Drowning by dr mahmoud zalam kfmc riyadh ksa
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it is a ppt about drowning in kids

it is a ppt about drowning in kids
etiology c/p diagnosis
risk factors complication
pathophysiology
management and how to prevent !!!!!!!

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  • In near drownings that involve falls, moving water, boating, and surfing accidents. Always take C-spine precautions
  • The Heimlich Maneuver is unproved in near drownings
  • Neurological deficit should not be assumed to be anoxic until C-spine Intracranial Injury Toxic encephalopathy Have been ruled out

Drowning by dr mahmoud zalam kfmc riyadh ksa Presentation Transcript

  • 1. Drowning DR MAHMOUD MOHAMED MAHMOUD
  • 2. Drowning
    • Objectives
      • Define drowning
      • Discuss
        • incidence
        • epidemiology
        • causes
      • Review prognostic indicators
      • Discuss therapeutic interventions
      • Discuss opportunities that impact outcome
  • 3. 2002 World Congress on Drowning
    • Drowning = process resulting in primary respiratory impairment from submersion/immersion in a liquid medium
    • Regardless of survival
    • Drowning without aspiration does not occur
    • Terms which are “out”
      • Dry, wet, active, silent, secondary, near-drowning
  • 4. Near Drowning
    • Definitions
    • Definitions were revised at 2002 World congress on Drowning in Amsterdam, Netherlands. They are now internationally accepted and more uniform
  • 5.  
  • 6. Drowning
  • 7. Statistics
    • 1995 data:
      • >1000 kids <14 years old drown
      • 60% <4 years old
    • 2000 CDC data:
      • 3,281 unintentional drownings in USA (adults & kids)
      • averaging 9 people/day - not including boating-related incidents 
    • 2003 CDC data:
      • For every child who drowns, 3 need ED care for non-fatal submersion injuries
      • >40% of these children require hospitalization
  • 8. EPIDEMIOLOGY
    • Freshwater drowning is more common than saltwater drowning, even in coastal areas
    • Places:lakes/rivers/canals/pools
    • Toddlers:
      • Any container of water can be responsible:
        • Buckets/fish tanks/washing machine/toilets/bathtub
  • 9. Morbidity & Mortality
    • 15% of children admitted for drowning die in the hospital
    • As many as 20% of drowning survivors suffer severe, permanent neurological disability
  • 10. Drowning modalities
    • Infants (age <1) - bathtubs, buckets & toilets
    • Children ages 1-4 years - swimming pools, hot tubs & spas
    • Children ages 5-14 years - swimming pools & open water sites
  • 11. Bucket drownings
    • ~500 children in the US since 1984
    • 7-15 months of age
    • 24 to 31 inches tall
    • Bucket may contain water or nasty cleaning fluid
  • 12. Tub drownings
    • Approximately 10% of childhood drownings
    • Typically lacking adult supervision
    • Do tub seats help?
  • 13. Baby swim classes
    • Done to “teach” babies to float
    • No reported drownings in class
    • Several reports of hyponatremic seizures following class (How was school today?)
    • False sense of security?
  • 14. Near Drowning Groups at Risk
    • Toddlers (40% of deaths < 5 y.o.)
    • School age boys
    • Teenagers
    • Males > females (5:1)
    • Children with:
      • seizures
      • cardiac dysrhythmias
  • 15. Near Drowning Risk Factors: Age
  • 16. Toddler Drownings
    • Tend to occur because of lapse in supervision
    • Majority in afternoon/early evening-meal time
    • Responsible supervising adult in 84% of cases
    • Only 18% of cases actually witnessed
  • 17. Causes of Near Drowning Recreational Boating
    • 90% of deaths due to drowning
    • 1,200/year
    • Small, open boats
    • 20% of deaths
      • too few or no floatation devices !
  • 18. Other Causes Diving Injuries
    • 700-800 per year
    • Peak incidence 18-31 years
      • No formal training
      • 1st dive in unfamiliar water
      • 40-50% alcohol related
  • 19. Other Causes Spas, Hot Tubs
    • Entrapment
      • drains
        • hair, body parts, clothing
      • winter pool/spa covers
  • 20. Near-Drowning Epilepsy
    • 2.5-4.6% of drowning victims had pre-existing seizure disorder
    • Drowned children with epilepsy more likely to: be older than 5, drown in bathtub, not be supervised
    • Relative risk of drowning for children with epilepsy:
      • 96 in bathtub (95% CI 33-275)
      • 23 in pool (95% CI 7.1-77.1)
  • 21. Near-Drowning Long QT Syndrome (LQTS)
    • Swimming may be a trigger for LQTS event
    • Near-drowning event may be first presentation of LQTS (15% of 1st LQTS syncopal events)
    • Gene-specific KVLQT1 mutation associated with swimming trigger and submersion event
    • Can test with cold water face immersion
    • Importance: early diagnosis of survivor, or of family members; consider with unexplained submersion
  • 22. Pathophysiology
  • 23. The event, part 1
    • Voluntary breath-holding
    • Aspiration of small amounts into larynx
    • Involuntary laryngospasm
    • Swallow large amounts
    • Laryngospasm abates (due to hypoxia)
    • Aspiration into lungs
  • 24. The event, part 2
    • Decrease in sats
    • Decrease in cardiac output
    • Intense peripheral vasoconstriction
    • Hypothermia
    • Bradycardia
    • Circulatory arrest, while VF rare
    • Extravascular fluid shifts, diuresis
  • 25. Pathophysiology with aspiration
    • Hypoxemia
      • Occurs whether or not patient aspirates
      • 85-90% aspirate
      • 10-15% DO NOT aspirate
  • 26. Pathophysiology with aspiration
    • Pulmonary Edema
      • Damage to Alveolar membrane
      • Damage to pulmonary microcirculation
  • 27. Pathophysiology without aspiration
    • Severe, persistent laryngospasm
    • Anoxic seizures
    • Death
  • 28. Pathophysiology
    • 3 Major metabolic abnormalities
      • Anoxia
      • Acidosis
      • Hypercapnia
  • 29. Pathogenesis 1
    • Asphyxia, hypoxemia, hypercarbia, & metabolic acidosis
    • Fresh water vs salt water - little difference (except for drowning in water with very high mineral content, like the Dead Sea)
    • Hypoxemia
      • Occlusion of airways with water & particulate debris
      • Changes in surfactant activity
      • Bronchospasm
      • Right-to-left shunting increased
      • Physiologic dead space increased
  • 30. Pathogenesis 2
    • Cardiac arrhythmias
    • Hypoxic encephalopathy
    • Renal insufficiency
    • Global brain anoxia & potential diffuse cerebral edema
  • 31. Salt vs Fresh There are REAL differences Salt vs Fresh
  • 32. Atelectasis Aspiration leads to collapse of the alveoli due to loss of surfactant and pulmonary edema normal alveoli surfactant collapsed alveoli
  • 33. Pulmonary Edema capillary Interstitial fluid shift Alveoli O 2 CO 2 Reduced perfussion O 2 CO 2
  • 34. Potential Fresh Water Damage
    • Hypoxia
    • Atelectasis
    • Pathogenic bacteria and impurities lethal
    • Produces greater long-term damage due to salt in pulmonary edema
  • 35. Drowning
    • Potential Salt Water Damage
      • Hypovolemia if large amounts swallowed
      • Hypertonic Elevation of Na, Cl and K, decrease blood volume
    • Salt water is 2 times as lethal
  • 36. Near Drowning Multi-Organ Effects
    • Hypoxic/ischemic cerebral injury
    • Fluid overload
    • Pulmonary injury
    • Hypothermia
  • 37. ASPHYXIA
    • Pulmonary System
    • 1. secondary apnea,
    • aspiration
    • 2. hypercapnea
    Central Nervous System 1. anoxic damage 2. defective autoregulation 3. cerebral edema 4. increased ICP Renal 1. acute tubular necrosis 2. acute cortical necrosis Cardiac 1. myocardial ischemia 2. fibrillation Asphyxia low BP
  • 38.
    • Hypothermia
    • CARDIAC
    • dysrhythm ia
    VASODILATION decreased ICP decreased BP CENTRAL NERVOUS 1. reduced metabolism 2. reduced ICP 3. ?protection? 4. may produce picture of clinical death DEATH RENAL FAILURE Rogers, Pediatric Critical Care
  • 39. WATER OVERLOAD
    • Pulmonary System
    • 1. alveolar fluid
    • 2. “ARDS”
    • 3. hypoventilation
    Central Nervous System 1. cerebral edema 2. intracranial hypertension Dilution Effects 1. hypokalemia 2. hemodilution 3. hemolysis Gastrointestinal 1. gastric distension 2. vomiting, aspiration 3. ileus Water Overload
  • 40. Near Drowning Multi-Organ Effects
    • Cerebral hypoxia is the final common pathway in all drowning victims
  • 41. Near Drowning CNS Injury
    • With significant hypoxia can have Lance-Adams syndrome
      • Post hypoxic (action) myoclonus
      • Often mistaken for seizures
      • Happens more often when coming out of sedation
      • Must be differentiated from myoclonic status which has poor prognosis
  • 42. Near Drowning Pulmonary Injury
    • Aspiration as little as 1-3 cc/kg can cause significant effect on gas exchange
      • Increased permeability
      • Exudation of proteinaceous material in alveoli
      • Pulmonary edema
      • decreased compliance
  • 43. Near Drowning Pulmonary Injury: Fresh Water vs. Salt Water
    • Theoretical changes not supported clinically
      • Salt water: hypertonic pulmonary edema
      • Fresh water: plasma hypervolemia, hyponatremia
      • Unless in Dead Sea
    • Humans (most aspirate 3-4cc/kg)
      • Aspirate > 20cc/ kg before significant electrolyte changes
      • Aspirate > 11cc/kg before fluid changes
  • 44. The Bottom Line Fresh Water and Salt Water
    • Both forms wash out surfactant
    • Damaged alveolar basement membrane
      • Pulmonary edema
      • ARDS
  • 45. Labs & tests
    • Very mild electrolyte changes
    • 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
  • 46. Essential First Aid Management
    • Conscious Unconscious
    • Evaluate for CPR (prolonged)
    • Aspiration 100% oxygen
    • NO YES
    • Observe 100% oxygen transfer to hospital
  • 47. Treatment Transport
    • Continue CPR
    • Establish airway
    • Remove wet clothes
    • Hospital evaluation
  • 48. Immediate hospital management
    • Assess and manage ABC
    • 100% oxygen
    • Pulse oximetry (watch for false readings caused by peripheral shutdown and acidosis)
    • ABGs, FBC, U&E
    • CXR
    • Observation
    • Management of associated hypothermia
  • 49. Treatment Emergency Department
    • Continue established therapies
    • History, physical, labs
    • Admit if: CNS or respiratory symptoms
    • Observe in ED for minimum 4-6 hours if:
      • Submersion > 1 min.
      • Cyanosis on extraction
      • CPR required
  • 50. Predicting Ability for ED Discharge
    • Several studies support selected ED discharge
    • Child can safely be discharged home if at 6 hours after ED presentation:
      • GCS > 13
      • Normal physical exam/respiratory effort
      • Room air pulse oximetry oxygen saturation > 95%
  • 51. The problem with looking well
    • Aspiration of water can cause late complications:
    • Neurogenic pulmonary oedema, Pneumonia, SIRS, DIC, Haemolysis, Hepatic & renal failure, bowel necrosis
    • Plus complications of hypothermia
  • 52. ICU Management Strategies Intubation/Ventilation
    • SpO 2 < 90% on FIO 2 > 0.6
    • PaCO 2 > 50 with pH < 7.3
    • Increased work of breathing
    • Abnormal CNS exam
    Indications
  • 53. ICU Management Strategies Respiratory
    • Oxygenate - avoid hypoxemia
    • Ventilate - avoid significant hyperventilation
    • PEEP may be beneficial but is not prophylactic
    • Exogenous surfactant
  • 54. Management Strategies Cardiovascular
    • Re-warming ( to a degree ? benefit hypothermia)
      • LOC 34 C
      • Pupils dialate 30 C
      • V Fib 28 C
      • EEG iso-electric 20C
    • CBF decrease 6-7% per degree C drop
  • 55. Management Strategies Central Nervous System
    • Protect against 2 0 injury
      • Perfuse it or lose it !!
    • ICP monitoring not beneficial or recommended
    • Some still monitor if:
      • Successful CPR followed by coma
      • Sudden, unexplaind deterioration
  • 56. Management Strategies Central Nervous System
    • ICP monitoring may not change outcome, just predict it
    • Low ICP Better outcome
    • High ICP Poor outcome
  • 57. ICU Management Strategies
    • Antibiotics - no benefit of prophylaxis, may increase super-infection
    • Fulminant Strep pneumoniae sepsis has been described after severe submersion
    • Steroids - no demonstrated benefit
    Other Issues
  • 58. SURVIVE OR NOT SURVIVE OR NOT
  • 59. Will the child die?
  • 60. Bad prognostic indicators
    • Submerged >10 min
    • Time till BLS >10 min
    • CPR >25 min
    • Initial GCS <5
    Age <3 years CPR in ER Initial ABG pH <7.1 Initial core temp <33o
  • 61. Neurologic prognosis
    • Absence of spontaneous respiration is an ominous sign associated with severe neurologic sequelae
    • Permanent neurologic sequelae persist in ~20% of victims who present comatose
      • Minimal brain dysfunction, spastic quadriplegia, extrapyramidal syndromes, optic and cerebral atrophy, and peripheral neuromuscular damage
  • 62. Near Drowning The Best Approach Therefore:
    • P revention !
    • P revention !
    • P revention !
  • 63. Near Drowning Keeping Your Child Safe
    • Never leave a child alone in or near water, even for a minute
    • Limit pool access.
    • Remove potential hazards
  • 64. Children with Epilepsy: Safety Recommendations
    • Child can swim in lifeguard-supervised swimming pool - no open water
    • Older child should shower in a non-glass cubicle - no bath
    • Leave bathroom unlocked
    • Supervision!
  • 65. Near Drowning Swimming Pool Lore
    • My Child is “Water Safe” because he/she has taken swimming lessons .
  • 66. Near Drowning Keeping Your Child Safe
    • Learn CPR
    • Use approved personal flotation devices
    • Teach safe water behavior
  • 67. Recommendations
    • Pre-hospital resuscitation, including early intubation, ventilation, vascular access, and administration of advanced life support medications
    • Continued resuscitation and stabilization in the ED
  • 68. Recommendations
    • Full supportive care in the ICU for a minimum of 48 hrs
    • Consider withdrawal of support if no neurologic improvement is detected after 48 hours
      • Ancillary testing such as brainstem evoked responses, EEG, and MRI (not CT) may prove helpful to corroborate the neurologic examination
  • 69.  
  • 70.