Near drowning
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Near drowning






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Near drowning Near drowning Presentation Transcript

  • Overview Definition Epidemiology Accidental vs. Non-accidental drowning Pathophysiology Management Prevention
  • Definition2002 World congress on drowning defined drowning as “a process resulting in primary respiratory impairment from submersion in a liquid medium”Near drowning refers to survival (even if temporary) beyond 24 hours after a submersion episode.Shepard, Suzanne et al. Drowning. Updated 6/9/2009 .
  • Fatal Drowning Statistics In 2005, 3,582 fatal unintentional drownings in U.S. 1 in 4 drownings were children < 14 years old Drowning is the second-leading cause of unintentional injury-related death for children ages 1 to 14 years India has a drowning mortality rate of 8.5/100000 population.Water Injuries-Fact Sheet. www Accessed25 Sept 2009.
  • Location of DrowningBrenner et al. looked at death certificates from victims of unintentional drownings in 1995Infant drownings: 55% in bathtubsAge 1-4 years, 56% in artificial pools and 26% in other bodies of freshwaterChildren 63% of drownings were in natural bodies of freshwater Brenner RA, Trumble AC, Smith GS, Kessler EP, Overpeck MD. Where children drown, United States, 1995. Pediatrics 2001;108(1):85 ミ
  • Features which differentiate between accidental, non-accidental, and homicidal submersion injuries to children Accidental submersion:  Typically a baby momentarily left alone or with a sibling in the bath  Majority of children 8-15 months of age  Child the youngest in the family  No features suggesting child abuse Epilepsy related:  Child with history of epilepsy  Bathing alone  A child older than 24 months Non-accidental submersion:  Atypical submersion description, with inconsistent details  Late referral to hospital  Associated history of child abuse  Child outside 8-24 month age span  Child left with unsuitable carer Homicidal drowning:  Maternal history of mental illness  Child outside the 8-24 month age range  Previous history of child abuse Kemp, Alison et al. Accidents and child abuse in bathtub submersions. Archives of Disease in Childhood 1994; 70: 435-438.
  • Signs & symptoms75% of kids who develop sxs do so within 7 hours of eventComa to agitated alertnessCyanosis, coughing, and the production of frothy pink sputumTachypnea, tachycardiaLow-grade feverRales, rhonchi & less often wheezesSigns of associated trauma to the head and neck should be sought
  • “Hypoxic March of Drowning”A pathophysiology summary 1. Involuntary submersion  Voluntary apnea, tachycardia, hypoxia, hypercarbia 1. Involuntary inspiration  Triggered by hypercarbia and hypoxia  arterial hypoxemia, tissue hypoxia, tissue acidosis, and tachycardia 1. Water enters lungs  Increased peripheral airway resistance, pulmonary vessel vasoconstriction/hypertension with shunting of blood, decreased lung compliance, decreased surfactantPearn, John. The management of near drowning. BMJ 1995. (291) 1447-1452
  • “Hypoxic March of Drowning”continued4. Decompensation -gasping with further inhalation -swallowing with emesis -loss of consciousness4. Neuronal dysfunction -blood brain barrier breaks down4. Cardiac dysfunction -bradycardia, arrhythmias, asystole7. Brain Death8. Somatic Death
  • Diving ReflexInfants and young childrenSudden contact with water less than 20 degrees CelsiusCauses: Bradycardia vasoconstriction of nonessential vascular beds shunting of blood to the coronary and cerebral circulation  Shepard, Suzanne et al. Drowning. Updated 6/9/2009 .
  • Dry Drowning10-20% of patients experience a laryngospasm that prevents aspiration of fluid into the lungsTight spasm often persists until cardiac arrestLungs remain dryLarge volumes of fluid ingested into stomachMajor cause for electrolyte abnormalities in children (hyponatremia from fresh water, hypernatremia from salt water)
  • Wet Drowning1-3 mL/kg water aspirated hinders gas exchangeWhen fluid is in the lungs, vagus nerve stimulates vasoconstriction pulmonary vessels and pulmonary hypertensionFreshwater diffuses rapidly across alveolar- capillary membrane and saltwater damages the membraneSurfactant is denatured by freshwater and washed away by salt waterIn both salt water and freshwater aspiration, compliance is decreased
  • Hypoxic-Ischemic EncephalopathyInitial phase Energy failure from hypoxia/ischemiaReperfusion Injury 6-24 hours later Cerebral edema, apoptosis
  • Mechanism of Hypoxic-Ischemic EncephalopathyExcitatory amino acids, glutamate and aspartate, are released in response to hypoxia/ischemiaActivation receptors, NMDA, AMPA, Kainate  Ion channels open  Influx of calcium into cells  Cell deathLipid peroxidation of cell membranes  Destruction of Na+/K+ ATPase  Cerebral edema, neuron deathIncreased rate of apoptosis  Related to influx of calcium into cell and nucleus
  • Complications of hypoxic-IschemicEncephalopathyAutonomic instability Hypertension Tachycardia Diaphoresis Agitation Muscle rigidity
  • AspirationChemical Pneumonia pH less than 2.5 Volume greater than 0.3mL/Kg Inflammatory reaction by cytokines  TNF-alpha, IL-8Bacterial Pneumonia Anaerobic organisms
  • Other organ involvementOccur 24-72 hours after initial insultHeart: decreased contractility, dilation, tricuspid regurgitation, stress induced cardiomyopathyRenal: acute tubular necrosis, oliguria, anuriaHepatic: increased LFT’s, hypoalbuminemia, coagulopathy, hyperbilirubinemiaRhabdomyolysis
  • DifferentialsChild Abuse & Neglect: Physical AbuseChild Abuse & Neglect: Sexual AbuseMunchausen Syndrome by Proxy
  • WORKUP-Laboratory Studies The following studies are indicated in near drowning: Blood gas analysis with co-oximetry to detect methemoglobinemia and carboxyhemoglobinemia CBC count, prothrombin time with international normalized ratio (INR), partial thromboplastin time, fibrinogen, D-dimer, fibrin split products
  • Serum electrolytes (with glucose)Liver enzymes, especially aspartate aminotransferase and alanine aminotransferaseRenal function tests (BUN, creatinine)
  • Drug screen and ethanol level (consider)Continuous pulse oximetry and cardiorespiratory monitoring (may be needed)Cardiac troponin I testing (may be useful as a marker to predict children who have an elevated risk of not surviving to hospital discharge)
  • Imaging StudiesChest radiographyHead CT and cervical spine imaging if trauma suspectedExtremity, abdominal, pelvic imaging if clinically indicatedEchocardiography if myocardial dysfunction present
  • Other TestsConsider electrocardiography if the patient has arrhythmias. Monitor the patient if rewarming is necessary, because dysrhythmias are common when rewarming patients who suffer cold-water immersion injuries.
  • Swan-Ganz catheter for monitoring cardiac output and related hemodynamic parameters may be useful in patients with unstable cardiovascular status or in those who require multiple inotropic and vasoactive medication requirements.
  • Labs & testschangesVery mild electrolyteModerate leukocytosisHct and Hgb usually normal initallyFresh water aspiration, the Hct may fall slightly in the first 24 hrs due to hemolysisIncrease in free Hgb without a change in Hct is commonDIC occasionallyABG – metabolic acidosis & hypoxemia
  • EKG-Sinus tachycardia & nonspecific ST-segment and T-wave changesReverts to normal within hoursOminous - ventricular arrhythmias, complete heart blockCXR-May be normal initially despite severe respiratory disturbancesPatchy infiltratesPulmonary edema
  • Management: necessary Bystander resuscitation CPR 30% pediatric cardiac arrest patients receive bystander CPR PUSH HARD, PUSH FAST Minimize interruptions Some bystander CPR, better than none Heimlich maneuver contraindicated because it can cause emesis, aspiration Rescue breaths at rates > 20 breaths/min contraindicated because venous return can be obstructed
  • Arrival to the hospital• General Assessment: • Appearance • Work of Breathing • Circulation• Primary Assessment: • Airway • Breathing • Circulation • Disability • Exposure Pediatric Advanced Life Support Provider Manual
  • Management ET intubation:  Cannot maintain PaO2 > 80 mm Hg on 100% O2 by face mask  Inability to protect airway or handle secretions  Respiratory failure - PaCO2 >45 mm Hg  Worsening ABG results Peep:  shifts interstitial pulmonary water into the capillaries  increases lung volume by preventing of alveolar collapse  provides better alveolar ventilation and decreases capillary blood flow
  • Management ECMO  If despite intubation, cannot oxygenateBroncoscopy  Removal of vomit, debris in lungsAlbuterol  For bronchospasmAspiration Pneumonia  Clindamycin for bacterial pneumonia is drug of choiceManage electrolyte abnormalities  hypoglycemia
  • Management of HypothermiaTwo types: 1. Rapid immersion in cold water, rapid onset of hypothermia, core temperature < 86 degrees F  Neuroprotective, preferential shunting of blood to heart, brain 2. Gradual onset of hypothermiaRapidly re-warm patients with gradual onset of hypothermia patients at risk for ventricular fibrillation and neuronal injury
  • Guidelines for treating cold-waterdrowning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.
  • ManagementDo not stop resuscitation of a patient until their core temperature is at least 30 degrees Celsius!
  • 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
  • Connpatients, the Conn classification system may beFor other classification system: used as a guideline to quantify the extent of cerebral hypoxia.Category A – AlertCategory B - Blunted consciousness; admit and observe for pulmonary compromise, which may result in hypoxemia and worsen CNS injuryCategory C - Comatose (C1 - decorticate, C2 - decerebrate, and C3 - flaccid [worse prognosis than C1])
  • PrognosisRelated to duration of submersion Time greater than 25 min, prognosis is poorIndicators of poor outcome: Fixed, dilated pupils Low GCS comaSurvivors of resuscitation have good neurological outcomes if they show purposeful movement within 24 hours
  • Prevention Designate a responsible adult to supervise water related activities Adults should not be doing other tasks at the same time as supervision, no alcohol while supervising Swim with a buddy No alcohol before, during swimming Learn to swim AAP does not recommend swimming lessons as a primary prevention method for children under 4 years old Learn CPRWater Injuries-Fact Sheet. www Accessed 25Sept 2009
  • PreventionFence swimming pools on 4 sides, at least 4 feet tallDo not use air or foam filled water toys in place of life-jackets