Neardrowning: Prehospital and Emergency Department

Management

James Hoekstra, MD, FACEP

Ohio State University

Case Report: Neardrowning

• 17 year old male ejected from a boat during a violent turn in a fresh water reservoir

• Pulled from the water by friends

• Unconscious, not breathing at the scene

• Given mouth to mouth

• Total time submerged: 3-5 minutes

• EMS arrival in 20 minutes

Case Report: EMS

• At EMS arrival, breathing but unconscious

• BP 130/90, P 110, R 24, good BS

• Obvious head injury with parietal scalp laceration, moving all fours to pain

• Backboard and C-collar immobilization

• O2 per face mask, monitor

• Transport, IV established en route

Case Report: ED Arrival

• Airway: Guarded, alert but confused• Breathing: R 32, good BS, Pulse Ox 96% on

100% FM• Circulation: Good color, BP 140/100, P 130,

pulses X 4• Neuro: Alert but confused, purposeful X 4• No signs of external trauma except scalp lac

Critical Actions • IV X2, O2 FM, Monitor

• Tetanus, Ancef

• CXR, CS, Pelvis

• ECG

• Labs sent, ABG sent

• Foley cath inserted

• NG inserted

• Secondary survey: No apparent trauma

Laboratory Results

• pH 7.30/pO2 72/pCO2 32/HCO3 16

• ECG: Sinus Tach, NAD

• CS and pelvis films normal

• WBC 14K, Hb 14, Hct 42

• Na 134, K 3.9, Cl 104, CO2 17, Glucose 133. Renal function normal

• EtOH .130

Clinical Course

• CT head normal

• CT abd normal

• C, T, L spine films normal

• Scalp wound closed in the ED

• Sedated for combativeness with Midazolam

• Admitted to SICU

Clinical Course, Cont.• Ventilation and oxygenation deteriorates,

requiring intubation and ventilation

• PEEP at high levels

• Barotrauma with bilateral chest tubes, sub Q air

• Fever, purulent sputum, IV broad spectrum antibiotics instituted

• Rocky course, SICU on vent for 3 weeks.

• D/C after 5 weeks in the hospital

Neardrowning

• Nomenclature

• Epidemiology

• Pathophysiology

• Prognostics

• Prehospital Management

• Hospital Management

Nomenclature

• Drowning

• Neardrowning

• Secondary Drowning

• Wet drowning

• Dry drowning

• Immersion Syndrome

Epidemiology

• 7-8000 reported cases per year in US

• 40% are children 0-5 years old

• 1% of pediatric ICU admissions

• Male predominance

• Backyard pools

• Lack of supervision, seizures

Epidemiology

• Adult drowning, third most common cause of accidental death

• Alcohol, alcohol, alcohol

• Boys 15-19

• Trauma, diving most common mechanism

• 90% within 10 feet of safety

• Swimming ability not a risk factor

Pathophysiology of Drowning

• Submersion

• Panic and Flailing (if conscious)

• Inhalation and aspiration or laryngospasm

• Hypoxia

• Cardiopulonary arrest

Near Drowning Pathophysiology

• Hypoxic episode interrupted with ROSC

• End organ damage with – ARDS (often delayed)– Hypoxic encephalophy– Renal failure (ATN)– Pancreatic necrosis– DIC– Cardiac dysrrhythmias

Fresh Water Inhalation (90%)• Hypotonic load to alveoli

• Water absorbed into circulation

• Surfactant washout

• Alveolar cell damage

• Chemical pneumonitis, pulmonary edema

• Hypervolemia

• Hyponatremia

• Hemodilution

• Hemolysis

Salt Water Inhalation (10%)• Hypertonic load to alveoli

• Protein rich effusion into alveoli

• Surfactant damage, alveolar basement membrane damage

• Alveolar cell damage

• Chemical pneumonitis, pulmonary edema

• Hypovolemia

• Hypernatremia

• Hemoconcentration

Salt versus Fresh Water

• Modell, series of 91 near drowning victims

• No significant electrolyte abnormalities

• No difference in treatment, but be vigil

• Differences in bacteria, chemical composition (chlorine), and temperature of the aspirated water more significant

• Conn: Animal model

Hypothermia

• Water conduction of heat

• Pulmonary heat exchange

• Cold water absorption

• Temperature of water a factor in fresh water near drowning

• Symptoms vary with degree of hypothermia

• Is hypothermia destructive or protective?

Prognostic Factors

• Submersion Time?

• Level of hypothermia?

• CPR?

• Mental Status?

• Combinations?

Submersion Time and Prognosis

• Frates: No correlation in time of submersion and survival

• Quan and Kinder: Duration of submersion >10 minutes predicts bad outcome (6/6)

• Field resuscitation >25 minutes predicts bad outcome (17/17)

CPR and Prognosis• 66 near drowning patients in warm water• 25% of victims who were under CPR with

GCS of 3 in the ED survived intact, 50% died, 25% neurologically impaired

• 91% of patients who were still GCS 3 in the ICU either died or were persistently vegetative state

• Peterson: All who arrived under CPR died or were damaged

Hypothermia and Prognosis

• Many case reports of long submersion up to 45 minutes with survival in cold water

• In warm water, hypothermia is an indication of prolonged submersion time, a bad prognostic factor

Neurologic Status and Prognosis• Kemp and Sibert: 188 admissions, dilated

pupils 6 hours after admission had poor outcome, reactive pupils on ED admission 33% recovered intact, 33% with neurologic impairment

• Lavel and Shaw: 44 admissions: Nonreactive pupils and GCS <5 poor outcome

• Dean: GCS <5, unreactive pupils, poor outcome

Conn et al: Neurologic Classification and Prognosis

• Classification based on 105 patients

• A: Awake

• B: Blunted

• C: Comatose

• C1: Decorticate

• C2: Decerebrate

• C3: Flaccid

Other Predictors

• Initial pH

• Age

• Cardiac standstill

• Cardiotonic medications

• Best Predictor: Resuscitation effectiveness determined 12-24 hours after admission

Prehospital Management• ABC’s

• Initiation of ventilation is the only way to interrupt the submersion time

• C-Spine control, backboard

• IV, O2, monitor, pulse ox

• ACLS if needed, with attention to hypothermia concerns

• Correction of acidosis

• NO HEIMLICH

Prehospital Management Cont.

• Passive Rewarming

• Rapid Transport

• All neardrowning victims need evaluation at a medical facility

• History is important

ED Management• ABC’s, with C-spine control

• IV, O2, Monitor, Pulse Ox

• CXR

• ABGs

• Electrolytes

• Trauma workup, primary and secondary assessment.

• Treatment of Complications

Hospital Management

• Pulmonary Support

• Rewarming

• Cerebral Resuscitation

Pulmonary Support• O2

• Intubation and Ventilation

• PEEP

• Steroids?

• Antibiotics?

• New ventilation techniques

• ECMO

• Liquid Ventilation

• Surfactant Therapy

Rewarming

• Passive External

• Active External (beware of afterdrop)

• Active Internal– IV– Vent– NG/Bladder/Peritoneal– Bypass

Cerebral Resuscitation

• Frequent neurologic exams

• ICP monitoring

• Resuscitation techniques– Steroids/Mannitol– Barbiturates– Hypothermia– HYPER

Conn et al: HYPER• Hyperhydration: diuretics and fluid

restriction

• Hyperventilation: pCO2 30-35 mmHg

• Hyperpyrexia: hypothermia to 30 degrees C

• Hyperexcitability: barbiturate coma

• Hyperrigidity: paralysis

• Effective in C2 and C1 patients, not C3

• Not supported elsewhere in the literature

Conclusions

• Neardrowning is a common cause of accidental death

• Remember:– Initiate ventilation early– Don’t forget trauma as a cause– Aggressive treatment of complications:

• Head, Lung, and Temperature