Near Drowning
Resident Rounds
June 26, 2003
Robbie N. Drummond
Not Waving but Drowning
Stevie Smith
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Nobody heard him, the dead man,
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But still he lay moaning:
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I was much further out than you thought
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And not waving but drowning.
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Poor chap, he always loved larking
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And now he's dead
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It must have been too cold for him his heart gave way,
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They said.
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Oh, no no no, it was too cold always
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(Still the dead one lay moaning)
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I was much too far out all my life
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And not waving but drowning.
IV. DEATH BY WATER (from the Wasteland, T.S. Eliot)
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PHLEBAS the Phoenician, a fortnight dead,
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Forgot the cry of gulls, and the deep seas swell
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And the profit and loss.
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A current under sea
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Picked his bones in whispers.As he rose and fell
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He passed the stages of his age and youth
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Entering the whirlpool.
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Gentile or Jew
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O you who turn the wheel and look to windward,
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Consider Phlebas, who was once handsome and tall as you.
The Tempest by Willy Boy the Spear Shaker
Act I Scene ii
 ARIEL sings]
 Full fathom five thy father lies;
 Of his bones are coral made;
 Those are pearls that were his eyes:
 Nothing of him that doth fade
 But doth suffer a sea-change
 Into something rich and strange.
 Sea-nymphs hourly ring his knell
 Hark! now I hear them,--Ding-dong, bell.
 FERDINAND The ditty does remember my drown'd father.
YODA’s 7 QUESTIONS ABOUT DROWNING
 There are a lot of terms to describe drowning how do I wade through
them all?
 What is the real difference between fresh and salt water drowning?
 How common is drowning are there any preventative measures to be
taken to avert death by water?
 There is a drowning victim in the ED what are the factors that suggest
he will survive?
 What is the best approach to resuscitating a drowning victim?
 What about the prophylaxis measures previously taken, steroids, hyper
therapy, antibiotics....etc.?
 Survivors of drownings usually are hypothermic what is the relation
between hypothermia and drowning?
There are many terms to describe drowning how do I wade
through them all?
 gets complicated..... Drowning, near-drowning, drowning
with/without aspiration, dry drowning, wet drowning,
secondary drowning, submersion vs immersion, immersion
syndrome,
 ORLOWSKI feels too complicated was supposed to imply
prognosis but does not
 Drowning “ suffocation by immersion or submersion in
any liquid medium, caused by the entrance of liquid in the
airways that partially or fully compromises ventilation or
oxygen exchange”
basic definitions
 drowning death within 24 hours of submersion
 near drowning death after 24 hours of submersion
 secondary drowning death from a complication of
submersion
 one author secondary drowning cause of death not related
to water (eg MI)
 drowning with or without aspiration
 immersion vs submersion partially vs totally covered
 aspiration of other fluids bodily etc
wet vs dry drowning
 10% no fluid found in lungs
 severe laryngospasm, hypoxia, convulsion and death
 one author “dry drownings probably do not exist.... if there
is no water in lungs victim probably not alive when entered
water”..... A la Brian Jones of the Stones.... It was Mick
and Keith, the glimmer twins, don’t you know it?
13 % of all drownings happens after
precipitating event
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drugs 36% (usually alcohol)
convulsion 18 %
trauma 16 %
cardiopulmonary 14%
SCUBA 3 %
others 11 %
My mother told me to splash water on my face
before.....
 Immersion Syndrome
 syncope provoked by arrhythmia
 sudden contact with water at least 5 degrees less than body
temperature
 syncope loss of consciousness and secondary drowning
 massive release of adrenaline
 reduced by wetting face and head before entering water
How common is drowning are there any preventative
measures to be taken to avert death by water?
 90 % of all drowning deaths occur within 10 meters of
safety
Some watery numbers
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500,000 per year worldwide
third most common cause of unintentional death
10 saves and five near drownings for every drowning
1996 62,747 rescues
55-60% less than 20 years of age
African-Americans two time rate of Caucasians
males five times as often as females
costs 6.5 billion buckaroos in US alone
bimodal distribution
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toddlers less than 2 and teenage boys 10 - 19 years
teenager (boys) risk taking, alcohol factor 60% of time
bathtubs usual site under one year of age
many as a result of abuse
bucket- related deaths
older toddlers pools
children and adolescents fresh water
POOLS
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50, 000 new pools built every year in USA
2.2 million residential pools
2.3 million nonresidential pools already in existence
in temperate areas of USA 70 - 90 % of drowning occur in
pools
PUBLIC HEALTH
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proper pool fencing and supervision
training in swimming and water safety essential
not leaving child unattended near tub or pool
personal flotation devices while boating
proper training, SCUBA boating etc
solar blankets support weight of toy not children hides
drowning child
 citizens trained in CPR
 avoidance of alcohol
PREVENTION
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the key to minimizing morbidity is successful prevention
AAP 23 recommendations
swimming lessons a good idea
but sometimes children not aware of their skill level and
parents not cautious enough
RISK FACTORS FOR SUBMERSION
ACCIDENTS
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, seizures, trauma, Etoh, hyperventilation,
drugs of abuse, hot tubs, hypothermia,
cvs disease, child abuse, diabetes, suicide
inability to swim
53% of individuals with a submersion incident over age
26 blood etoh >100
 9% of suicides due to drowning
 Time of day: toddler drowning :
 meal preparation times early evenings
What is the real difference between fresh and
salt water drowning?
 animal models (ie threw man’s best friend in water to see
what happens)
 struggle small amounts fluid hypopharynx laryngospasm
 swallowing water
 laryngospasm abates aspiration large amounts water
 vomiting aspiration of gastric contents
 evolving hypoxemia , circulatory collapse
 myocardial damage, and multiorgan failure
 ischemic brain injury....death
the Pacific vs Georgian Bay
 for many years suggested difference between fresh and
salt water drowning
 give dogs 44 ml /kg fresh water causes potassium
disturbance
 previous theory was fresh water more hypotonic
 hemodilution hyper volemia, red cell rupture
 dilution of pulmonary surfactant alveolar collapse
 sea water hypovolemia, and increased electrolyte
hemoconcentration
 fluid movement from intravascular to alveoli
In reality....
 more than 11 ml per kg for change in blood volume
 only 15% who die in the water aspirate more than this
quantity most less than 4ml/kg
 22 ml/kg for changes in electrolytes
 in a study by spilzman 1994 187 drowning victims had no
electrolyte abnormality
 seawater drowning does not cause hypovolemia
 freshwater drowning does not cause hypervolemia,
hemolysis, or hyperkalemia
no difference
 from clinical point of view no difference fresh vs salt water
 most immediate cause is hypoxia and metabolic acidosis
 both produce surfactant destruction alveolitis,
noncardiogenic pulmonary edema
 disruption of gas exchange increased shunt leading to
profound hypoxia
 as little as 1 ml /kg aspiration profound alterations in gas
exchange decreased compliance
 cerebral hypoxia is the final common pathway
 resp disturbance more on amount than type of water
2 small points
 sometimes physiologic changes many hours after insult
 water may be contaminated with chemicals, bacteria, sand
etc.
DEAD SEA
Dead Sea
 unless you drown in the dead sea (Yagil et al arch In Med
1985)
 one case hypercalcemia and hypermagnesemia
What is the best approach to resuscitating a
drowning victim?
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drowning victims present risk to rescuer
approach with caution or intermediate object
instinctive drowning response
drowning victims unable to call for help
upright position slapping or thrashing water
children 10 - 20 seconds
adult up to 60 seconds
CPR ASAP SVP
 first description of CPR 1600’s : Paracelcus a Swiss
physician
inserting fireplace bellows in the victim’s mouth or nostrils
 always remember underlying causes for drowning
 caution re neck injuries
 citizens trained in CPR
 in water CPR usually ineffective and dangerous
 delay in CPR prolongs hypoxia
 because circumstance are never clear
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resuscitation should always be initiated in the field
drowning victims swallow much more water
than they inhale
 no attempt to remove water from lung
 great quantities of water in stomach likely to aspirate
 Heimlich himself suggested his maneuver to expel water
from lungs,,,, counterproductive
 gastric acid aspiration from abdominal pressure
 lots of fluid in stomach
 up to 60 % of drowning victims vomit
 right lateral decubitus head down ? Sellick’s maneuver
 high risk for vomiting spontaneously or on resuscitation
There is a drowning victim in the ED what are
the factors that suggest he will survive?
ORLOWSKI’s 5 unfavourable prognostic factors
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age of 3 or less
submersion > 5 minutes
no attempts at resuscitation for 10 minutes
coma on admission to ED
severe acidosis pH <7.1
 lack of controlled studies which factors greatest impact
<2.... 90 % recovery
 >3.... 5 % likelihood of recovery
Check out the GCS
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GCS adds predictability
2-6 hours after if no improvement unlikely to improve
if some increase GCS 50%
if alertness normal sequelae limited
other factors
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resuscitation > 25 minutes
asystole on arrival at hospital GCS < 5
elevated ICP, coma or CPR needed in ED
some survival in some individuals with some or all of
these factors
water temperature, duration and degree of hypothermia
the diving reflex, the victim’s age, water contamination,
duration of cardiac arrest
the speed and effectiveness of initial treatment cerebral
resuscitation
success of resuscitation major determinant of
outcome
 prognosis response to serial neurologic exams
 3 point improvement on GCS on arrival to ICU portends
 100 % full recovery in pediatric population
 conscious on arrival excellent chance of survival
 CONN scale alert 100%’
 blunted mortality rate 10%
 comatose greater than 35%
The Opposite of Drowning?
What is the best approach to resuscitating a
drowning victim in ED?
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continuous cardiac monitoring
observation for 4-6 hours if asymptomatic
serial ABG measurements (Arterial line)
oxygen therapy
NGT and FOLEY
ETT degree of respiratory distress pa o2 below 50 paco2
greater than 50%
Read my lips “it’s the anoxia, stupid!!!”
 grading system from 1 to 7 based on need for aggressive
airway intervention
 grade 2 only by cannula, grade 4 mechanical
 pneumothoraces usually as result of baro trauma
 most significant implication is anoxic ischemic cerebral
insult
 most common cause of late death
 every effort to maintain oxygenation and prevent cerebral
edema
r/o other cause of injury
 toxicological insult spinal injury
 evaluate and treat associated conditions,
 hypovolemia, hypothermia, hypoglycemia
 careful neurological assessment and reassessment
both respiratory and metabolic acidosis
 may still need fluid resuscitation despite pulmonary edema
 shock is uncommon in drowning
 do not use furosemide to treat pulmonary edema may need
volume
 in ICU many patients will need PEEP
 ARDS common in drowning same management as any
ARDS patient
 delayed onset of pulmonary edema (up to 12 hrs)
PATHOPHYSIOLOGY
 although some difference drowning is an asphyxia injury like like
hanging, foreign body aspiration, apnea etc
 noncardiac pulmonary edema, noncardiogenic pulmonary injury,
surfactant loss, inflammatory contaminants, and cerebral hypoxia
 global hypoxic ischemic event affecting brain, lungs, and heart
 cardiovascular function usually preserved
 aggressive pulmonary support is required to prevent long term
sequelae of hypoxia
 optimal treatment for anoxic brain injury remains unclear
 no prognostic scale accurately predicts long term neurologic outcome
Consequences global hypoxia
 cns dysfunction from initial hypoxic injury increased ICP
edema
 aggressive control of cerebral perfusion pressure
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does not improve out come
 CNS damage progresses after circulation reestablished
 cardiac dysrhythmias : a result of hypoxemia/acidosis
 low cardiac index elevated right and left heart filling
pressures increased SVR
 renal failure uncommon
 coagulopathies esp DIC and hemolysis
What about the prophylaxis measures
previously taken, steroids, hyper therapy,
antibiotics....etc.?
 prophylactic antibiotics of limited use
 treat when infection
 antibiotics only if grossly contaminated water
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contributing to injury is aspiration of sand bacteria algae or
particulate matter emesis and chemical irritant
 corticosteroids of limited use
HYPER THERAPY
 early theory (BOHN Critical care medicine 1986)
 hyperhydration, hyperventilation, hyperpyrexia, hyperexcitability, hyperrigid
 suggested use of diuretic, hypothermia, barbituates
glucocorticoids barbituate coma, muscle paralysis and
monitoring and treating of ICP
 subsequent reviews failed to show improvement with these
protocols
 most centers no longer use hyper therapy
 current approach supportive care
disposition
 four groups
 1) no evidence of sig. submersion d/c’d quickly
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cxray and abg unnecessary serial sats reassuring
pts without any symptoms and completely normal respiratory
status may be discharged with instruction to return immediately if
respiratory distress developed
 2) asymptomatic after sig. episode observed for four to six
hours then d/c’d
 3) poor oxygenation mod hypoxemia admitted followed
once o2 resolved ....home
??? ICU
 final group... Intubated: depends on neurological status
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any respiratory complaints or symptoms, cxray abnormalities,
demonstrated oxygen requirement monitored for 24 hours usually
in ICU
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any patient with LOC, cyanosis, or apnea, CPR or resuscitative
efforts need to be monitored closely
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GCS needs to be done sequentially
CXRAY
 20 % of severe drowning normal cxray
 typical findings perihilar infiltrates, pulmonary edema
Pediatrics
 peds use fairly aggressive PEEP protocol
 increased risk of nosocomial infection
 children larger surface area less fat more prone to
hypothermia
 hypothermia some degree of protection
 rapid cooling necessary in icy water <5 deg to offer
benefit
 usually severe hypothermia increased mortality
 large costs realistic goal re prognosis
 families need time to adjust
POOR PROGNOSIS IF:
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absence of cognitive function / recovery 48 -72 hours
seizures beyond 12 hours
despite early enthusiasm, ICP monitoring: no benefit
CT only helpful if ass’d with other injury
MRI day 1 and day 3 change helpful in predicting outcome
EEG often obscured by drugs and resuscitation
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persistent flat tracing attenuated record without med or burst suppression
poor prognosis
 brainstem evoked potential: controversial many confounding factors
 most useful for predicting outcome is repeated clinical neurological
examination
Survivors of drownings are often hypothermic
what is the relation between hypothermia and
drowning?
 continue resuscitation till core temperature 30 -35degreesC
 one child recovered successfully after 66 minute
immersion in cold water
 hypothermic protection dependant on slowing cerebral
metabolism before irreversible damage
 works with sudden immersion in very icy water or in
victims above water cooling before immersion
HYPOTHERMIA
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definition core temperature less than 35 degrees
significant pathophysiology develops below 35 degrees
primary direct exposure to cold
secondary systemic disorders
heat preservation shivering, autonomic and endocrinologic
responses.... adaptive behavioral responses
35-32-27....mild, moderate, severe
 mild 32 -35
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32 -35 shivering stops, hr and bp decline, oxygen consumption
declines
depressed CNS increase metabolic rate & pulse , dysarthria,
amnesia, ataxia, apathy
 moderate 27 - 32
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decreased loc and vitals, shivering extinguished, arrhythmias, qt
prolonged, j wave (Osborne) cannot rewarm spontaneously
cold diuresis
Severe Hypothermia
 severe less than 27 degrees coma and areflexia with
 profoundly depressed vital signs
 co2 production decreases 50% for each 8 degrees fall in
temperature
 increase heat loss impaired thermoregulation
 extreme bradycardia spont VF or asystole
 coagulopathy prolonged clotting times and platelet
dysfunction
physiologic changes
 protein binding increases temp drops drugs ineffective
 wait with monitoring 60 second before initiating CPR
 most recommend CPR with PEA even with profound
hypothermia
 pulse oximetry accurate in hypothermic patients
 caution irritating heart in central line insertion
 most rhythms revert spontaneously with rewarming
 most VF refractory until rewarmed
 three shocks trial if unsuccessful rewarm CPR attempt at
higher temperature
changes in hypothermia
 tachycardia disproportionate to temperature suspect
hypoglycemia hypovolemia or OD
 hyperventilation suggests A CNS system lesion systemic
acidosis DKA or lactic acidosis
 cold induced rectus spasm and ileus may mask or mimic an
acute abdomen
 need core temperature
 anemia is masked because hematocrit increase 2% per 1
degree drop in temperature
 leukocytes sequestered
active rewarming
 passive vs active warming
 passive noninvasive
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involves simply covering the patient in a warm environment
 active rewarming if cvs instability
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temperature less than 32.2
 active core rewarming heated humidified air inhalation,
heated infusion lavage, extracorporeal rewarming
Invasive techniques
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thorocostomy tube irrigation
IV fluids 40- 42 degrees
double catheter peritoneal lavage
2 liters of 40 -45 degrees NS suction after 20 minutes
extracorporeal rewarming
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cardiopulmonary bypass arteriovenous and venovenous rewarming
hemodialysis lifesaving in cardiac arrest situations
caution:
 drop in core temp after initiation of rewarming
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temperature equilibration circulatory
return of cold peripheral blood to the core
 overwhelms a depressed cvs system
 vasoconstricted skin prone to burning caution with
warming extremities
What is the Diving Reflex?
 mammalian response
 protective bradycardia shunting blood to brain and heart
 victims age ration of body mass to surface area development of
hypothermia
 hypothermia more protective in children than the diving reflex
 water must be 10 degrees or colder
 sudden immersion in cold water can cause ventricular fibrillation
 controversy over diving reflex
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breath holding intense vaso constriction bradycarda decreased Cardiac
output and increased MAP selective vasoconstriction and heart and CNS
perfused
 breath holding reduced when children submerged in cold water
Answers to Yoda’s seven questions
 drowning is a form of asphyxia main injury is anoxia and its
consequences
 there is no clinical difference between fresh and salt water drowning
 90% of drowning occurs within 10 meters of safety prevention is the
key
 level of consciousness on presentation to the ED best prognostic
indicator followed by sequential neurologic assessments
 main features of management is aggressive respiratory support
 prophylaxis is not indicated
 the usual dicturm applies the patient is not dead till he is warm and
dead
Yoda’s real feeling about water
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Nothing in the world is more flexible
and yielding than water.
Yet when it attacks the firm and strong
none can withstand it,
because they have no way to change it.
So the flexible overcome the adamant,
the yielding overcome the forceful.
Everyone knows this,
but no one can do it.
This is why the sages say
those who can take on the disgrace of nations
are leaders of lands;
those who can take on the misfortune of nations
are rulers of the world.
True sayings seem paradoxical.
References
 DROWNING Pediatric clinics of North America June
2001Orlowski et al
 EMR June 1997Schwab et al Emergencies of Summer
 NEAR DROWNING Critical Care Clinics April199
Sachdeva
 SUBMERSION AND ASPHYXIAL INJURIES Ibsen and
Kock Critical Care medicine Nov 2002
 TINTINELLI’s 2002
 Rosen’s 2002
 EMERGENCY MEDICINE SECRETS THIRD EDITION
Markovchick 2003+
the (deep) end