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Drowning

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drowning

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Drowning

  1. 1. DROWNING DR NIRAV DHINOJA
  2. 2. DEFINITION • “DROWNING IS THE PROCESS OF EXPERIENCING RESPIRATORY IMPAIRMENT FROM SUBMERSION/IMMERSION IN LIQUID.” • THE TERM DROWNING DOES NOT IMPLY THE FINAL OUTCOME, DEATH OR SURVIVAL; THE OUTCOME SHOULD BE DENOTED AS FATAL OR NONFATAL DROWNING. • USE OF CONFUSING DESCRIPTIVE TERMS SUCH AS “NEAR,” “WET,” “DRY,” “SECONDARY,” “SILENT,” “PASSIVE,” AND “ACTIVE” SHOULD
  3. 3. EPIDEMIOLOGY • HIGHEST DROWNING DEATH RATES WERE SEEN IN CHILDREN AGED 1-4 YR AND 15-19 YR. • IN CHILDREN, DROWNING IS SECOND ONLY TO MOTOR VEHICLE INJURY AS A LEADING CAUSE OF DEATH FROM UNINTENTIONAL INJURY. • CHILDREN YOUNGER THAN 1 YR : • BATHTUB(71%) • HOUSEHOLD BUCKETS(16%) • CHILDREN 1-4 YR : • POOL • IRRIGATION DITCHES • NEARBY PONDS & RIVERS.
  4. 4. • SCHOOL AGE CHILDREN • SWIMMING OR BOATING ACTIVITIES. • NATURAL WATER RESERVOIRS : LAKES, PONDS, RIVERS, CANALS. • ADOLESCENT • M : F = 10 : 1. (LIKELY DUE TO GREATER RISK TAKING BEHAVIOUR & ALCOHOL USE.) • 70 % DEATHS DUE TO DROWNING IN NATURAL WATER RESERVOIRS. • UNDERLYING CONDITIONS • EPILEPSY • LONG QT SYNDROME • VENTRICULAR ARRHYTHMIAS • ALCOHOL USE • WATER SPORTS & RECREATIONAL ACTIVITIES
  5. 5. PATHOPHYSIOLOGY • MOST OF DROWNING VICTIMS DROWN SILENTLY. • VOCALIZATION IS PRECLUDED BY EFFORTS TO ACHIEVE MAXIMAL LUNG VOLUME OR KEEP THE HEAD ABOVE THE WATER, OR BY ASPIRATION LEADING TO LARYNGOSPASM. • YOUNG CHILDREN CAN STRUGGLE FOR ONLY 10-20 SEC BEFORE BEING FINALLY SUBMERGED. • GLOBAL HYPOXIA IS THE INJURY, WITH THE SEVERITY OF INJURY DEPENDENT
  6. 6. ANOXIC-ISCHEMIC INJURY Small amounts of water enter the hypopharynx, triggering laryngospasm Progressive decrease in arterial blood oxygen saturation (Sao2), and the victim soon loses consciousness from hypoxia Profound hypoxia and medullary depression lead to terminal apnea The cardiovascular response leads to progressively decreasing cardiac output and oxygen delivery. By 3-4 min, the circulation abruptly fails because of myocardial hypoxia
  7. 7. Ineffective cardiac contractions with electrical activity may occur briefly, but there is no effective perfusion (pulseless electrical activity). Several hours after cardiopulmonary arrest, cerebral edema may occur.. Severe cerebral edema can elevate intracranial pressure (ICP), contributing to further ischemia. Intracranial hypertension is an ominous sign of profound CNS damage.
  8. 8. EFFECT OF HYPOXIC-ISCHEMIC INJURY ON OTHER SYSTEM • LUNG : • ASPIRATION LEADS TO DAMAGE TO THE PULMONARY VASCULAR ENDOTHELIUM RESULTS IN ARDS. • HEART : • MYOCARDIAL DYSFUNCTION. • ARTERIAL HYPOTENSION. • DECREASED CARDIAC OUTPUT. • ARRHYTHMIAS & CARDIAC INFARCTION. • RENAL : • ACUTE TUBULAR NECROSIS, CORTICAL NECROSIS, AND RENAL FAILURE. • VASCULAR ENDOTHELIAL INJURY MAY INITIATE DIC, HEMOLYSIS, AND THROMBOCYTOPENIA. • GASTROINTESTINAL DAMAGE : • BLOODY DIARRHEA WITH MUCOSAL SLOUGHING. • SERUM LEVELS OF HEPATIC TRANSAMINASES AND PANCREATIC ENZYMES ARE OFTEN ACUTELY INCREASED. • VIOLATION OF NORMAL MUCOSAL PROTECTIVE BARRIERS PREDISPOSES THE VICTIM TO BACTEREMIA AND
  9. 9. PULMONARY INJURY • IN HUMANS, ASPIRATION OF SMALL AMOUNTS (1-3 ML/KG) CAN LEAD TO MARKED HYPOXEMIA AND A 10-40% REDUCTION IN LUNG COMPLIANCE. • ASPIRATED WATER DOES NOT OBSTRUCT AIRWAYS AND IS READILY MOVED INTO THE PULMONARY CIRCULATION WITH POSITIVE PRESSURE VENTILATION. • IT CAN WASH OUT SURFACTANT AND CAUSE ALVEOLAR INSTABILITY, VENTILATION-PERFUSION MISMATCH, AND INTRAPULMONARY SHUNTING.
  10. 10. PULMONARY INJURY • THE COMPOSITION OF ASPIRATED MATERIAL CAN AFFECT THE PATIENT’S CLINICAL COURSE: • GASTRIC CONTENTS, PATHOGENIC ORGANISMS, TOXIC CHEMICALS, AND OTHER FOREIGN MATTER CAN INJURE THE LUNG OR CAUSE AIRWAY OBSTRUCTION. • CLINICAL MANAGEMENT IS NOT SIGNIFICANTLY DIFFERENT IN SALTWATER AND FRESHWATER ASPIRATIONS, BECAUSE MOST
  11. 11. HYPOTHERMIA • ACCORDING TO CORE BODY TEMPERATURE MEASUREMENT : • MILD (34-36°C). • MODERATE (30-34°C). • SEVERE (<30°C). • DROWNING SHOULD BE DIFFERENTIATED FROM COLD WATER IMMERSION INJURY, IN WHICH THE VICTIM REMAINS AFLOAT, KEEPING THE HEAD ABOVE WATER WITHOUT RESPIRATORY IMPAIRMENT. • THE DEFINITION OF COLD WATER VARIES FROM 60 TO 70°F.
  12. 12. • HEAT LOSS THROUGH CONDUCTION AND CONVECTION IS MORE EFFICIENT IN WATER THAN IN AIR. • IF THE WATER IS COOL, HEAT PRODUCTION CANNOT BE MATCHED BY THE BODY’S THERMOGENIC MECHANISMS. • CHILDREN ARE AT INCREASED RISK FOR HYPOTHERMIA BECAUSE : • RELATIVELY HIGH RATIO OF BODY SURFACE AREA TO MASS. • DECREASED SUBCUTANEOUS FAT. • LIMITED THERMOGENIC CAPACITY. • HYPOTHERMIA MAY DEVELOP MORE QUICKLY WITH IMMERSION IN FAST-FLOWING WATER AS A RESULT OF INCREASED CONVECTION.
  13. 13. • AS CORE TEMPERATURE DROPS TO <35°C, COGNITION, COORDINATION, AND MUSCLE STRENGTH BECOME PROGRESSIVELY IMPAIRED. • WITH PROGRESSIVE HYPOTHERMIA, THERE MAY BE LOSS OF CONSCIOUSNESS, WATER ASPIRATION, DECREASES IN HEART RATE AND CARDIAC OUTPUT, INEFFECTIVE BREATHING, AND CARDIAC ARREST. • IMMEDIATE EFFECTS OF COLD WATER IMMERSION ARE RESPIRATORY AND CARDIOVASCULAR.
  14. 14. • AFTER THE CHILD IS REMOVED FROM THE WATER, BODY TEMPERATURE MAY CONTINUE TO FALL AS A RESULT OF COLD AIR, WET CLOTHES, HYPOXIA, AND HOSPITAL TRANSPORT. • HYPOTHERMIA IN PEDIATRIC DROWNING VICTIMS IS OBSERVED EVEN AFTER DROWNING IN RELATIVELY WARM WATER AND IN WARM CLIMATES. • UNRECOGNIZED PROGRESSIVE HYPOTHERMIA CAN LEAD TO FURTHER DECOMPENSATION.
  15. 15. • IN HYPOTHERMIC VICTIMS, COMPENSATORY MECHANISMS USUALLY ATTEMPT TO RESTORE NORMOTHERMIA AT BODY TEMPERATURES >32°C; AT LOWER TEMPERATURES, THERMOREGULATION MAY FAIL AND SPONTANEOUS REWARMING WILL NOT OCCUR. • WITH MODERATE TO SEVERE HYPOTHERMIA, PROGRESSIVE BRADYCARDIA, IMPAIRED MYOCARDIAL CONTRACTILITY, AND LOSS OF VASOMOTOR TONE CONTRIBUTE TO INADEQUATE PERFUSION, HYPOTENSION, AND POSSIBLE SHOCK. • AT BODY TEMPERATURE <28°C, EXTREME BRADYCARDIA IS USUALLY PRESENT, AND THE PROPENSITY FOR SPONTANEOUS VENTRICULAR FIBRILLATION (VF) OR ASYSTOLE IS HIGH. • CENTRAL RESPIRATORY CENTER DEPRESSION WITH MODERATE TO SEVERE HYPOTHERMIA RESULTS IN HYPOVENTILATION AND EVENTUAL APNEA.
  16. 16. COLD WATER SHOCK • IN HUMAN ADULTS, IMMERSION IN ICY WATER RESULTS IN INTENSE INVOLUNTARY REFLEX HYPERVENTILATION AND TO A DECREASE IN BREATH-HOLDING ABILITY TO <10 SECONDS, WHICH LEADS TO FLUID ASPIRATION, CONTRIBUTING TO MORE RAPID AND DEEP HYPOTHERMIA. • SEVERE BRADYCARDIA OCCURS IN ADULTS BUT IS TRANSIENT AND RAPIDLY FOLLOWED BY SUPRAVENTRICULAR AND ECTOPIC TACHYCARDIAS AND HYPERTENSION.
  17. 17. NEUROPROTECTION AND HYPOTHERMIA • IT MAY BE POSSIBLE FOR THE BRAIN TO RAPIDLY COOL TO A NEUROPROTECTIVE LEVEL, IF THE WATER IS COLD ENOUGH, THE COOLING PROCESS IS QUICK, AND CARDIAC OUTPUT LASTS LONG ENOUGH FOR SUFFICIENT HEAT EXCHANGE TO OCCUR. • ONCE SUBMERSION-ASSOCIATED HYPOXIA, APNEA, AND CARDIOVASCULAR COMPROMISE DECREASE BLOOD CIRCULATION, THE EFFECT OF HYPOTHERMIA’S NEUROPROTECTION IS MITIGATED.
  18. 18. MANAGEMENT • PRE-HOSPITAL MANAGEMENT • HOSPITAL BASED MANAGEMENT • CARDIORESPIRATORY • NEUROLOGICAL • HYPOTHERMIA • OTHER
  19. 19. PRE-HOSPITAL MANAGEMENT • THE GOAL IS TO REVERSE THE ANOXIA FROM SUBMERSION AND PREVENT SECONDARY HYPOXIC INJURY AFTER SUBMERSION. • INITIAL RESUSCITATION MUST FOCUS ON RAPIDLY RESTORING OXYGENATION, VENTILATION, AND ADEQUATE CIRCULATION. • THE AIRWAY SHOULD BE CLEAR OF VOMITUS AND FOREIGN MATERIAL, WHICH MAY CAUSE OBSTRUCTION OR ASPIRATION. • ABDOMINAL THRUSTS SHOULD NOT BE USED FOR FLUID REMOVAL, BECAUSE MANY VICTIMS HAVE A DISTENDED ABDOMEN FROM SWALLOWED WATER; ABDOMINAL THRUSTS MAY INCREASE THE RISK OF REGURGITATION AND ASPIRATION.
  20. 20. • THE CERVICAL SPINE SHOULD BE PROTECTED IN ANYONE WITH POTENTIAL TRAUMATIC NECK INJURY. • THE NECK SHOULD BE MAINTAINED IN A NEUTRAL POSITION AND PROTECTED WITH A WELL-FITTING CERVICAL COLLAR. • IF THE VICTIM HAS INEFFECTIVE RESPIRATION OR APNEA, VENTILATORY SUPPORT MUST BE INITIATED IMMEDIATELY(MOUTH-TO- MOUTH OR MOUTH-TO-NOSE BREATHING). • AS SOON AS IT IS AVAILABLE, SUPPLEMENTAL OXYGEN SHOULD BE ADMINISTERED TO ALL VICTIMS.
  21. 21. • POSITIVE PRESSURE BAG-MASK VENTILATION WITH 100% INSPIRED OXYGEN SHOULD BE INSTITUTED IN PATIENTS WITH RESPIRATORY INSUFFICIENCY. • IF APNEA, CYANOSIS, HYPOVENTILATION, OR LABORED RESPIRATION PERSISTS, TRAINED PERSONNEL SHOULD PERFORM ET INTUBATION AS SOON AS POSSIBLE. • INTUBATION IS ALSO INDICATED TO PROTECT THE AIRWAY IN PATIENTS WITH DEPRESSED MENTAL STATUS OR HEMODYNAMIC INSTABILITY. • HYPOXIA MUST BE CORRECTED RAPIDLY TO OPTIMIZE THE CHANCE OF RECOVERY.
  22. 22. • SLOW CAPILLARY REFILL, COOL EXTREMITIES, AND ALTERED MENTAL STATUS ARE POTENTIAL INDICATORS OF SHOCK. • HEART RATE AND RHYTHM, BLOOD PRESSURE, TEMPERATURE, AND END-ORGAN PERFUSION REQUIRE URGENT ASSESSMENT. • CONTINUOUS MONITORING OF THE ECG ALLOWS APPROPRIATE DIAGNOSIS AND TREATMENT OF ARRHYTHMIAS.
  23. 23. • CPR SHOULD BE INSTITUTED IMMEDIATELY IN PULSELESS, BRADYCARDIC, OR SEVERELY HYPOTENSIVE VICTIMS. • IV FLUIDS AND CARDIOACTIVE MEDICATIONS ARE REQUIRED TO IMPROVE CIRCULATION AND PERFUSION. • EPINEPHRINE IS USUALLY THE INITIAL DRUG OF CHOICE IN VICTIMS WITH CARDIOPULMONARY ARREST.
  24. 24. HOSPITAL BASED MANAGEMENT • PEDIATRIC DROWNING VICTIMS SHOULD BE OBSERVED FOR AT LEAST 6-8 HR, EVEN IF THEY ARE ASYMPTOMATIC ON PRESENTATION. • SERIAL MONITORING OF VITAL SIGNS AND REPEATED PULMONARY EXAMINATION, AND NEUROLOGIC ASSESSMENT SHOULD BE PERFORMED IN ALL DROWNING VICTIMS. • MOST ALERT CHILDREN WITH EARLY RESPIRATORY SYMPTOMS RESPOND TO OXYGEN AND, DESPITE ABNORMAL INITIAL RADIOGRAPHS, BECOME ASYMPTOMATIC WITH A RETURN OF NORMAL ROOM AIR SAO2 AND PULMONARY EXAMINATION BY 4-6 HR. • SUBSEQUENT DELAYED RESPIRATORY DETERIORATION IS EXTREMELY UNLIKELY IN SUCH CHILDREN. • SELECTED LOW- RISK PATIENTS WHO ARE ALERT AND ASYMPTOMATIC WITH NORMAL PHYSICAL FINDINGS AND OXYGENATION LEVELS MAY BE CONSIDERED
  25. 25. CARDIORESPIRATORY MANAGEMENT • ADEQUATE OXYGENATION AND VENTILATION IS A PRE-REQUISITE TO IMPROVING MYOCARDIAL FUNCTION. • FLUID RESUSCITATION AND INOTROPIC AGENTS ARE OFTEN NECESSARY TO IMPROVE HEART FUNCTION AND RESTORE TISSUE PERFUSION. • FOR PATIENTS WITH PERSISTENT CARDIOPULMONARY ARREST ON ARRIVAL AFTER NON–ICY WATER DROWNING, THE DECISION TO WITHHOLD OR STOP RESUSCITATIVE EFFORTS CAN BE ADDRESSED BY REVIEW OF THE HISTORY AND THE RESPONSE TO TREATMENT. • DEATH OR SEVERE NEUROLOGIC SEQUELAE ARE QUITE LIKELY IN PATIENTS WITH • DEEP COMA. • APNEA. • ABSENCE OF PUPILLARY RESPONSES. • HYPERGLYCEMIA. • SUBMERSION DURATIONS >10 MIN. • FAILURE OF RESPONSE TO CPR GIVEN FOR 25 MIN.
  26. 26. NEUROLOGICAL MANAGEMENT • DROWNING VICTIMS WHO PRESENT TO THE HOSPITAL AWAKE AND ALERT USUALLY HAVE NORMAL NEUROLOGIC OUTCOMES. • COMATOSE DROWNING PATIENTS ARE AT RISK FOR INTRACRANIAL HYPERTENSION. • ICP MONITORING AND THERAPY TO REDUCE INTRACRANIAL HYPERTENSION WOULD SEEM LIKELY TO PRESERVE CEREBRAL PERFUSION AND PREVENT HERNIATION, BUT THERE IS LITTLE EVIDENCE THAT THESE MEASURES IMPROVE OUTCOMES FOR DROWNING VICTIMS. • CONVENTIONAL NEUROLOGIC INTENSIVE CARE THERAPIES, SUCH AS FLUID RESTRICTION, HYPERVENTILATION, AND ADMINISTRATION OF MUSCLE RELAXANTS, OSMOTIC AGENTS, DIURETICS, BARBITURATES, AND STEROIDS, HAVE NOT BEEN SHOWN TO BENEFIT THE DROWNING VICTIM, EITHER INDIVIDUALLY OR IN COMBINATION.
  27. 27. • EEG MONITORING HAS ONLY LIMITED VALUE IN THE MANAGEMENT AND IS GENERALLY NOT RECOMMENDED, EXCEPT TO DETECT SEIZURES OR AS AN ADJUNCT IN THE CLINICAL EVALUATION OF BRAIN DEATH. • SEIZURES SHOULD BE TREATED IF POSSIBLE, ALTHOUGH THEY TEND TO BE VERY REFRACTORY. • THERE IS NO EVIDENCE THAT TREATMENT OF SEIZURES AFTER DROWNING IMPROVES OUTCOME. • FOSPHENYTOIN OR PHENYTOIN LOADING DOSE FOLLOWED BY MAINTENANCE DOSING MAY BE CONSIDERED.IT MAY HAVE SOME NEUROPROTECTIVE EFFECTS AND MAY MITIGATE NEUROGENIC PULMONARY EDEMA.
  28. 28. • WITH OPTIMAL MANAGEMENT, MANY INITIALLY COMATOSE CHILDREN CAN HAVE IMPRESSIVE NEUROLOGIC IMPROVEMENT, BUT USUALLY DO SO WITHIN THE 1ST 24-72 HR. • ALMOST HALF OF DEEPLY COMATOSE DROWNING VICTIMS ADMITTED TO THE PICU DIE OF THEIR HYPOXIC BRAIN INJURY OR SURVIVE WITH SEVERE NEUROLOGIC DAMAGE. • MANY CHILDREN BECOME BRAIN DEAD. • DEEPLY COMATOSE DROWNING VICTIMS WHO DO NOT SHOW SUBSTANTIAL IMPROVEMENT ON NEUROLOGIC EXAMINATION AFTER 24-72 HR AND WHOSE COMA CANNOT BE OTHERWISE EXPLAINED SHOULD BE SERIOUSLY CONSIDERED FOR WITHDRAWAL OF SUPPORT.
  29. 29. HYPOTHERMIA MANAGEMENT • DAMP CLOTHING SHOULD BE REMOVED FROM ALL DROWNING VICTIMS. • THE GOAL IS TO PREVENT OR TREAT MODERATE OR SEVERE HYPOTHERMIA. • REWARMING MEASURES ARE GENERALLY CATEGORIZED AS PASSIVE, ACTIVE EXTERNAL, OR ACTIVE INTERNAL. • PASSIVE REWARMING MEASURES CAN BE APPLIED IN THE PRE-HOSPITAL OR HOSPITAL SETTING. • THEY INCLUDE THE PROVISION OF DRY BLANKETS, A WARM ENVIRONMENT, AND PROTECTION FROM FURTHER HEAT LOSS. • REWARMING MEASURES SHOULD BE INSTITUTED AS SOON AS POSSIBLE FOR HYPOTHERMIC DROWNING VICTIMS WHO HAVE NOT HAD A CARDIAC ARREST.
  30. 30. • FULL CPR WITH CHEST COMPRESSIONS IS INDICATED FOR HYPOTHERMIC VICTIMS IF NO PULSE CAN BE FOUND OR IF NARROW COMPLEX QRS ACTIVITY IS ABSENT ON ECG. • WHEN VF IS PRESENT IN SEVERELY HYPOTHERMIC VICTIMS (CORE TEMPERATURE <30°C), UP TO 3 DEFIBRILLATION ATTEMPTS SHOULD INITIALLY BE DELIVERED, BUT FURTHER DEFIBRILLATION ATTEMPTS SHOULD BE HELD UNTIL THE CORE TEMPERATURE IS ≥30°C, AT WHICH TIME SUCCESSFUL DEFIBRILLATION MAY BE MORE LIKELY.
  31. 31. • THERE IS SIGNIFICANT CONTROVERSY REGARDING THE DISCONTINUATION OF PROLONGED RESUSCITATIVE EFFORTS IN HYPOTHERMIC DROWNING VICTIMS. • VICTIMS WITH PROFOUND HYPOTHERMIA MAY APPEAR CLINICALLY DEAD, BUT FULL NEUROLOGIC RECOVERY IS POSSIBLE, ALTHOUGH RARE. • BODY TEMPERATURE, WHETHER THE WATER WAS ICY OR THE COOLING WAS VERY RAPID WITH FAST-FLOWING COLD WATER SHOULD BE TAKEN INTO ACCOUNT BEFORE RESUSCITATIVE
  32. 32. • REWARMING EFFORTS SHOULD USUALLY BE CONTINUED UNTIL THE TEMPERATURE IS 32-34°C. • IF THE VICTIM CONTINUES TO HAVE NO EFFECTIVE CARDIAC RHYTHM AND REMAINS UNRESPONSIVE TO AGGRESSIVE CPR, THEN RESUSCITATIVE EFFORTS MAY BE DISCONTINUED. • COMPLETE REWARMING IS NOT INDICATED FOR ALL ARREST VICTIMS BEFORE RESUSCITATIVE EFFORTS ARE ABANDONED. • DISCONTINUING RESUSCITATION IN VICTIMS OF NON–ICY WATER SUBMERSION WHO REMAIN ASYSTOLIC DESPITE 30 MINUTES OF CPR IS PROBABLY WARRANTED. • ONCE A DROWNING VICTIM HAS UNDERGONE SUCCESSFUL CPR AFTER A CARDIAC ARREST, TEMPERATURE MANAGEMENT SHOULD BE CAREFULLY CONSIDERED, AND
  33. 33. • VICTIMS IN WHOM RESUSCITATION DURATION HAS BEEN LONGER ARE MORE LIKELY TO REMAIN COMATOSE; TEMPERATURE MANAGEMENT IN THESE INDIVIDUALS IS AN AREA OF CONTROVERSY. • FEVER COMMONLY DEVELOPS WITHIN THE 1ST 24-48 HR OF DROWNING. • FEVER OR HYPERTHERMIA (CORE BODY TEMPERATURE >37.5°C) IN COMATOSE DROWNING VICTIMS RESUSCITATED FROM CARDIAC ARREST SHOULD BE PREVENTED AT ALL TIMES IN THE ACUTE RECOVERY PERIOD (AT LEAST THE 1ST 24-48 HR). • HYPERTHERMIA AFTER DROWNING MAY INCREASE THE RISK OF MORTALITY AND EXACERBATE HYPOXIC-ISCHEMIC CNS DAMAGE.
  34. 34. THERAPEUTIC HYPOTHERMIA • FOR DROWNING VICTIMS WHO REMAIN COMATOSE AFTER SUCCESSFUL CPR, MORE IMP ISSUES INCLUDE: • REWARMING OF HYPOTHERMIC VICTIMS. • CONTROLLED APPLICATION OF THERAPEUTIC HYPOTHERMIA. • HYPOTHERMIC DROWNING VICTIMS WHO REMAIN UNRESPONSIVE BECAUSE OF HYPOXIC-ISCHEMIC ENCEPHALOPATHY AFTER RESTORATION OF ADEQUATE SPONTANEOUS CIRCULATION SHOULD NOT BE ACTIVELY REWARMED TO NORMAL BODY TEMPERATURES. • ACTIVE REWARMING SHOULD BE LIMITED TO VICTIMS WITH CORE BODY TEMPERATURES <32°C, BUT TEMPERATURES 32-37.5°C SHOULD BE ALLOWED WITHOUT FURTHER REWARMING EFFORTS.
  35. 35. • THE 2002 WORLD CONGRESS ON DROWNING RECOMMENDED THAT HYPOTHERMIA (32-34°C) BE INSTITUTED AS SOON AS POSSIBLE AFTER RESUSCITATION AND SUSTAINED FOR 12-24 HR. • THESE PATIENTS SHOULD BE INTUBATED, MECHANICALLY VENTILATED, AND TREATED WITH SEDATIVES AND/OR ANALGESICS (WITH OR WITHOUT NEUROMUSCULAR BLOCKING AGENTS) AS NECESSARY TO PREVENT SHIVERING AND MAINTAIN HYPOTHERMIA. • REWARMING AFTER THIS PERIOD SHOULD BE VERY GRADUAL.
  36. 36. • A SPECIFIC RECOMMENDATION FOR THERAPEUTIC HYPOTHERMIA, ESPECIALLY IN CHILDREN, IS NOT YET GENERALLY ACCEPTED. • THE ADVANCED LIFE SUPPORT TASK FORCE OF THE INTERNATIONAL LIAISON COMMITTEE ON RESUSCITATION (2002) DID NOT RECOMMEND THERAPEUTIC HYPOTHERMIA IN CHILDREN RESUSCITATED AFTER CARDIOPULMONARY ARREST.
  37. 37. OTHER MANAGEMENT ISSUES • ACUTE RENAL FAILURE : • DIURETICS, • FLUID RESTRICTION. • DIALYSIS IF REQUIRED. • PROFUSE BLOODY DIARRHEA AND MUCOSAL SLOUGHING : • BOWEL REST. • NASOGASTRIC SUCTION. • GASTRIC PH NEUTRALIZATION. • FEVER : • ALMOST HALF OF DROWNING VICTIMS HAVE A FEVER DURING THE 1ST 48 HR AFTER SUBMERSION. • HYPERTHERMIA IS USUALLY NOT DUE TO INFECTION AND RESOLVES WITHOUT ANTIBIOTICS IN APPROXIMATELY 80% OF PATIENTS. • PROPHYLACTIC ANTIBIOTICS ARE NOT RECOMMENDED.
  38. 38. PROGNOSIS • THE OUTCOMES FOR DROWNING VICTIMS ARE REMARKABLY BIMODAL. • MAJORITY OF VICTIMS EITHER HAVE A GOOD OUTCOME (INTACT OR MILD NEUROLOGIC INJURY) OR A BAD OUTCOME (PERSISTENT VEGETATIVE STATE OR DEATH). • FINNISH STUDY OF PEDIATRIC DROWNING SHOWED SUBMERSION DURATION WAS THE BEST PREDICTOR OF OUTCOME.
  39. 39. • THE GCS SCORE HAS SOME LIMITED UTILITY IN PREDICTING RECOVERY. • IMPROVEMENT IN THE GCS SCORE DURING THE FIRST SEVERAL HOURS OF HOSPITALIZATION MAY INDICATE A BETTER PROGNOSIS. • NEUROLOGIC EXAMINATION AND PROGRESSION DURING THE 1ST 24-72 HR ARE CURRENTLY THE BEST PROGNOSTIC INDICATORS OF LONG-TERM CNS OUTCOME.
  40. 40. THANK YOU

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