14.3 - Drowning Flashcards
A 20-year-old man is brought to the emergency department having been pulled from a river where he got into difficulties whilst swimming.
a) Describe the relevant history (5 marks) and
investigations (8 marks) for this patient who has suffered near-drowning.
> > Medical history:
seek possible medical cause for near-drowning
such as
epilepsy,
arrhythmia,
cardiac history,
uncontrolled diabetes.
> > Toxins:
drugs, alcohol ingestion.
> > Trauma:
may have associated injuries such as
injury from a boat, diving,
debris in water, foul play.
> > Scene:
timings, duration of submersion,
contaminants in water,
type of water (this question says river),
ambient and water temperature.
Witnesses useful.
Investigations for near drowning
> > Core body temperature.
> > Capillary blood glucose:
• Poor control of diabetes may be cause of events.
• Target normal blood glucose to maximise
neurological outcome.
> > Arterial blood gases:
• Likely hypoxic, hypercapnic, with lactic acidosis.
> > Venous blood:
• Urea, creatinine, creatine kinase. Acute kidney injury may develop from myoglobinuria, hypoxaemia, hypoperfusion, haemolysis.
• Electrolytes. Occasionally, electrolyte changes from fluid shifts.
• Full blood count and coagulation. Disseminated intravascular coagulation may occur.
• Toxicological assays for drugs and alcohol.
> > 12-lead ECG:
• Risk of arrhythmias due to hypothermia, hypoxia, acid-base disturbance.
• May identify underlying cardiac event.
> > Chest x-ray:
• Risk of ARDS.
> > Transthoracic echo:
• May help optimise cardiovascular management in the presence of instability.
Trauma imaging:
• Cervical spine imaging, CT head, as indicated by history and examination.
» Microbiology:
• Sputum or tracheal aspirates once intubated. May help with antimicrobial management in the presence of developing sepsis
b) He has a Glasgow Coma Score of 13 but is found to have an arterial oxygen partial pressure of 6 kPa
(45 mm Hg) breathing 4 l of oxygen via a variable performance mask.
Outline your initial management of this patient. (7 marks)
I would call for help and adopt an ABCDE trauma team management approach to this patient, assessing and treating him simultaneously as issues are revealed.
A:
» Assess airway patency, open airway.
> > Prepare for rapid sequence induction (RSI) if patient unable to maintain own airway or does not respond rapidly to measures to improve breathing adequacy.
> > Cervical spine control with all airway manoeuvres if there is any possibility
of injury.
B:
» 100% oxygen by non-rebreathe bag, saturations monitoring, aim to rapidly improve PaO2 as monitored by ABG. Need to resolve hypoxia to reduce risk of secondary brain injury. GCS may improve with better PaO2. Move on to preoxygenation with a tight-fitting mask if insufficient improvement.
> > Chest examination and auscultation may give evidence of associated injuries (including pneumothorax), developing ARDS, foreign body inhalation.
> > If PaO2 and GCS not rapidly improving with higher inhaled oxygen concentration, proceed with RSI (stomach likely full of water), intubate.
> > Consider orogastric or nasogastric (if no associated head injury) tube to empty stomach of water and facilitate ventilation.
> > Lung protective ventilation: 6 ml/kg, high PEEP, 100% oxygen initially.
> > CXR may demonstrate ARDS, foreign body aspiration (e.g. sand – consider bronchoalveolar lavage).
C:
» Large-bore intravenous access.
> > Intravascular depletion occurs due to pulmonary and systemic extravasation.
> > Warmed intravenous fluids with cardiac output monitoring guidance.
> > Arterial cannulation to monitor blood pressure and blood gases. Aim MAP greater than 80 mm Hg for neuroprotection.
> > Inotropes or vasopressors may be required.
> > Monitor for, and manage, arrhythmias caused by hypothermia or electrolyte disturbance.
> > Catheterise. Monitor urine output as an indicator of end-organ perfusion.
D:
Manage secondary brain injury risks:
» Maintain glucose 5–10 mmol/l.
> > Warm to 34°C only: warmed fluids, forced air warming, electrical warming pads for 24 hours (fully rewarm if patient is not intubated).
> > Observe for seizures; treat with benzodiazepines as first line.
> > 15–20 degree head-up tilt.
> > Care with tube tie tightness – do not obstruct venous return.
E:
» Manage coexisting injuries, or precipitating causes.
