Download Near Drowning - Driscoll Children`s Hospital

10/1/2015
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Describe the need for a universal drowning
definition
Name two of the organs that may be
impacted from a submersion injury
Describe at least three appropriate
prehospital care interventions in caring for
the submersion injury patient
Identify three possible current nursing
management strategies for managing the
submersion patient
Incidence/recent data
 Males 5 times more than females
 2005-2009 mean 3880 deaths/year
 Estimated 5789 people treated for nonfatal drowning
▪ Difficult to know???
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Preventable measures
 Fence (self closing gate)
 Unattended children
▪ Lifeguard distracted (socializing, other duties or chores)
 Poor pool maintenance
▪ Murky waters make it difficult to see
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2005 Data
 Most prevalent from May to August
 After 1 year of age males account for 75% of
drowning deaths (riskier behavior?)
 Age distribution (peaks)
▪ <5 years:
pools, bath tubs, liquid filled containers
▪ 1-4 years 50% die in swimming pools
▪ 15 – 25 years: natural bodies of water
▪ Beaches-rip currents account for 80%
 Boating drownings: 50% R/T ETOH
▪ >50% adult drownings believed to be R/T ETOH
 Epilepsy (tub)
 LQT Syndrome/Heart issues
▪ Cold water and exercise
arrhythmias in LQT Syndrome?
▪ Long QT syndrome difficult to
prove but mutations have been
identified on some drowning victims
▪ Catecholaminergic polymorphic VT?
 Suicide/homicide
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Infants < 1 year of age
 About 50% drownings occurred in bathtub
 Medical eval, search for other injuries, get social
work involved
 Abuse, neglect?
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Various, ambiguous, terminology (at least 20)
 Near drowning, silent drowning, passive
drowning, wet/dry drowning etc. etc. etc.
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No uniformity has caused confusion
 Amongst clinicians
 Amongst data interpreters
▪ Studies inconsistent
▪ Enhance future reporting and enable greater analysis for
better treatment options
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2002 World Congress of Drowning
 “Drowning is a process resulting in primary
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respiratory impairment from
submersion/immersion in a liquid medium.”
Term drowning used no matter the outcome
Outcomes should be classified as death,
morbidity, or no morbidity
Discourages use of other terms ie wet/dry
drowning, near drowning etc.
Def accepted by WHO, CDC, ILCOR, AHA
Head above water
 Child struggles 20 seconds
 Adult struggles 60 seconds
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Head below water = panic and hold breath
H2O in oropharynx/larynx may trigger
involuntary laryngospasm (7-10%)
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No gas exchange
(hypoxia/hypercarbia)=acidosis
Water is swallowed
Prolonged hypoxia ceases laryngeal
spasm/obstruction (if occurred)
Victim inhales liquid
Victim’s O2 levels quickly dwindle
Not enough O2 to the brain
 Loss of consciousness
 Apnea
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Changes in lungs, body fluids, pulm edema,
pulm hypertension
 Death results from prolonged
submersion R/T hypoxia
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Dry drownings happen about 2%
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Fresh vs. saltwater
Floating in Dead Sea
 Not much difference as
earlier thought (canine studies)
 Aspiration of 22ml/kg
for electrolyte change
 Aspiration of 11 ml/kg
for blood vol change
 Avg. aspiration 2-4 ml/kg
 Aspiration of fluid content may be clinically relevant
▪ Silt, mud, sewage, bacteria , seaweed, sand, etc.
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Salt water
 Impurities and bacteria
 Pseudomonas putrefactions, Staph. aureus
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Cascade of events leading
to secondary drowning
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Lung changes (variable length of submersion)
 Sig. impairment to gas exchange aspiration (1-3
ml/kg)
 Surfactant washed out
▪ Alveolar instability
▪ Atelectasis
▪ Dec. lung compliance
▪ V/Q mismatch
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Damage to alveolar-capillary membrane
leads to pulmonary edema
Asp. Fluid causes vagal reflexes
which causes pulmon.
vasoconstriction and
pulmon HTN
Aspirate vomit further complicate acute lung injury
Bronchospasm
 Fluid in airways
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ARDS (evidence usually occurs promptly)
 Noncardiogenic Pulmonary Edema
 Impaired oxygenation
 Bilat. Pulm infiltrates
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Cardiovascular Effects
 Hypovolemia R/T increased capillary permeability
 Rewarming (surface)associated with vasodilatation
 Pulmonary HTN
▪ Difficult to pump blood to lungs
▪ Less blood returns from lungs
▪ Decreased cardiac output
 Decreased cardiac output R/T hypoxemia, acidosis
 Myocardial dysfunction R/T arrythmias
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CNS effects
 Initial injury R/T tissue hypoxia and ischemia
 Secondary injury
▪ Reperfusion, Cerebral edema, Excitory transmitters
▪ Impaired cerebral autoregulation
▪ Hypotension
▪ Sustained acidosis
▪ Hyperglycemia, hypoglycemia
▪ Seizures
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Hypothermia
 Hypotension, bradycardia, conduction abnormalities
▪ Hypotension from cold water diuresis
 Antiarrythmics, insulin may be ineffective and
accumulate to toxic levels R/T slowed metabolism and
excretion
 Neuro protective if rapid hypothermia prior to cardiac
arrest
▪ Icy water submersion (<10-20 C)
▪ Mammalian diving reflex?
▪ Not happening here?
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Drowning
 Factors (anything that can precipitate syncope)
▪ Seizures, hypoglycemia, hyperventilation (divers 87 vs
146 sec), hypothermia, ETOH, drugs, trauma
▪ Epileptics (15-19 times more likely to drown)
▪ LQTS (exertion, cool water, swimming)
▪ Stroke, heart attack (older pop)
 What caused the drowning??
 Most want to breathe so don’t cry for help
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Treatment of drowning patients
 Minimally asymptomatic
▪ Small cough, no foam at mouth or nose
▪ Usually released with instructions to watch for signs
 All patients with respiratory symptoms
▪ Dyspnea, foam, rales
▪ Transport with O2
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BLS at scene (biggest factor influencing survival)
 ABC not CAB
▪ IF in water pulse check unnecessary
▪ If not in full arrest should
respond with few breaths
▪ IF out of water
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Credit Wellcome Library
Prior to compressions
 AHA – 2 breaths
 ERC-5 breaths
▪ Pulse may be hard to feel
 Bradycardia, hypoxemia,
 Hypothermia, vasoconstriction
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Cervical spine injury
 Very uncommon
 11 out of 2244 victims (0.5%)
▪ All had signs of trauma
▪ Diving, motor vehicle crash
 Use caution but don’t delay resuscitation
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Remove from water
Maintaining airway
 Jaw thrust
 Obstructed with foam or water
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Rescue breathing in water useful
 Ventilation and O2 most important initially
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Chest compressions in water?
Heimlich maneuver?
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100% oxygen
 Until pt is able to keep sats >mid 90’s
 Intubate?
▪ Supraglottic airway (LMA)?
 PPV use cricoid pressure
▪ Full stomach
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Suction
 Vomit
▪ Lateral decubitus
▪ Suction equipment (soft tipped, yankauers, etc)
 Pulmonary edema (copious secretions)?
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Remove wet clothing if possible
Cover with blankets
Monitor VS
Monitor for further vomiting
Monitor for deterioration
 Pulmonary edema
 Shock
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History
 Fluid pt was submerged in
 Temperature of solution
 Duration of submersion
 Resuscitative efforts at scene
 Response to efforts
 ETOH/drugs suspected (Narcan??)
 Pre-existing conditions or diseases
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Crucial in management (full neurologic recovery)
 60 minutes in icy water?
 20 minutes in cool water (5-10 mins by other source)?
 Hot springs or hot tubs much shorter times
Submersions (non icy) greater than 25 mins
likelihood for poor outcome approaches 100%
 Inaccurate (rough estimate)
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 Emotional excitement
 Time of call to rescue arrival
 Hence, attempt to resuscitate all victims
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Drowning scope can range from asymptomatic
patient (dunked) to pulseless arrest
 Asymptomatic (observe for approx 4-8 hours then
discharge if physician decides with instructions to
responsible parent/adult about symptoms)
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Awake, alert
No adventitious breath sounds
No required rescue breathing or supp O2
Normal pulse ox
Normal x ray
Resuscitation
 PALS guidelines but ABC
 Usually tachycardia then bradycardia then PEA the
asystole
 Hypothermic (<35 C core temp) patient (effects include
arrythmias, coagulopathy, impaired immune function,
acidosis)
▪ May appear dead d/t profound bradycardia, intense
vasoconstriction, marked depression of brain and cardiovascular
patient, dilated pupils—begin CPR if unsure
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AHA unsure of what temp to start defib
 Try at least once—may keep trying? (says to follow
PALS/ACLS protocols)
 Medications
▪ “may be reasonable to consider administration of a
vasopressor during arrest” AHA 2010 Part 12 Drowning
▪ Ice water drowning rewarm core to minimum of 30 C before
stopping CPR—others experts say higher
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European Resuscitation Council
 Suggest 3 defibrillations performed
 Hold Epi until core temp > 30 C, then double time to
next dose until temp >35 C
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Resuscitation
 Hypothermia (never allow hyperthermia)
▪ Aggressive attempts to restore normal body temp and
establish safe steady warming rate while maintaining
cardiac stability
▪ Rewarm pt 1-2 C/hour to 33-36 C
▪ Passive rewarming
 Remove wet cold clothing
 Warm blankets to insulate patients
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Resuscitation
 Hypothermia
▪ Rewarming techniques
▪ Active external rewarming
 Hot packs
 Heat lamps
 Forced air external rewarmers
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Resuscitation
 Hypothermia
▪ Active internal rewarming
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Warmed humidified O2 (mask, ETT)
Warmed IVF (40-44 C, shortest possible tubing length)
Warm saline lavage (gastric, peritoneal, rectal, mediastinal)
ECMO (preferred treatment for victim with persistent cardiac
instability)
Treat shock (tissue perfusion,
tachycardia, pulses, cap refill,
ALOC, oliguria, etc)
 Myocardial dysfunction (hypoxia, acidosis)
 Fluid shift
▪ 20 ml/kg to achieve euvolemia (wary of pulm edema)
▪ Inotropes
▪ Dobutamine
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Respiratory
 Intubation (age formula vs Broselow tape)
Protects airway
▪ Cuffed vs. uncuffed
▪ Allows administration of higher O2 conc. (protect brain)
▪ Steroids not proven to help and may interfere with
healing
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Respiratory
 PEEP (pulmonary edema, decreased lung compliance)
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Recruit atelectic areas of lungs (improve ventilation)
Dec degree intrapulmonary shunting
Dec. V/Q mismatch
Shifts interstitial pulmonary water into capillaries
Inc. diameter small and large airways to improve distribution of
ventilation
▪ Start usually at 5 and inc from there watching oxygenation and
blood pressure
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Respiratory
 Bronchodilators for bronchospasm (albuterol)
 Surfactant administration
▪ Case studies have shown some effectiveness in peds but
not adults
 Wean vent after 24 hours?
▪ Allows time for surfactant regeneration
▪ Pulmonary edema may recur if not resolved sufficiently
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Methods of ventilation
 Changes in lung compliance, airway resistance,
cardiovascular status
 Maintain normocarbia and adequate oxygenation
 Prevent ventilator associated lung injury (low tidal
volumes, high PEEP)
 HFOV
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Save the brain (cerebral edema
ICP R/T hypoxic neuronal injury)
 Maintain adequate oxygenation, ventilation
(avoid hyperventilating, ETCO2 trends with ABG)
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Hyperventilate as temporary measure (surgeon on way)
 Avoid hypotension, hyperthermia (exacerbate
neuro damage)
 Avoid /treat hypo or hyperglycemia
▪ Keep within a range
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Save the brain
 Treat seizures
▪ Increases blood flow
▪ Consumes cerebral O2
▪ May not see (cont EEG?)
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Save the brain
 CP monitoring not warranted but may choose to
(still treat but no proof of better outcome)
 Continue to elevate HOB 30 (C-spine cleared)
 No proof of benefit from barbiturates
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Therapeutic hypothermia not working
(increased sepsis)?
 Some experts maintain to consider this option
early in course
▪ Neouroprotective
▪ Some say if pt hypothermic with ROSC, then try it
▪ Many variables at play may not reflect on research
studies
▪ Vfib cardiac arrest vs asphyxial cardiac arrest
 NGT/OGT
▪ Removes swallowed water/debris
▪ Warmed gastric saline lavage
▪ Helps ventilation so lungs can expand
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Pneumonia
 Pneumonia after submersion showed 60%mortality
rate
▪ Aeromonas highest mortality rate
 Prophylactic ATB not recommended
▪ Unless exposure to grossly contaminated water i.e. sewage
 Tracheal and blood cultures usually drawn in ED
▪ ATB started at 1st signs infection—many will present with
them
 Patients with signs of pneumonia, bacterial cause
should be found and treated…if not coverage should
be aimed at prevalent nosocomial flora of hospital
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Special considerations
 Bronchoscopy (removal foreign bodies, debris)
▪ Silt or sand from surfing accident
 ECMO
▪ Extreme hypothermia
▪ Lung injury (evidence lacking but survival case studies published)
▪ To help remove CO2 (help the brain)
▪ Technologically challenging, practical, logistical issues
 ARDS
▪ Altered surfactant volume or function, neurogenic pulmonary
edema complicates submersion injury
▪ High mortality rate
▪ Permissive hypercapnea to avoid barotrauma may not be an option
with hypoxic CNS injury
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Poor prognosis---No high quality evidence to
predict poor neuro outcomes
 Submersion time > 5 minutes, others say 10 minutes
 Time to BLS > 10 minutes
 Resuscitation > 25 minutes
 Age > 14 years
 GCS < 5 (comatose, about 75% predictive)
 ABG pH < 7.1 upon presentation
 Pupils not reacting after 24 hours (post resuscitation)
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Poor prognosis
 No pupil response 24 hours after resuscitation
(TH)
 EEG patterns (burst suppression, loss of reactivity
to stimulation)
 CT scan
▪ First 24 hours may look normal
▪ Loss of gray/white matter differentiation and/or cerebral
edema associated with poor prognosis in patients that
have arrested
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Prognosis
 Peds more likely to get ROSC than adults from
drowning
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More witnesses, more people to help (bystander CPR)
Comorbidities of adults
Protective mechanisms (diving reflex)
More aggressive treatment
 Unfavorable neuro outcome
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Where do we go?
 Prevention
Questions?
Resusci Anne –drowned in the 1880’s France
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Available upon request
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