Drowning by dr mahmoud zalam kfmc riyadh ksa

DrowningDrowning

DR MAHMOUD MOHAMED MAHMOUD

DrowningDrowning ObjectivesObjectives

Define drowningDefine drowning DiscussDiscuss

• incidenceincidence• epidemiologyepidemiology• causescauses

Review prognostic indicatorsReview prognostic indicators Discuss therapeutic interventionsDiscuss therapeutic interventions Discuss opportunities that impact outcomeDiscuss opportunities that impact outcome

2002 World Congress on Drowning2002 World Congress on Drowning

Drowning = process resulting in primary Drowning = process resulting in primary respiratory impairment from respiratory impairment from submersion/immersion in a liquid mediumsubmersion/immersion in a liquid medium

RegardlessRegardless of survival of survival Drowning without aspiration does Drowning without aspiration does notnot

occuroccur Terms which are “out”Terms which are “out”

Dry, wet, active, silent, secondary, near-Dry, wet, active, silent, secondary, near-drowningdrowning

Near DrowningNear Drowning

DefinitionsDefinitions Definitions were revised at 2002 World Definitions were revised at 2002 World

congress on Drowning in Amsterdam, congress on Drowning in Amsterdam, Netherlands. They are now Netherlands. They are now internationally accepted and more internationally accepted and more uniformuniform

DrowningDrowning

StatisticsStatistics

1995 data:1995 data: >1000 kids <14 years old drown>1000 kids <14 years old drown 60% <4 years old60% <4 years old

2000 CDC data:2000 CDC data: 3,281 unintentional drownings in USA (adults & kids)3,281 unintentional drownings in USA (adults & kids) averaging 9 people/day - not including boating-related averaging 9 people/day - not including boating-related

incidents  incidents  2003 CDC data:2003 CDC data:

For every child who drowns, 3 need ED care for non-For every child who drowns, 3 need ED care for non-fatal submersion injuriesfatal submersion injuries

>40% of these children require hospitalization>40% of these children require hospitalization

EPIDEMIOLOGYEPIDEMIOLOGY

Freshwater drowning is more Freshwater drowning is more common than saltwater drowning, common than saltwater drowning, even in coastal areaseven in coastal areas

Places:lakes/rivers/canals/poolsPlaces:lakes/rivers/canals/pools Toddlers:Toddlers:

Any container of water can be Any container of water can be responsible:responsible:• Buckets/fish tanks/washing Buckets/fish tanks/washing

machine/toilets/bathtubmachine/toilets/bathtub

Morbidity & MortalityMorbidity & Mortality

15% of children admitted for drowning die 15% of children admitted for drowning die in the hospitalin the hospital

As many as 20% of drowning survivors As many as 20% of drowning survivors suffer severe, permanent neurological suffer severe, permanent neurological disabilitydisability

Drowning modalitiesDrowning modalities

Infants (age <1) - bathtubs, buckets & Infants (age <1) - bathtubs, buckets & toiletstoilets

Children ages 1-4 years - swimming Children ages 1-4 years - swimming pools, hot tubs & spaspools, hot tubs & spas

Children ages 5-14 years - swimming Children ages 5-14 years - swimming pools & open water sitespools & open water sites

Bucket drowningsBucket drownings

~500 children in the US ~500 children in the US since 1984since 1984

7-15 months of age7-15 months of age 24 to 31 inches tall24 to 31 inches tall Bucket may contain water or Bucket may contain water or

nasty cleaning fluidnasty cleaning fluid

Tub drowningsTub drownings Approximately 10% of childhood drowningsApproximately 10% of childhood drownings Typically lacking adult supervisionTypically lacking adult supervision Do tub seats help?Do tub seats help?

Baby swim classesBaby swim classes

Done to “teach” babies to floatDone to “teach” babies to float No reported drownings in classNo reported drownings in class Several reports of hyponatremic seizures Several reports of hyponatremic seizures

following class following class (How was school today?)(How was school today?)

False sense of security?False sense of security?

Near DrowningNear DrowningGroups at RiskGroups at Risk

Toddlers (40% of deaths < 5 y.o.)Toddlers (40% of deaths < 5 y.o.) School age boysSchool age boys TeenagersTeenagers Males > females (5:1)Males > females (5:1) Children with:Children with:

seizuresseizures cardiac dysrhythmiascardiac dysrhythmias

Near DrowningNear DrowningRisk Factors: AgeRisk Factors: Age

0

100

200

300

400

500

600

0-4 yr 5-9 yr 10-14 yr 15-19

Male

Female

Toddler DrowningsToddler Drownings

Tend to occur because of lapse in Tend to occur because of lapse in supervisionsupervision

Majority in afternoon/early evening-meal Majority in afternoon/early evening-meal timetime

Responsible supervising adult in 84% of Responsible supervising adult in 84% of casescases

Only 18% of cases actually witnessedOnly 18% of cases actually witnessed

Causes of Near DrowningCauses of Near DrowningRecreational BoatingRecreational Boating

90% of deaths due 90% of deaths due to drowningto drowning

1,200/year1,200/year Small, open boatsSmall, open boats 20% of deaths20% of deaths

too few or no too few or no floatation devices !floatation devices !

Other CausesOther CausesDiving InjuriesDiving Injuries

700-800 per year700-800 per year Peak incidence Peak incidence

18-31 years18-31 years No formal trainingNo formal training 1st dive in 1st dive in

unfamiliar waterunfamiliar water 40-50% alcohol 40-50% alcohol

relatedrelated

Other CausesOther CausesSpas, Hot TubsSpas, Hot Tubs

EntrapmentEntrapment drainsdrains

• hair, body parts, clothinghair, body parts, clothing winter pool/spa coverswinter pool/spa covers

Near-Drowning Near-Drowning EpilepsyEpilepsy

2.5-4.6% of drowning victims had pre-2.5-4.6% of drowning victims had pre-existing seizure disorderexisting seizure disorder

Drowned children with epilepsy more likely Drowned children with epilepsy more likely to: be older than 5, drown in bathtub, not to: be older than 5, drown in bathtub, not be supervisedbe supervised

Relative risk of drowning for children with Relative risk of drowning for children with epilepsy:epilepsy: 96 in bathtub (95% CI 33-275)96 in bathtub (95% CI 33-275) 23 in pool (95% CI 7.1-77.1) 23 in pool (95% CI 7.1-77.1)

Near-Drowning Near-Drowning Long QT Syndrome (LQTS)Long QT Syndrome (LQTS)

Swimming may be a trigger for Swimming may be a trigger for LQTS eventLQTS event

Near-drowning event may be Near-drowning event may be first presentation of LQTS (15% first presentation of LQTS (15% of 1st LQTS syncopal events)of 1st LQTS syncopal events)

Gene-specific KVLQT1 mutation Gene-specific KVLQT1 mutation associated with swimming associated with swimming trigger and submersion eventtrigger and submersion event

Can test with cold water face Can test with cold water face immersion immersion

Importance: early diagnosis of Importance: early diagnosis of survivor, or of family members; survivor, or of family members; consider with unexplained consider with unexplained submersionsubmersion

PathophysiologyPathophysiology

The event, part 1The event, part 1 Voluntary breath-holdingVoluntary breath-holding Aspiration of small amounts into Aspiration of small amounts into

larynxlarynx Involuntary laryngospasmInvoluntary laryngospasm Swallow large amountsSwallow large amounts Laryngospasm abates (due to Laryngospasm abates (due to

hypoxia)hypoxia) Aspiration into lungsAspiration into lungs

The event, part 2The event, part 2

Decrease in satsDecrease in sats Decrease in cardiac outputDecrease in cardiac output Intense peripheral vasoconstrictionIntense peripheral vasoconstriction HypothermiaHypothermia BradycardiaBradycardia Circulatory arrest, while VF rareCirculatory arrest, while VF rare Extravascular fluid shifts, diuresisExtravascular fluid shifts, diuresis

Pathophysiology Pathophysiology withwith aspirationaspiration

HypoxemiaHypoxemia Occurs whether or not patient aspiratesOccurs whether or not patient aspirates 85-90% aspirate85-90% aspirate 10-15% DO NOT aspirate10-15% DO NOT aspirate

Pathophysiology Pathophysiology withwith aspirationaspiration

Pulmonary EdemaPulmonary Edema Damage to Alveolar membraneDamage to Alveolar membrane Damage to pulmonary microcirculationDamage to pulmonary microcirculation

Pathophysiology Pathophysiology withoutwithout aspirationaspiration

Severe, persistent laryngospasmSevere, persistent laryngospasm Anoxic seizuresAnoxic seizures DeathDeath

PathophysiologyPathophysiology

3 Major metabolic abnormalities3 Major metabolic abnormalities AnoxiaAnoxia AcidosisAcidosis HypercapniaHypercapnia

Pathogenesis 1Pathogenesis 1 Asphyxia, hypoxemia, hypercarbia, & metabolic acidosisAsphyxia, hypoxemia, hypercarbia, & metabolic acidosis Fresh water vs salt water - little difference (except for Fresh water vs salt water - little difference (except for

drowning in water with very high mineral content, like the drowning in water with very high mineral content, like the Dead Sea)Dead Sea)

HypoxemiaHypoxemia Occlusion of airways with water & particulate debrisOcclusion of airways with water & particulate debris Changes in surfactant activityChanges in surfactant activity BronchospasmBronchospasm Right-to-left shunting increasedRight-to-left shunting increased Physiologic dead space increasedPhysiologic dead space increased

Pathogenesis 2Pathogenesis 2

Cardiac arrhythmiasCardiac arrhythmias Hypoxic encephalopathyHypoxic encephalopathy Renal insufficiencyRenal insufficiency Global brain anoxia & potential diffuse Global brain anoxia & potential diffuse

cerebral edemacerebral edema

SaltSaltvsvs

FreshFresh

There are REAL differencesThere are REAL differences

SaltSaltvsvs

FreshFresh

AtelectasisAtelectasis

Aspiration leads to

collapse of the alveoli due to loss

of surfactant and

pulmonary edema

normal

alveoli

surfactant

collapsed alveoli

Pulmonary EdemaPulmonary Edema

capillary

Interstitial fluid shift

AlveoliO2

CO2

Reduced perfussion

O2 CO2

Potential Fresh Water DamagePotential Fresh Water Damage

HypoxiaHypoxia AtelectasisAtelectasis Pathogenic bacteria and impurities lethalPathogenic bacteria and impurities lethal Produces greater long-term damage due Produces greater long-term damage due

to salt in pulmonary edemato salt in pulmonary edema

DrowningDrowning

Potential Salt Water DamagePotential Salt Water Damage Hypovolemia if large amounts swallowedHypovolemia if large amounts swallowed HypertonicHypertonic

Elevation of Na, Cl and K, Elevation of Na, Cl and K, decrease blood volumedecrease blood volume

Salt water is 2 times as lethalSalt water is 2 times as lethal

Near DrowningNear DrowningMulti-Organ EffectsMulti-Organ Effects

Hypoxic/ischemic cerebral injuryHypoxic/ischemic cerebral injury Fluid overloadFluid overload Pulmonary injuryPulmonary injury HypothermiaHypothermia

ASPHYXIAASPHYXIA

Pulmonary SystemPulmonary System 1. secondary apnea,1. secondary apnea, aspirationaspiration 2. hypercapnea2. hypercapnea

Central Nervous SystemCentral Nervous System1. anoxic damage1. anoxic damage2. defective autoregulation2. defective autoregulation3. cerebral edema 3. cerebral edema 4. increased ICP4. increased ICP

RenalRenal1. acute tubular necrosis1. acute tubular necrosis2. acute cortical necrosis2. acute cortical necrosis

CardiacCardiac1. myocardial ischemia1. myocardial ischemia2. fibrillation2. fibrillation

AsphyxiaAsphyxia

low BPlow BP

HypothermiaHypothermia CARDIACCARDIAC dysrhythmdysrhythmiaia

VASODILATIONVASODILATIONdecreased ICPdecreased ICPdecreased BPdecreased BP

CENTRALCENTRALNERVOUSNERVOUS1. reduced 1. reduced metabolismmetabolism2. reduced ICP2. reduced ICP3. ?protection?3. ?protection?4. may produce 4. may produce picturepicture of clinical deathof clinical death

DEATHDEATH

RENAL RENAL FAILUREFAILURE

Rogers, Pediatric Critical CareRogers, Pediatric Critical Care

WATER OVERLOADWATER OVERLOAD Pulmonary SystemPulmonary System 1. alveolar fluid1. alveolar fluid 2. “ARDS”2. “ARDS” 3. hypoventilation3. hypoventilation

Central Nervous SystemCentral Nervous System1. cerebral edema1. cerebral edema2. intracranial hypertension2. intracranial hypertension

Dilution EffectsDilution Effects1. hypokalemia1. hypokalemia2. hemodilution2. hemodilution3. hemolysis3. hemolysis

GastrointestinalGastrointestinal1. gastric distension1. gastric distension2. vomiting, aspiration2. vomiting, aspiration3. ileus3. ileus

Water OverloadWater Overload

Near DrowningNear Drowning Multi-Organ EffectsMulti-Organ Effects

Cerebral Cerebral hypoxia is the hypoxia is the final common final common pathway in all pathway in all drowning drowning victimsvictims

Near DrowningNear DrowningCNS InjuryCNS Injury

With significant hypoxia can have Lance-With significant hypoxia can have Lance-Adams syndrome Adams syndrome Post hypoxic (action) myoclonusPost hypoxic (action) myoclonus Often mistaken for seizuresOften mistaken for seizures Happens more often when coming out of Happens more often when coming out of

sedationsedation Must be differentiated from myoclonic status Must be differentiated from myoclonic status

which has poor prognosis which has poor prognosis

Near DrowningNear DrowningPulmonary InjuryPulmonary Injury

Aspiration as little as 1-3 cc/kg can cause Aspiration as little as 1-3 cc/kg can cause significant effect on gas exchangesignificant effect on gas exchange Increased permeabilityIncreased permeability Exudation of proteinaceous material in alveoliExudation of proteinaceous material in alveoli Pulmonary edemaPulmonary edema decreased compliancedecreased compliance

Near DrowningNear DrowningPulmonary Injury:Pulmonary Injury:

Fresh Water vs. Salt WaterFresh Water vs. Salt Water Theoretical changes not supported clinicallyTheoretical changes not supported clinically

Salt water: hypertonic pulmonary edemaSalt water: hypertonic pulmonary edema Fresh water: plasma hypervolemia, hyponatremiaFresh water: plasma hypervolemia, hyponatremia Unless in Dead SeaUnless in Dead Sea

Humans (most aspirate 3-4cc/kg) Humans (most aspirate 3-4cc/kg) Aspirate > 20cc/ kg before significant electrolyte Aspirate > 20cc/ kg before significant electrolyte

changeschanges Aspirate > 11cc/kg before fluid changesAspirate > 11cc/kg before fluid changes

The Bottom LineThe Bottom LineFresh Water and Salt WaterFresh Water and Salt Water

Both forms wash out surfactantBoth forms wash out surfactant Damaged alveolar basement Damaged alveolar basement

membranemembrane Pulmonary edemaPulmonary edema ARDSARDS

Labs & testsLabs & tests

Very mild electrolyte changesVery mild electrolyte changes Moderate leukocytosisModerate leukocytosis Hct and Hgb usually normal Hct and Hgb usually normal

initallyinitally Fresh water aspiration, Fresh water aspiration,

the Hct may fall slightly in the Hct may fall slightly in the first 24 hrs due to the first 24 hrs due to hemolysishemolysis

Increase in free Hgb Increase in free Hgb without a change in Hct is without a change in Hct is commoncommon

DIC occasionallyDIC occasionally ABG – metabolic acidosis & ABG – metabolic acidosis &

hypoxemiahypoxemia

EKGEKGSinus tachycardia & nonspecific ST-Sinus tachycardia & nonspecific ST-segment and T-wave changessegment and T-wave changes

Reverts to normal within hoursReverts to normal within hoursOminous - ventricular arrhythmias, Ominous - ventricular arrhythmias, complete heart blockcomplete heart block

CXRCXRMay be normal initially despite severe May be normal initially despite severe respiratory disturbancesrespiratory disturbancesPatchy infiltratesPatchy infiltratesPulmonary edemaPulmonary edema

Essential First Aid ManagementEssential First Aid Management

ConsciousConscious UnconsciousUnconscious

Evaluate forEvaluate for CPR (prolonged)CPR (prolonged)Aspiration Aspiration 100% oxygen100% oxygen

NONO YESYES

ObserveObserve 100% oxygen100% oxygen transfer to transfer to hospitalhospital

TreatmentTreatmentTransportTransport

Continue CPRContinue CPR Establish airwayEstablish airway Remove wet clothesRemove wet clothes Hospital evaluationHospital evaluation

Immediate hospital managementImmediate hospital management

Assess and manage ABCAssess and manage ABC 100% oxygen100% oxygen Pulse oximetry (watch for false readings caused Pulse oximetry (watch for false readings caused

by peripheral shutdown and acidosis)by peripheral shutdown and acidosis) ABGs, FBC, U&EABGs, FBC, U&E CXRCXR ObservationObservation Management of associated hypothermiaManagement of associated hypothermia

TreatmentTreatmentEmergency DepartmentEmergency Department

Continue established therapiesContinue established therapies History, physical, labsHistory, physical, labs Admit if: CNS or respiratory symptomsAdmit if: CNS or respiratory symptoms Observe in ED for minimum 4-6 hours if:Observe in ED for minimum 4-6 hours if:

Submersion > 1 min.Submersion > 1 min. Cyanosis on extractionCyanosis on extraction CPR requiredCPR required

Predicting Ability for ED DischargePredicting Ability for ED Discharge

Several studies support selected ED Several studies support selected ED dischargedischarge

Child can safely be discharged home if at Child can safely be discharged home if at 6 hours after ED presentation:6 hours after ED presentation: GCS GCS >> 13 13 Normal physical exam/respiratory effortNormal physical exam/respiratory effort Room air pulse oximetry oxygen saturation > Room air pulse oximetry oxygen saturation >

95%95%

The problem with looking wellThe problem with looking well

Aspiration of water can cause late Aspiration of water can cause late complications:complications:

Neurogenic pulmonary oedema, Neurogenic pulmonary oedema, Pneumonia, SIRS, DIC, Haemolysis, Pneumonia, SIRS, DIC, Haemolysis, Hepatic & renal failure, bowel necrosisHepatic & renal failure, bowel necrosis

Plus complications of hypothermiaPlus complications of hypothermia

ICU Management StrategiesICU Management StrategiesIntubation/VentilationIntubation/Ventilation

SpOSpO22 < 90% on FIO < 90% on FIO22 > 0.6 > 0.6

PaCOPaCO2 2 > 50 with pH < 7.3> 50 with pH < 7.3

Increased work of breathingIncreased work of breathing Abnormal CNS examAbnormal CNS exam

IndicationsIndications

ICU Management StrategiesICU Management StrategiesRespiratoryRespiratory

Oxygenate - avoid hypoxemiaOxygenate - avoid hypoxemia Ventilate - avoid significant Ventilate - avoid significant

hyperventilationhyperventilation PEEP may be beneficial but is not PEEP may be beneficial but is not

prophylacticprophylactic Exogenous surfactantExogenous surfactant

Management StrategiesManagement StrategiesCardiovascularCardiovascular

Re-warming ( to a degree ? benefit Re-warming ( to a degree ? benefit hypothermia)hypothermia) LOC 34 CLOC 34 C Pupils dialate 30 CPupils dialate 30 C V Fib 28 CV Fib 28 C EEG iso-electric 20CEEG iso-electric 20C

CBF decrease 6-7% per degree C CBF decrease 6-7% per degree C dropdrop

Management StrategiesManagement StrategiesCentral Nervous SystemCentral Nervous System

Protect against 2Protect against 20 0 injuryinjury Perfuse it or lose it !!Perfuse it or lose it !!

ICP monitoring not beneficial or ICP monitoring not beneficial or recommendedrecommended

Some still monitor if:Some still monitor if: Successful CPR followed by comaSuccessful CPR followed by coma Sudden, unexplaind deteriorationSudden, unexplaind deterioration

Management StrategiesManagement StrategiesCentral Nervous SystemCentral Nervous System

ICP monitoring may not change ICP monitoring may not change outcome, just predict itoutcome, just predict it

Low ICP Better outcomeLow ICP Better outcome High ICP Poor outcomeHigh ICP Poor outcome

ICU Management StrategiesICU Management Strategies

Antibiotics - no benefit of prophylaxis, Antibiotics - no benefit of prophylaxis, may increase super-infectionmay increase super-infection

Fulminant Strep pneumoniae sepsis Fulminant Strep pneumoniae sepsis has been described after severe has been described after severe submersionsubmersion

Steroids - no demonstrated benefitSteroids - no demonstrated benefit

Other IssuesOther Issues

SURVIVE OR NOT

SURVIVE OR NOT

Will the child die?Will the child die?

Bad prognostic indicatorsBad prognostic indicators

Submerged >10 minSubmerged >10 min Time till BLS >10 minTime till BLS >10 min CPR >25 minCPR >25 min Initial GCS <5Initial GCS <5

Age <3 yearsAge <3 yearsCPR in ERCPR in ERInitial ABG pH <7.1Initial ABG pH <7.1Initial core temp <33oInitial core temp <33o

Neurologic prognosisNeurologic prognosis

Absence of spontaneous respiration is an Absence of spontaneous respiration is an ominous sign associated with severe ominous sign associated with severe neurologic sequelaeneurologic sequelae

Permanent neurologic sequelae persist in Permanent neurologic sequelae persist in ~20% of victims who present comatose~20% of victims who present comatose Minimal brain dysfunction, spastic Minimal brain dysfunction, spastic

quadriplegia, extrapyramidal syndromes, optic quadriplegia, extrapyramidal syndromes, optic and cerebral atrophy, and peripheral and cerebral atrophy, and peripheral neuromuscular damageneuromuscular damage

Near Drowning Near Drowning The Best Approach Therefore:The Best Approach Therefore:

P P revention ! revention ! P P revention !revention !P P revention !revention !

Near Drowning Near Drowning Keeping Your Child SafeKeeping Your Child Safe

Never leave a child alone in or Never leave a child alone in or near water, even for a minutenear water, even for a minute

Limit pool access.Limit pool access.Remove potential hazardsRemove potential hazards

Children with Epilepsy: Children with Epilepsy: Safety RecommendationsSafety Recommendations

Child can swim in lifeguard-supervised Child can swim in lifeguard-supervised swimming pool - no open waterswimming pool - no open water

Older child should shower in a non-glass Older child should shower in a non-glass cubicle - no bathcubicle - no bath

Leave bathroom unlockedLeave bathroom unlocked Supervision!Supervision!

Near DrowningNear DrowningSwimming Pool LoreSwimming Pool Lore

My Child is My Child is “Water Safe” “Water Safe” because he/she has taken because he/she has taken swimming lessonsswimming lessons..

Near DrowningNear DrowningKeeping Your Child SafeKeeping Your Child Safe

Learn CPRLearn CPRUse approved personal Use approved personal

flotation devicesflotation devicesTeach safe water behaviorTeach safe water behavior

RecommendationsRecommendations

Pre-hospital resuscitation, including Pre-hospital resuscitation, including early intubation, ventilation, vascular early intubation, ventilation, vascular access, and administration of access, and administration of advanced life support medicationsadvanced life support medications

Continued resuscitation and Continued resuscitation and stabilization in the EDstabilization in the ED

RecommendationsRecommendations Full supportive care in the ICU for a Full supportive care in the ICU for a

minimum of 48 hrsminimum of 48 hrs Consider withdrawal of support if no Consider withdrawal of support if no

neurologic improvement is detected after neurologic improvement is detected after 48 hours48 hours Ancillary testing such as brainstem Ancillary testing such as brainstem

evoked responses, EEG, and MRI (not evoked responses, EEG, and MRI (not CT) may prove helpful to corroborate CT) may prove helpful to corroborate the neurologic examinationthe neurologic examination