ICU Treatment ofDrowning Injuries  Andrew Schmidt, DO, MPH    Emergency Medicine
Drowning• Standard definition developed by the World  Congress on Drowning in 2002 -   The process of experiencing respirat...
Drowning• Terms such as “near”, “secondary”, “active/  passive” drowning should be avoided• It is imperative to have every...
Pathophysiology• The bottom line - There are many ways in which a patient can      drown  -   The final common pathway is a...
Physiologic Effects
Salt Water                      Fresh Water Hypertonic                       Hypotonicfluid in alveloi                  flui...
Salt Water                      Fresh Water Hypertonic                       Hypotonicfluid in alveloi                  flui...
Pulmonary               ShuntDecreased      Arterial      Decreased Volume        Hypoxa         Output              Cereb...
Pulmonary               ShuntDecreased      Arterial      Decreased Volume        Hypoxa         Output              Cereb...
Cardiac Effects• Most important cardiac effects are  arrhythmias, most often V-fib -   Most likely due to a mix of hypoxia,...
Cardiac Effects• Cold water submersion - May lead to myocardial irritability and      conduction abnormalities  -   Freque...
Volume effects• Significant volumes of aspirated water may  cause hypovolemia secondary to pulmonary  edema• This can be ex...
Decreased      Arterial      Decreased Volume        Hypoxa         Output              Cerebral              Hypoxia     ...
Decreased      Arterial      Decreased Volume        Hypoxa         Output              Cerebral              Hypoxia     ...
Decreased      Arterial      Decreased Volume        Hypoxa         Output              Cerebral              Hypoxia     ...
ICU Treatment
ICU treatment• Two priorities - Ventilatory support     • Restore more normal FRC     • Restore more normal V/Q ratio -   ...
Ventilatory Support• Non-invasive positive pressure ventilation - PaO2/FiO2 ratio < 200 - RR > 24 - Dyspnea - Conscious pt...
Ventilatory Support• Invasive Mechanical Ventilation - NPPV fails to correct gas exchange - Comatose pts or those with sev...
Aspiration• Along with water, patients may also aspirate  debris and stomach contents  -   Theoretical risk of aspiration ...
Circulatory Support• Large aspiration of water may lead to  significant fluid shifts leading to hypotension• Animal models s...
Neurological Support• Mild hyperventilation to maintain PCO2  30-35 may reduce ICP• Increase head of bed if no C-spine inj...
Hypothermia• CAN HAPPEN IN FLORIDA• Heat conducted much easier through water• Depends on water temp, time of exposure,  cl...
Hypothermia• Depressed deep body temps can have  varying effects on physiology (rough  estimates) -   35 C: AMS -   33 C: ...
Hypothermia• Below deep body temp of 28 C - Fluid shifts out of vasculature - Depressed renal function, augmented     diur...
Hypothermia• Treatment strategies - Passive external rewarming (insulate) - Warm fluids - Radiant heating - Forced air rewa...
Prognosis• Many theorized and tested prognostic  systems, but none have been universally  accepted• ICU admission characte...
Prognosis• Other indicators of poor prognosis - Duration of submersion >10 minutes - Time to effective BLS >10 minutes - R...
That’s all
ICU Treatment of Drowning Injuries
ICU Treatment of Drowning Injuries
ICU Treatment of Drowning Injuries
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ICU Treatment of Drowning Injuries

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ICU Treatment of Drowning Injuries

  1. 1. ICU Treatment ofDrowning Injuries Andrew Schmidt, DO, MPH Emergency Medicine
  2. 2. Drowning• Standard definition developed by the World Congress on Drowning in 2002 - The process of experiencing respiratory impairment due to submersion or immersion in liquid. - 3 outcomes • Morbidity • No morbidity • Mortality
  3. 3. Drowning• Terms such as “near”, “secondary”, “active/ passive” drowning should be avoided• It is imperative to have everyone speaking the same language - Sempsrott, Slattery, Schmidt, Penalize, Crittle. Systematic Review Of Non-Utstein Style Drowning Terms. • 47.3% of papers since standard definition use improper terms (97% “near drowning”)
  4. 4. Pathophysiology• The bottom line - There are many ways in which a patient can drown - The final common pathway is always the same no matter the cause - Ventilation-perfusion mismatch with right to left shunt to inhalation of water
  5. 5. Physiologic Effects
  6. 6. Salt Water Fresh Water Hypertonic Hypotonicfluid in alveloi fluid in alveoli Increased Efflux of fluid capillary perm to capillary Influx of Surfactantcapillary fluid disruption Pulmonary Shunt
  7. 7. Salt Water Fresh Water Hypertonic Hypotonicfluid in alveloi fluid in alveoli Increased Efflux of fluid capillary perm to capillary Influx of Surfactantcapillary fluid disruption Pulmonary Shunt
  8. 8. Pulmonary ShuntDecreased Arterial Decreased Volume Hypoxa Output Cerebral Hypoxia Ischemic Brain Injury
  9. 9. Pulmonary ShuntDecreased Arterial Decreased Volume Hypoxa Output Cerebral Hypoxia Ischemic Brain Injury
  10. 10. Cardiac Effects• Most important cardiac effects are arrhythmias, most often V-fib - Most likely due to a mix of hypoxia, acidosis, and catecholamine surge - Human studies have not uncovered significant electrolyte imbalances • Exceptions are those who drowned in The Dead Sea
  11. 11. Cardiac Effects• Cold water submersion - May lead to myocardial irritability and conduction abnormalities - Frequently associated with J-wave - Vulnerability to V-Fib is increased - Hypothermic heart is relatively unresponsive to both electrical and pharmacological interventions
  12. 12. Volume effects• Significant volumes of aspirated water may cause hypovolemia secondary to pulmonary edema• This can be exacerbated by cold water diuresis• Hypovolemia combined with rhabdomyolysis may lead to acute renal failure
  13. 13. Decreased Arterial Decreased Volume Hypoxa Output Cerebral Hypoxia Ischemic Brain Injury
  14. 14. Decreased Arterial Decreased Volume Hypoxa Output Cerebral Hypoxia Ischemic Brain Injury
  15. 15. Decreased Arterial Decreased Volume Hypoxa Output Cerebral Hypoxia Ischemic Brain Injury
  16. 16. ICU Treatment
  17. 17. ICU treatment• Two priorities - Ventilatory support • Restore more normal FRC • Restore more normal V/Q ratio - Circulatory support • Restore adequate oxygen delivery to tissues
  18. 18. Ventilatory Support• Non-invasive positive pressure ventilation - PaO2/FiO2 ratio < 200 - RR > 24 - Dyspnea - Conscious pt, good airway reflexes, and mild gas exchange
  19. 19. Ventilatory Support• Invasive Mechanical Ventilation - NPPV fails to correct gas exchange - Comatose pts or those with severe gas exchange impairment
  20. 20. Aspiration• Along with water, patients may also aspirate debris and stomach contents - Theoretical risk of aspiration pneumonitis and pneumonia - No evidence supporting empiric antibiotics, but threshold for treatment should be low - Very little evidence supporting the administration of steroids
  21. 21. Circulatory Support• Large aspiration of water may lead to significant fluid shifts leading to hypotension• Animal models show benefits of fludis - Mechanical ventilation or inotropes alone fail to adequate resuscitate patients• Monitor hemodynamics closely in critical patients - CVP, pulmonary artery pressure
  22. 22. Neurological Support• Mild hyperventilation to maintain PCO2 30-35 may reduce ICP• Increase head of bed if no C-spine injury• Seizure prophylaxis, Phenytoin preferred• Maintain euglycemia• Evidence for therapeutic hypothermia still inconclusive
  23. 23. Hypothermia• CAN HAPPEN IN FLORIDA• Heat conducted much easier through water• Depends on water temp, time of exposure, clothing type, prehospital care, age, and underlying health of patient
  24. 24. Hypothermia• Depressed deep body temps can have varying effects on physiology (rough estimates) - 35 C: AMS - 33 C: Arrhythmias - 30 C: LOC - 28 C:V-Fib - 25 C: Cardiac arrest
  25. 25. Hypothermia• Below deep body temp of 28 C - Fluid shifts out of vasculature - Depressed renal function, augmented diuresis - Impaired hepatic metabolism - Impaired ion channel regulation - Decreased GI smooth muscle motility - Insulin dependent glucose transport ceases
  26. 26. Hypothermia• Treatment strategies - Passive external rewarming (insulate) - Warm fluids - Radiant heating - Forced air rewarming - Extracorporeal blood rewarming• Unless hypothermic treatment encourage by facility, maintain normothermia
  27. 27. Prognosis• Many theorized and tested prognostic systems, but none have been universally accepted• ICU admission characteristics found to be predictive of poor outcome - GCS < 5 and lack of pupillary response - Highlights important role of brain hypoxia• Others: Age, sex, duration, APACHE II
  28. 28. Prognosis• Other indicators of poor prognosis - Duration of submersion >10 minutes - Time to effective BLS >10 minutes - Resuscitation duration >25 minutes - Water temperature >10ºC (50ºF) - Age <3 years - Persistent apnea and CPR in ED - Arterial pH < 7.1 upon presentation
  29. 29. That’s all

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