high respiratory rate and can be treated by the administration of and can be treated by the administration of oxygen by facemask at a rate of 15 liters of oxygen by facemask at a rate of 15 liters of oxygen per minute.oxygen per minute.

– Not breathing:Not breathing:Early intubation and Early intubation and mechanical ventilation are indicated when the mechanical ventilation are indicated when the person shows signs of deterioration or fatigue person shows signs of deterioration or fatigue (grade 3 or 4).(grade 3 or 4).

• IV AccessIV Access– Peripheral venous access is the Peripheral venous access is the

preferred route for drug administrationpreferred route for drug administration– If hypotension is not corrected by If hypotension is not corrected by

oxygenation, a rapid crystalloid infusion oxygenation, a rapid crystalloid infusion should be administered.should be administered.

Care in EDCare in ED

• Continue maintain: Continue maintain: – AirwayAirway– OxygenationOxygenation– VentilationVentilation– Thermal insulationThermal insulation

• Physical examinationPhysical examination• Chest radiographyChest radiography• Measurement of arterial blood gasesMeasurement of arterial blood gases

** Metabolic acidosis occurs in the majority of Metabolic acidosis occurs in the majority of patients and is usually corrected by the patients and is usually corrected by the patient’s spontaneous effort to increase minute patient’s spontaneous effort to increase minute ventilation or by setting a higher minute ventilation or by setting a higher minute ventilation or a higher peak inspiratory ventilation or a higher peak inspiratory pressure (35 cm of water) on the mechanical pressure (35 cm of water) on the mechanical ventilator.ventilator.

• toxicologic investigation toxicologic investigation • Computed tomography of the head Computed tomography of the head

and neck and neck

** Hospitalization is recommended for all patients Hospitalization is recommended for all patients with a presentation of grade 2 to 6.with a presentation of grade 2 to 6.

** Patients with a presentation of grade 3 to 6, who Patients with a presentation of grade 3 to 6, who usually need intubation and mechanical usually need intubation and mechanical ventilation, are admitted to an intensive care unit ventilation, are admitted to an intensive care unit (ICU)(ICU)

TREATMENT IN THE TREATMENT IN THE ICUICU

RESPIRATORY SYSTEMRESPIRATORY SYSTEM1.1. Followed guidelines for ventilation in ARDSFollowed guidelines for ventilation in ARDS

2.2. Best not to initiate weaning from mechanical Best not to initiate weaning from mechanical ventilation for at least 24 hours, even when gas ventilation for at least 24 hours, even when gas exchange appears to be adequate (PF ratio >250).exchange appears to be adequate (PF ratio >250).

* * local pulmonary injury may not have resolved local pulmonary injury may not have resolved sufficiently, and pulmonary edema may recursufficiently, and pulmonary edema may recur

3.3. Glucocorticoid therapyGlucocorticoid therapy ** very little evidence for reducing pulmonary injuryvery little evidence for reducing pulmonary injury

** may have a beneficial effect on bronchospasm but may have a beneficial effect on bronchospasm but should be should be considered only after a trial of considered only after a trial of bronchodilators has failedbronchodilators has failed

4.4. Monitor sepsis parametersMonitor sepsis parameters ** Prophylactically administered antibiotics Prophylactically administered antibiotics

tend to select more resistant and aggressive organisms.tend to select more resistant and aggressive organisms.

** In a series of hospitalized cases, only 12% of In a series of hospitalized cases, only 12% of persons rescued from drowning had pneumonia and needed persons rescued from drowning had pneumonia and needed treatment with antibiotic agentstreatment with antibiotic agents

** Definitive therapy should be substituted once Definitive therapy should be substituted once the results of culture and sensitivity testing are available.the results of culture and sensitivity testing are available.

artificial surfactant, inhaled nitric oxide, and artificial surfactant, inhaled nitric oxide, and partial liquid ventilation with perfluorocarbons partial liquid ventilation with perfluorocarbons are under investigation; none of these are under investigation; none of these treatments can be recommended now.treatments can be recommended now.

CIRCULATORY SYSTEMCIRCULATORY SYSTEM• No evidence supports the use of a specific fluid No evidence supports the use of a specific fluid

therapy, diuretics, or water restriction in therapy, diuretics, or water restriction in persons who have been rescued from drowning persons who have been rescued from drowning in salt water or fresh waterin salt water or fresh water

• Echocardiography can help inform decisions Echocardiography can help inform decisions about the use of inotropic agents, vasopressors, about the use of inotropic agents, vasopressors, or both.or both.

NEUROLOGIC SYSTEMNEUROLOGIC SYSTEM• goals are to achieve: goals are to achieve:

– Normal values for glucoseNormal values for glucose– Normal partial pressure of arterial oxygenNormal partial pressure of arterial oxygen– Normal partial pressure of carbon dioxideNormal partial pressure of carbon dioxide– Avoidance of any situation that increases brain Avoidance of any situation that increases brain

metabolismmetabolism– Induced hypothermia with the cor temperature Induced hypothermia with the cor temperature

maintained between 32°C and 34°C for 24 hours may maintained between 32°C and 34°C for 24 hours may be neuroprotectivebe neuroprotective** The paradox in resuscitation after drowning is that a The paradox in resuscitation after drowning is that a person with person with hypothermia needs to be warmed initially in order hypothermia needs to be warmed initially in order to be effectively to be effectively resuscitated but then may benefit from resuscitated but then may benefit from induced therapeutic hypothermia induced therapeutic hypothermia after successful resuscitationafter successful resuscitation

UNUSUAL UNUSUAL COMPLICATIONSCOMPLICATIONS

1.1. Sepsis and disseminated intravascular Sepsis and disseminated intravascular coagulation are possible complications coagulation are possible complications during the first 72 hours after during the first 72 hours after resuscitationresuscitation

2.2. Renal insufficiency or failure is rare but Renal insufficiency or failure is rare but can occur as a result of anoxia, shock, can occur as a result of anoxia, shock, myoglobinuria, or hemoglobinuria.myoglobinuria, or hemoglobinuria.

PREVENTIONPREVENTION