Near drowning


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  • N-methyl-D-aspartate A-3-hydroxy-5-methly-4-isoxazole propionate
  • New onset RAD, chronic lung sequela are rare
  • Near drowning

    1. 1. DR CH. HAREEN
    2. 2. Overview Definition Epidemiology Accidental vs. Non-accidental drowning Pathophysiology Management Prevention
    3. 3. 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 .
    4. 4. 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.
    5. 5. 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
    6. 6. 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.
    7. 7. 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
    8. 8. “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
    9. 9. “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
    10. 10. 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 .
    11. 11. 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)
    12. 12. 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
    13. 13. Hypoxic-Ischemic EncephalopathyInitial phase Energy failure from hypoxia/ischemiaReperfusion Injury 6-24 hours later Cerebral edema, apoptosis
    14. 14. 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
    15. 15. Complications of hypoxic-IschemicEncephalopathyAutonomic instability Hypertension Tachycardia Diaphoresis Agitation Muscle rigidity
    16. 16. 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
    17. 17. 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
    18. 18. DifferentialsChild Abuse & Neglect: Physical AbuseChild Abuse & Neglect: Sexual AbuseMunchausen Syndrome by Proxy
    19. 19. 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
    20. 20. Serum electrolytes (with glucose)Liver enzymes, especially aspartate aminotransferase and alanine aminotransferaseRenal function tests (BUN, creatinine)
    21. 21. 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)
    22. 22. 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
    23. 23. 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.
    24. 24. 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.
    25. 25. 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
    26. 26. 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
    27. 27. 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
    28. 28. Arrival to the hospital• General Assessment: • Appearance • Work of Breathing • Circulation• Primary Assessment: • Airway • Breathing • Circulation • Disability • Exposure Pediatric Advanced Life Support Provider Manual
    29. 29. 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
    30. 30. 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
    31. 31. 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
    32. 32. 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.
    33. 33. ManagementDo not stop resuscitation of a patient until their core temperature is at least 30 degrees Celsius!
    34. 34. 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
    35. 35. 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])
    36. 36. 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
    37. 37. 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
    38. 38. 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