Uptodate till Jan'18

1. Drowning ( Submersion injuries )
Dr Ashutosh Bhardwaj
MD,IDCCM,EDIC
Clinical Lead & Senior Consultant ,
Critical Care Medicine ,
Dharmshila Narayana Superspeciality Hospital ,
Vasundhara Enclave, Delhi -96

2. Introduction
• Every year, drowning accounts for at least
500,000 deaths worldwide
– Low and middle-income countries-highest rates of
fatal drowning (over 90 percent of such fatalities)
• Major cause of accidental death- under the age
of 45 years and in children under five years of age
– The age distribution of submersion injury is bimodal
• Statistics for nonfatal drowning - difficult to
obtain, may occur several hundred times as
frequently as reported drowning deaths
 Papa L, Hoelle R, Idris A. Systematic review of definitions for drowning incidents. Resuscitation 2005;65:255
 Bierens JJ, Knape JT, Gelissen HP. Drowning. Curr Opin Crit Care 2002; 8:578
 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477
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3. < 100 350-400
100-150 400-450
150-200 450-500
200-250 500-600
250-300 600-700
300-350 >700
Age-standardised Disability-Adjusted Life Year (DALY) rates from Drownings by
country (per 100,000 inhabitants)
 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477
3

4. Terminology
• Multiple definitions of drowning, nonfatal
drowning, and submersion injury - creating
confusion
• Nonfatal drowning - survival, at least temporarily,
after aspiration of fluid into the lungs ("wet
nonfatal drowning") or after a period of asphyxia
secondary to laryngospasm ("dry nonfatal
drowning")
• The Utstein definitions & methods of data
reporting for drowning and related event - to
improve consistency
 Idris AH, Bierens JJLM, Perkins GD, et al. 2015 revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related
resuscitation: An ILCOR advisory statement. Resuscitation 2017;118:147.
 Youn CS, Choi SP, Yim HW, Park KN. Out-of-hospital cardiac arrest due to drowning: An Utstein Style report of 10 years of experience from St. Mary's
Hospital. Resuscitation 2009; 80:778.
4

5. Terminology
• Utstein guidelines, drowning refers to: "a process
resulting in primary respiratory impairment from
submersion or immersion in a liquid medium"
• Suggest to remove ambiguous or confusing
terms such as "near-drowning," "secondary
drowning," and "wet drowning"
 Idris AH, Bierens JJLM, Perkins GD, et al. 2015 revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related
resuscitation: An ILCOR advisory statement. Resuscitation 2017;118:147.
 Youn CS, Choi SP, Yim HW, Park KN. Out-of-hospital cardiac arrest due to drowning: An Utstein Style report of 10 years of experience from St. Mary's
Hospital. Resuscitation 2009; 80:778.
5

6. Risk factors
• Inadequate adult supervision
• Inability to swim or overestimation of swimming
capabilities.
• Risk-taking behavior ,Use of alcohol and illicit
drugs
 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477
 Olshaker JS. Near drowning. Emerg Med Clin North Am 1992; 10:339
 Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics 1993;91:612.6

7. • Hypothermia,Concomitant trauma, stroke, or
myocardial infarction
• Seizure disorder or developmental/behavioral
disorders in children
• Undetected primary cardiac arrhythmia
• Hyperventilation prior to a shallow dive
 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477
 Olshaker JS. Near drowning. Emerg Med Clin North Am 1992; 10:339
 Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics 1993;91:612.7

8. 8
Causes
Salt Water 1-2%
Fresh water 98%
swimming pools: public 50%
swimming pools: private 3%
lakes, rivers, streams, storm drains 20%
bathtubs 15%
buckets of water 4%
fish tanks or pools 4%
toilets 1%
washing machines 1%
 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477
 Olshaker JS. Near drowning. Emerg Med Clin North Am 1992; 10:339
 Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics 1993;91:612.

9. Pathophysiology
• Fatal and nonfatal drowning- begins with a period
of panic, loss of the normal breathing pattern,
breath-holding, air hunger
• Reflex inspiratory efforts - hypoxemia by means
of either aspiration or reflex laryngospasm
• Hypoxemia-affects every organ system especially
brain
 Kenny D, Martin R. Drowning and sudden cardiac death. Arch Dis Child 2011; 96:5.
 Ibsen LM, Koch T. Submersion and asphyxial injury. Crit Care Med 2002; 30:S402.
 Karpovich, PV. Water in the lungs in drowned animals. Arch Pathol 1933; 15:828.
 Giammona ST. Drowning: pathophysiology and management. Curr Probl Pediatr 1971; 1:1.
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10. Pathophysiology
 Kenny D, Martin R. Drowning and sudden cardiac death. Arch Dis Child 2011; 96:5.
 Ibsen LM, Koch T. Submersion and asphyxial injury. Crit Care Med 2002; 30:S402.
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11. • 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
Pathophysiology
 Karpovich, PV. Water in the lungs in drowned animals. Arch Pathol 1933; 15:828.
 Giammona ST. Drowning: pathophysiology and management. Curr Probl Pediatr 1971;
1:1.
11

12. • 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
 Karpovich, PV. Water in the lungs in drowned animals. Arch Pathol 1933; 15:828.
 Giammona ST. Drowning: pathophysiology and management. Curr Probl Pediatr 1971;
1:1.
12

13. 13

14. 14

15. Pathophysiology – Fresh vs Salt water
• Hypertonic vs hypotonic - No longer considered
important
• More apparent among persons who are dead on
arrival
• Aspiration of >11 mL/kg must before blood
volume changes & > 22 mL/kg before electrolyte
changes
• Unusual for nonfatal drowning victims to aspirate
more than 3 to 4 mL/kg
• Both result in decreased lung compliance, V/Q
mismatch and intrapulmonary shunting -
hypoxemia  Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am
2001;48:627
 Harries MG. Drowning in man. Crit Care Med 1981; 9:407
 Harries M. Near drowning. BMJ 2003; 327:1336.
15

16. End organs effects
• Tissue hypoxia
• Pulmonary
– Fluid aspiration-hypoxemia
– Both salt water and fresh water wash out surfactant -
noncardiogenic pulmonary edema and ARDS
– Pulmonary insufficiency - shortness of breath,
crackles, and wheezing
– Chest radiograph or CT - normal to localized, perihilar,
or diffuse pulmonary edema
 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults.
CritCare Clin 1997;13:477
 Olshaker JS. Near drowning. Emerg Med Clin North Am 1992; 10:339.
16

17. • Neurologic -
– Hypoxemia and ischemia - neuronal damage, cerebral
edema and elevations in intracranial pressure
– 20 percent of nonfatal drowning victims sustain
neurologic damage
• Cardiovascular –
– Arrhythmias secondary to hypothermia and
hypoxemia
– In some pts ECG may show s/o MI
– Initial arrhythmias-sinus tachycardia, sinus bradycardia
and atrial fibrillation
– Diving can precipitate fatal ventricular arrhythmias in
patients with congenital long QT syndrome
End organs effects
 Sarnaik AP, Preston G, Lieh-Lai M, Eisenbrey AB. Intracranial pressure and cerebral perfusion pressure in near-drowning. Crit Care Med 1985; 13:224
 Gonzalez-Rothi RJ. Near drowning: consensus and controversies in pulmonary and cerebral resuscitation.Heart Lung 1987; 16:474
 Rivers JF, Orr G, Lee HA. Drowning. Its clinical sequelae and management. Br Med J 1970; 2:157
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18. • Acid-base and electrolytes -
– Metabolic and/or respiratory acidosis
– Significant electrolyte imbalances rare in nonfatal
drowning survivors except those submerged in
unusual media, such as the Dead Sea - extremely
concentrated seawater
• Renal –
– Rare & due to acute tubular necrosis resulting from
hypoxemia, shock, hemoglobinuria, or myoglobinuria
• Coagulation –
– Hemolysis and coagulopathy are rare
End organs effects
 Yagil Y, Stalnikowicz R, Michaeli J, Mogle P. Near drowning in the dead sea. Electrolyte imbalances and therapeutic implications. Arch
Intern Med 1985; 145:50.
 Fandel I, Bancalari E. Near-drowning in children: clinical aspects. Pediatrics 1976; 58:573.
 Bonnor R, Siddiqui M, Ahuja TS. Rhabdomyolysis associated with near-drowning. Am J Med Sci 1999;318:201.
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19. Management
• Prehospital care and acute interventions
• Emergency department management
• Patient disposition
• Inpatient management
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20. Prehospital care and acute interventions
• Rescue and immediate resuscitation by
bystanders improves the outcome of drowning
victims
• CPR - as soon as possible
– without compromising the safety of the rescuer or
delaying the removal of the victim from the water
– Ventilation is the most important initial treatment
– Follow ABC & NOT CAB
• Cervical spinal cord injury is uncommon
– Unless clinical signs or history suggestive
– As per ACLS- routine cervical spine immobilization not
recommended
 Venema AM, Groothoff JW, Bierens JJ. The role of bystanders during rescue and resuscitation of drowning victims. Resuscitation 2010; 81:434.
 Watson RS, Cummings P, Quan L, et al. Cervical spine injuries among submersion victims. J Trauma 2001; 51:658.
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21. • Pulses may be very weak and difficult to palpate
– May be because of hypothermia or arrythmias
– Check for at least one min before initiating chest
compressions
• The Heimlich maneuver or other postural
drainage technique – no proven value
– Don’t delay rescue breaths
• Give supplemental oxygen
• Initiate rewarming in hypothermic pt ( <33⁰C)
 Rosen P, Stoto M, Harley J. The use of the Heimlich maneuver in near drowning: Institute of Medicine report. J Emerg Med 1995; 13:397.
 Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015American Heart Association Guidelines Update for Cardiopulmonary
Resuscitation and EmergencyCardiovascular Care. Circulation 2015; 132:S501.
Prehospital care and acute interventions
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22. 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
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23. Emergency department management
• Prehospital resuscitative efforts to be continued
• Indications for O2,NIV & intubation –
GCS,PaO2,PaCO2
• Frequent vital sign measurements and clinical
reassessment
• Trauma evaluation and appropriate imaging
studies
• Rewarm the hypothermic patients
• Importance of prolonged resuscitative efforts
 Jolly BT, Ghezzi KT. Accidental hypothermia. Emerg Med Clin North Am 1992; 10:311.
 Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome. Resuscitation 2014; 85:790.
 Kieboom JK, Verkade HJ, Burgerhof JG, et al. Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide
retrospective cohort study. BMJ 2015;350:h418.
23

24. Predicting Ability for ED Discharge
• Several studies support selected ED discharge
• Observe in ED for minimum 4-6 hours if:
– Submersion > 1 min.
– Cyanosis on extraction
– CPR required
• Admit if: CNS or respiratory symptoms
• 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%
 Jolly BT, Ghezzi KT. Accidental hypothermia. Emerg Med Clin North Am 1992; 10:311.
 Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome. Resuscitation 2014; 85:790.
 Kieboom JK, Verkade HJ, Burgerhof JG, et al. Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide
retrospective cohort study. BMJ 2015;350:h418.
24

25. Patient disposition
Drowning classification system
Adapted from Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am. 2001;48:627-646.
[BMJ Best Practice: drowning classification system
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26. Inpatient management
• Respiratory
– Ventilation
– Treatment of bronchospasm
– Steroids: no benefits
– Bronchoscopy
– Prophylactic abx: no benefits
• Pneumonia – Grossly contaminated water, Gastric juices
• Thinks of water borne bugs
– Surfactant: no beneficial
• Cardiovascular
– Restore adequate oxygen delivery to tissues
– Hypotension – cold diuresis -
 Pearn J. Pathophysiology of drowning. Med J Aust 1985; 142:586.
 Anker AL, Santora T, Spivey W. Artificial surfactant administration in an animal model of near drowning. Acad Emerg Med 1995; 2:204.
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27. Inpatient management
• Neurological
• Outcome
– GCS on presentation, duration of LOC
• Goal is to prevent secondary neurologic injuries
– Brain CT – not indicated, unless TBI suspected
– ICP monitoring - not indicated, typically irreversible
hypoxic cellular injury
– Mild hyperventilation?
– Osmotherapy – not indicated
– Corticosteroids (dexamethasone) - no proven benefit
-
 Moler FW, Hutchison JS, Nadkarni VM, et al. Targeted Temperature Management After Pediatric Cardiac
Arrest Due To Drowning: Outcomes and Complications. Pediatr Crit Care Med 2016; 17:712.
 Tipton MJ, Golden FS. A proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion.
Resuscitation 2011; 82:819.
 Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte
abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution.
Resuscitation 2010; 81:1400.
27

28. Inpatient management
– Shivering or random, purposeless movements can
increase ICP
– Seizures - treat aggressively
– Hypothermia and barbiturate coma - highly
controversial & unlikely to benefit the patient
– Avoid NMBs
– Maintain Euglycemia
• Therapeutic (induced) hypothermia in the
postresuscitation period – Equivocal data
 Moler FW, Hutchison JS, Nadkarni VM, et al. Targeted Temperature Management After Pediatric Cardiac
Arrest Due To Drowning: Outcomes and Complications. Pediatr Crit Care Med 2016; 17:712.
 Tipton MJ, Golden FS. A proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion.
Resuscitation 2011; 82:819.
 Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte
abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution.
Resuscitation 2010; 81:1400.
28

29. Prognosis
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30. Prognosis predictors
• Poor outcomes
– Age >14 yrs
– Submersion time: >5 min
– Time to effective BLS >10 min
– Serum pH: <7.1 on presentation
– CPR >25 min
– Initial core temp <33ºC
– GCS <5 ie comatose
– No association between water temperature & outcome
-
Quan L, Mack CD, Schiff MA. Association of water temperature and submersion
duration and drowning outcome. Resuscitation 2014; 85:790.
30

31. Prognosis predictors
-
Submersion time survival Fatality
0-5 min 7/67 10%
6-9 min 5/9 56%
10-25 min 21/25 88%
>25 min 4/4 100%
Quan L, Mack CD, Schiff MA. Association of water temperature and submersion
duration and drowning outcome. Resuscitation 2014; 85:790. 31

32. Neurologic prognosis
• Absence of spontaneous respiration,Poor GCS,
duration of LOC are 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
 Orlowski JP. Prognostic factors in pediatric cases of drowning and near-drowning. JACEP 1979; 8:176.
 Biggart MJ, Bohn DJ. Effect of hypothermia and cardiac arrest on outcome of near-drowning accidents in children. J Pediatr 1990; 117:179. 32

33. Safety Recommendations
• Never leave a child alone in or near water, even
for a minute
• Limit pool access.
• Children with Epilepsy
– 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!
 O'Flaherty JE, Pirie PL. Prevention of pediatric drowning and near-drowning: a survey of members of the American Academy
of Pediatrics. Pediatrics 1997; 99:169.
 Modell JH. Prevention of needless deaths from drowning. South Med J 2010; 103:650. 33

34. Safety Recommendations
• Learn CPR
• Use approved personal flotation devices
• Teach safe water behaviour
• The Best Approach Therefore:
• P revention !
• P revention !
• P revention !
 O'Flaherty JE, Pirie PL. Prevention of pediatric drowning and near-drowning: a survey of members of the American Academy
of Pediatrics. Pediatrics 1997; 99:169.
 Modell JH. Prevention of needless deaths from drowning. South Med J 2010; 103:650. 34

35. Summary
• Ventilation is the most important initial
treatment for victims of submersion injury –
ventilation strategies are standard
• Rescue breathing should begin as soon as the
rescuer reaches shallow water or a stable surface
• In critically ill patients, standard practices are
employed to reduce the risk of brain injury
• The role of therapeutic hypothermia remains
unclear
• There is no good evidence to support the routine
use of glucocorticoids or prophylactic antibiotics
in nonfatal drowning victims
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37. 37