Drowning

Question 1

Define drowning and immersion syndrome

Answer 1

#Drowning
The process of experiencing respiratory im[airment from submersion/emmersion in liquid

It should have its outcomes defined as fatal, morbidity or no morbidity

#Immersion syndrome 
- referes specifically to syncope resulting from cardiac dysrythmias on sudden contact with water that is at least 5 degrees lower than body temperature.

Question 2

Disk risk factors for drowning

Answer 2

Extremes of age 
Intoxication 
Siezure disorders
Autism 
Prolonged QTC syndrome secondary to vagal stimulation from entering cold water

Question 3

Discuss pathophysiology of drowning

Answer 3

Unexpected submersion triggers breathholding, panic and a struggle to surface
Airhunger and hypoxia develop
As breath holding is overcome involuntary gasps result in inspiration - quantity rather than composition determines subsequent pulmonary derangement.

Most droiwning death are associated with aspiration of 10-15ml/kg
Aspiration of 1-3ml/kg of either fresh water or salt water destroys the integrity of pulmonary surfactant leading to alveolar collapse, atelectasis, non cardiogenic pulmonary oedema, intrapulmonary shunting and VQ mismatch.
Profound hypoxia and metabolic and respiratory acidosis ensure leading to CVS collapse

Question 4

DIscuss prognostic factors surrounding drowning patients

Answer 4

Hypoxia
-submersion time

Poor prognosis (at scene)

• age younger than 3
• submersion longer than 5-10 minutes
• initial CPR more than 10 minutes after rescure

Poor prognosis (Arrival at ED)

• hypothermia
• severe acidosis <7.1
• unreactive pupils
• GCS 3
• Asystole or need for ongoing CPR

ORLOWSKI specific

1) age <3
2) estimated submersion >5
3) no attempted resus in first 10 minutes after resuce
4) coma on arrival to the ED
5) metabolic acidosis on arrival to the ED with pH of <7.1

Question 5

Discuss IX of drowning victims

Answer 5

Telemetry and ECG to exclude underlying arrythmia as cause of drowning

ABG
FBC, glucose, U&E for electrolyte (especially if large amount of salt water)
ETOH
LFT and COAGs- may be deranged later in course - including DIC

CXR - may be normal initially and may underestimate the severity of pulmonary injury. Subsequent CXR should be performed if ongoing respiratory symptoms.

Trauma survey if concerns for other injury

Question 6

Discuss management of drowning patients

Answer 6

As this is a hypoxic driven arrest compression only ASL may not be as effective. If cold CPR should continue until warmed to at least between 32-35 degrees

A- c-spine injury are rare in drowning victoms, unless signs of serious trauma or history fo MVA, fall from height or dive into water c-spine immobilization does not need to be performed.
Normal indications for intubation (loss of airway reflexes, inability for O or V)

B - decompression of stomach is essential as likely to have swallowed much more water than aspirated and BVM with CPR is likely to distend stomach impairing ventilation - important for kids
-can develop ARDS and should be ventilated with lung protective strategy

C: Life threatening arrhythmias may be found in drowning as a result of or cause of and should be treated promptly

D

E: potential for significant hypothermia and re-warming is indicated - Comatose patient who have been resuscitated after reasonable submersion time regardless of rhythm should not be re-warmed higher than 34
-full trauma survey should be performed

I: only indicated for patient drowning in grossly contaminated water

Question 7

Discuss prevention of drowning

Answer 7

Children aged 0-14

1) promotion of adult supervision
2) legislation for and compliance with four sided pool fencing
3) promotion of community wide resucure and CPR skills
4) age appropriate water familiarisation and survival swimming skills.

For adolescents and young adults
1) reduce risk taking behaviours and the use of drug and alcohol around water