DrowningDrowningNew Definitions and ProtocolsNew Definitions and Protocols

Charles Stewart MD, EMDMCharles Stewart MD, EMDMDirector of ResearchDirector of ResearchUniversity of OklahomaUniversity of Oklahoma

Tulsa School of Community MedicineTulsa School of Community MedicineOklahoma Institute for Disaster and Emergency MedicineOklahoma Institute for Disaster and Emergency Medicine

Drowning

• Much of our experience with the Much of our experience with the resuscitation of patients is a direct result resuscitation of patients is a direct result of man’s ventures into the water.of man’s ventures into the water.

Drowning

• DemographicsDemographics– 6,000 - 8,000 deaths per year6,000 - 8,000 deaths per year– The 3rd leading cause of accidental death The 3rd leading cause of accidental death

in USAin USA– The 2nd leading cause of death in childrenThe 2nd leading cause of death in children– 25,000 rescues each summer on California 25,000 rescues each summer on California

beachesbeaches

Drowning

• Statistical Risk FactorsStatistical Risk Factors– Age: Youth 40% under 4 years oldAge: Youth 40% under 4 years old– Location: Pools, bathtubs, lakes, riversLocation: Pools, bathtubs, lakes, rivers– Sex: Male 3:1Sex: Male 3:1– Time of year: Warm months Time of year: Warm months

Drowning

• We really don’t know how many ‘near’ We really don’t know how many ‘near’ drownings occur each year.drownings occur each year.– Death statistics are readily availableDeath statistics are readily available– >15% of school children have at least one >15% of school children have at least one

submersion incident per year.submersion incident per year.– With 7.4 per 100,000 reported mortality, With 7.4 per 100,000 reported mortality,

that means at least ½ million per year in that means at least ½ million per year in South Carolina alone!.South Carolina alone!.

Near Drowning

• Statistical Risk FactorsStatistical Risk Factors– Predisposing Illnesses: Epilepsy, seizuresPredisposing Illnesses: Epilepsy, seizures– Trauma: Diving and boating accidents, fallsTrauma: Diving and boating accidents, falls– Mental impairment: Drugs and alcoholMental impairment: Drugs and alcohol

Near Drowning

• Most common sites:Most common sites:– Fresh inland bodies of waterFresh inland bodies of water

• LakesLakes• RiversRivers• QuarriesQuarries• Residential swimming poolsResidential swimming pools

Predisposing Factors

• Coma, seizuresComa, seizures

• Alcohol/DrugsAlcohol/Drugs

• ExhaustionExhaustion

• HyperventilationHyperventilation

• Rapidly moving waterRapidly moving water

Predisposing Factors

• Poor swimming abilityPoor swimming ability

• ExhaustionExhaustion

• PanicPanic

• HypothermiaHypothermia

• TraumaTrauma

Near Drowning

Murder ???Murder ???

Suicide ???Suicide ???

Near Drowning

DefinitionsDefinitionsDefinitions were revised at 2002 World Definitions were revised at 2002 World

congress on Drowning in Amsterdam, congress on Drowning in Amsterdam, Netherlands. They are now Netherlands. They are now

internationally accepted and more internationally accepted and more uniformuniform

Drowning

Drowning

The fluid does not have to The fluid does not have to be waterbe water

Drowning

• UnconsciousnessUnconsciousness– Due to :Due to :

• TraumaTrauma• SeizureSeizure• ComaComa• Drug/Alcohol abuseDrug/Alcohol abuse

Drowning Pathophysiology

• 3 Major metabolic abnormalities3 Major metabolic abnormalities– AnoxiaAnoxia– AcidosisAcidosis– HypercapniaHypercapnia

Wet Drowning

• Approximately 90% of drowning victimsApproximately 90% of drowning victims– aspirate wateraspirate water– vomitvomit– coughcough– gaspgasp– flood lungs with waterflood lungs with water

Pathophysiology with aspiration

• HypoxemiaHypoxemia– Occurs whether or not patient aspiratesOccurs whether or not patient aspirates– 85-90% aspirate85-90% aspirate– 10-15% DO NOT aspirate10-15% DO NOT aspirate

Pathophysiology without aspiration

• Severe, persistent laryngospasmSevere, persistent laryngospasm

• Anoxic seizuresAnoxic seizures

• DeathDeath

Pathophysiology with aspiration

• HypoxemiaHypoxemia– Asphyxia starts the HypoxiaAsphyxia starts the Hypoxia– Intrapulmonary shunting leads to further Intrapulmonary shunting leads to further

hypoxemiahypoxemia– Pulmonary damage continues the processPulmonary damage continues the process

Does the type of Does the type of

aspirated water matter?aspirated water matter?

Pathophysiology

• Consequences of AspirationConsequences of Aspiration– Few survivors of drowning aspirate enough Few survivors of drowning aspirate enough

water to cause significant changes in either water to cause significant changes in either blood volume or serum electrolytes.blood volume or serum electrolytes.

Pathophysiology

• Consequences of AspirationConsequences of Aspiration– 2.2 cc/kg2.2 cc/kg HypoxiaHypoxia– 11 cc/kg11 cc/kg Blood volume changesBlood volume changes– 22 cc/kg22 cc/kg Electrolyte changesElectrolyte changes

• Average aspiration is only 2-4 cc/kgAverage aspiration is only 2-4 cc/kg

Pathophysiology with aspiration

• Pulmonary EdemaPulmonary Edema– Damage to Alveolar membraneDamage to Alveolar membrane– Damage to pulmonary microcirculationDamage to pulmonary microcirculation

SaltSalt

vsvs

FreshFresh

There are REAL differencesThere are REAL differences

Near Drowning

• Potential Fresh Water DamagePotential Fresh Water Damage– HypoxiaHypoxia– Atelectasis Atelectasis Strips surfactant Strips surfactant– Pulmonary EdemaPulmonary Edema– HypotonicHypotonic– HemolysisHemolysis

• Lowered Na, Cl, and KLowered Na, Cl, and K

Potential Fresh Water Damage• HypoxiaHypoxia

• AtelectasisAtelectasis

• Pathogenic bacteria and impurities Pathogenic bacteria and impurities lethallethal

• Produces greater long-term damage Produces greater long-term damage due to salt in pulmonary edemadue to salt in pulmonary edema

Drowning

• Potential Salt Water DamagePotential Salt Water Damage– Hypovolemia if large amounts swallowedHypovolemia if large amounts swallowed– HypertonicHypertonic

Elevation of Na, Cl and K, Elevation of Na, Cl and K, decrease blood volumedecrease blood volume

• Salt water is 2 times as lethalSalt water is 2 times as lethal

Drowning Final Pathway

• Pulmonary EdemaPulmonary Edema

• HypoxiaHypoxia

COLD WATERCOLD WATERandand

WARM WATERWARM WATERdrownings are differentdrownings are different

Warm Water

• 2020ooC and aboveC and above

• 7272ooF and aboveF and above

• Lakes, ponds, quarriesLakes, ponds, quarries

Hot Water

• Body temperature and aboveBody temperature and above

• Hot tubs, bath tubs, hot springsHot tubs, bath tubs, hot springs

Warm Water Drownings

• 49 Warm Water Drownings in Children49 Warm Water Drownings in Children– 29 died29 died 58%58%– 13 neurological cripples13 neurological cripples 27%27%– 7 survived intact7 survived intact 15%15%

Cold water has more survivors

Very Cold Water

• The definition is not easyThe definition is not easy– It is usually below 21It is usually below 21ooC or (71C or (71ooF)F)

Hou

rs

Water Temperature

6

5

4

3

2

1

20 30 40

50

100% Lethal 50%unconscious

ProbableDrowning

Safe

-8

-2

4 10

Mammalian Diving Reflex

• Circulatory system shunts blood to the Circulatory system shunts blood to the brain and heart from extremities, GI brain and heart from extremities, GI tract and skintract and skin

• Apnea and bradycardia follow, allowing Apnea and bradycardia follow, allowing prolonged submersionprolonged submersion

Mammalian Diving Reflex

• Found in all mammalsFound in all mammals• Heart Rate SlowsHeart Rate Slows• Airway closesAirway closes• Circulatory system shunts blood to brain Circulatory system shunts blood to brain

and heart from extremities, GI tract and and heart from extremities, GI tract and skinskin

• Apnea and bradycardia follow, allowing Apnea and bradycardia follow, allowing prolonged submersionprolonged submersion

Mammalian Diving Reflex

• Mammalian Diving Reflex in HumansMammalian Diving Reflex in Humans– Not very activeNot very active– Probably not the mechanism for survival in Probably not the mechanism for survival in

prolonged submersions in childrenprolonged submersions in children

Immersion syndrome

• Sudden exposure to very cold water.Sudden exposure to very cold water.

• Probably vagal dysrhythmiaProbably vagal dysrhythmia– AsystoleAsystole– Ventricular fibrillationVentricular fibrillation– Alcohol and intoxicants are predispositionAlcohol and intoxicants are predisposition

Immersion Hypothermia

A special case….A special case….

Cold water immersion

• Survival Times - Persons of Average BuildSurvival Times - Persons of Average Build

• Water Temperature Water Temperature Survival TimeSurvival Time

• 0 Deg C 0 Deg C 45 minutes45 minutes

• 9.5 deg C 9.5 deg C 2 to 3 hours2 to 3 hours

• 11 deg C 11 deg C 4 hours4 hours

• 14 deg C 14 deg C 6 hours6 hours

• 18 deg C 18 deg C 10 hours10 hours

Immersion hypothermia

• HuddleHuddle

• HELPHELP

Submersion victimsSubmersion victims

aren’t dead until aren’t dead until

they are WARM and DEADthey are WARM and DEAD

Field Management

Drown not thyself to save a drowning man

Old Old ProverbProverb

Rescue

• Most people drown within 10 to 30 feet Most people drown within 10 to 30 feet of safety. of safety. – ReachReach– ThrowThrow– RowRow– Go?Go?

American Red Cross

Scene Assessment

• Type of incident?Type of incident?

• Duration of submersion?Duration of submersion?

• Type and temperature of water?Type and temperature of water?

• Duration of on scene CPR?Duration of on scene CPR?

• Prior health of patient?Prior health of patient?

• Drug and Alcohol use?Drug and Alcohol use?

Near Drowning

• Watch for trauma in rapidly moving Watch for trauma in rapidly moving waterwater

Resuscitation

#1Restore Ventilation !!!

CPR

• Cardiopulmonary ResuscitationCardiopulmonary Resuscitation– The immediate actions of the Primary The immediate actions of the Primary

Responder significantly affects the Responder significantly affects the outcome of the near drowning victimoutcome of the near drowning victim

Field Management

In near drownings that involve falls, In near drownings that involve falls, moving water, boating, and surfing moving water, boating, and surfing

accidents.accidents.

Always take C-spine precautionsAlways take C-spine precautions

The Heimlich Maneuver The Heimlich Maneuver

is unproved in near drowningsis unproved in near drownings

EmergencyDepartment Management

Intubate

• Secures airwaySecures airway

• Protects against aspirationProtects against aspiration

• Allows suction of secretionsAllows suction of secretions

• Better ventilationBetter ventilation

Suction

• Suction equipment must be availableSuction equipment must be available

• Many patients will vomitMany patients will vomit

• Many will have heavy secretions form Many will have heavy secretions form pulmonary edemapulmonary edema

Emergency Department Management• Cardiac monitoring needed for all Cardiac monitoring needed for all

patientspatients

• Acidosis and Hypoxia will decrease the Acidosis and Hypoxia will decrease the fibrillation thresholdfibrillation threshold

Emergency Department Management• Core body temperature should be Core body temperature should be

measuredmeasured

• Keep patient dryKeep patient dry

History of Patient

• Obtain Medical History ASAPObtain Medical History ASAP

• AgeAge

• Pre-existing diseasesPre-existing diseases

• Physical conditionPhysical condition

• MedicationMedication

Near Drowning

• In near drowning victims suspect:In near drowning victims suspect:– Child abuseChild abuse– SuicideSuicide– Attempted murderAttempted murder– Cervical spine traumaCervical spine trauma– SeizuresSeizures– Drug/Alcohol abuseDrug/Alcohol abuse

Emergency Department Management• Reassess ABC’s and vital signs Reassess ABC’s and vital signs

frequentlyfrequently

• Include Neuro checksInclude Neuro checks

• Neurological deficit should not be Neurological deficit should not be assumed to be anoxic untilassumed to be anoxic until– C-spineC-spine– Intracranial InjuryIntracranial Injury– Toxic encephalopathyToxic encephalopathy

• Have been ruled outHave been ruled out

Emergency Department Management

Laboratory

• Arterial blood gasesArterial blood gases

• ElectrolytesElectrolytes

• BUN/ CreatinineBUN/ Creatinine

• Platelets/ PT & PTT/ CBCPlatelets/ PT & PTT/ CBC

• Serum & Urine HemoglobinSerum & Urine Hemoglobin

Clinical Manifestations

• Radiographic ChangesRadiographic Changes– Non-cardiac pulmonary edema with normal Non-cardiac pulmonary edema with normal

heart sizeheart size– Perihilar patternPerihilar pattern– Seen in 1/3 to 2/3 of patients initiallySeen in 1/3 to 2/3 of patients initially

Adjunctive Therapy

Hypoxia

• Respiratory Management ObjectiveRespiratory Management Objective– Try to achieve a Pa OTry to achieve a Pa O22 of 70-100 mm Hg of 70-100 mm Hg

– 70% will require more aggressive therapy70% will require more aggressive therapy

PEEP

• Indicated when pOIndicated when pO22 < 60 and FIO < 60 and FIO22 > 50 > 50

• Try to keep the pOTry to keep the pO22 at 75-90 at 75-90

• This prevents pulmonary edema and This prevents pulmonary edema and ARDS ??? (acute respiratory distress ARDS ??? (acute respiratory distress syndrome)syndrome)

Hypoxia

• BronchospasmBronchospasm

• Treat with:Treat with:– A) Nebulized AgentsA) Nebulized Agents– B) TheophyllineB) Theophylline– C) Consider steroidsC) Consider steroids

Steroids

As always .... controversial As always .... controversial

Infection

• Prophylactic AntibioticsProphylactic Antibiotics– Not usually indicatedNot usually indicated– Septic tank?Septic tank?– Daily gram stainsDaily gram stains– Treat the proper bugTreat the proper bug

Experimental Therapies

• ? Controlled hypothermia? Controlled hypothermia

• ? Calcium channel blockers? Calcium channel blockers

• ? Barbiturate coma therapy? Barbiturate coma therapy

• ? Hyperbaric oxygenation? Hyperbaric oxygenation

• ? Hyperventilation? Hyperventilation

Hospital Management

• Resuscitation Resuscitation

• Cerebral resuscitationCerebral resuscitation– HYPER regimen advocated in comatose HYPER regimen advocated in comatose

childrenchildren

• ??? Utility??? Utility

Disposition

• All patients with submersion injuries All patients with submersion injuries should be admittedshould be admitted

• High incidence of delayed complicationsHigh incidence of delayed complications

Patients should be admitted Patients should be admitted

and observed ...and observed ...

But for how long?But for how long?

Disposition

• WARD BED WARD BED - Asymptomatic with - Asymptomatic with normal vital signs, normal vital signs,

CXR, CXR, and ABG and ABG

• ICUICU - Symptomatic or abnormal vital - Symptomatic or abnormal vital signs, CXR, or ABG signs, CXR, or ABG

Prognosis

Prognosis

• Survival depends upon a variety of Survival depends upon a variety of interrelated factorsinterrelated factors– AgeAge– Underlying diseaseUnderlying disease– Water type and temperatureWater type and temperature– Duration of submersionDuration of submersion– Degree of hypothermiaDegree of hypothermia

Clinical Manifestations

• Neurological DamageNeurological Damage

• Flaccid is BAD!Flaccid is BAD!

Bad Prognostic Factors

• Older ageOlder age

• Warm waterWarm water

• Spinal cord damageSpinal cord damage

• Inadequate CPRInadequate CPR

• Decorticate / DecerebrateDecorticate / Decerebrate

• UnconsciousUnconscious

• Septic tankSeptic tank

Good Prognostic Factors

• Older child or young adultOlder child or young adult

• Cold waterCold water

• Adequate CPR/on scene ACLS/BLSAdequate CPR/on scene ACLS/BLS

• ConsciousConscious

• Short submersionShort submersion

• HealthyHealthy

Warm Water Submersion• In warm water submersionIn warm water submersion

– Submersion > 5 minutesSubmersion > 5 minutes– Fixed and dilated pupils (in the ED)Fixed and dilated pupils (in the ED)– No CPR for 10 minutes or moreNo CPR for 10 minutes or more– pH less than 7.1 on arrival at hospitalpH less than 7.1 on arrival at hospital– Need for in hospital resuscitation or Need for in hospital resuscitation or

ventilationventilation

• Severe neurologic impairment or Severe neurologic impairment or mortality is likelymortality is likely

Check the K!

• Potassium of > 10 is uniformly Potassium of > 10 is uniformly associated with mortality…associated with mortality…– OK to call the arrest at this point.OK to call the arrest at this point.

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

• FencesFences

• Self-locking gatesSelf-locking gates

• Immersion alarmsImmersion alarms

• Keep pool fullKeep pool full

Prevention

• Decrease intoxicants around the pool!Decrease intoxicants around the pool!

Prevention

• Proper protective gearProper protective gear– survival suitsurvival suit– Flotation deviceFlotation device

• Cold water trainingCold water training

Prevention

• Supervise patients with seizuresSupervise patients with seizures

• Other handicaps?Other handicaps?

Prevention

• Prevention TipsPrevention Tips– Swimming lessonsSwimming lessons– Appropriate people to watch childrenAppropriate people to watch children– Teach children to obey the swimming pool Teach children to obey the swimming pool

rulesrules

Prevention

• Prevention tipsPrevention tips– Don’t mix alcohol and drugs with swimming Don’t mix alcohol and drugs with swimming

activitiesactivities– Do not overexertDo not overexert– Avoid dangerous situationsAvoid dangerous situations– Buddy swimBuddy swim

Pitfalls

• Low oxygen saturation???Low oxygen saturation???– Calls for significant monitoring – can Calls for significant monitoring – can

decompensate quicklydecompensate quickly

• Head trauma and drowning???Head trauma and drowning???• Look for cervical spine traumaLook for cervical spine trauma

• Hot water drowningHot water drowning• Much quicker lethality…lower survivalMuch quicker lethality…lower survival

Pitfalls

• Cold water drowning???Cold water drowning???– Don’t give up quickly – longer survivalDon’t give up quickly – longer survival

• High potassium???High potassium???– OK to stop CPROK to stop CPR

• Septic tank drowningSeptic tank drowning– Massive bacterial contaminationMassive bacterial contamination

Summary

Drowning Claims

> 8,000 death/year

Drowning Claims

>50,000 deaths/year

Prevention

Prevention

Prevention