Drowning

Question 1

What proportion of apparently dead (fixed dilated pupils, coma) drowning patients, make a full recovery?

Answer 1

10-20%

Prolonged ALS indicated.

Question 2

Pathologies potentially associated with drowning:

Answer 2

TBI/SCI
Hypothermia
Diving/decompression illness
Intoxication/ psychiatric
NAI/ neglect in children

Question 3

Pathophysiology of drowning:

Answer 3

Initial breath holding (1min)
Involuntary breath
Laryngospasm
—> swallow water ++ whilst gasping
Apnoea and aspiration

—> Surfactant wash out, compliance reduced 5-10x
—> Bronchospasm
—> Massive pulmonary oedema (3x the aspiration volume)

Hypoxic MODS

Consider complication/ concurrent processes: trauma, hypoxia. Etc.

Question 4

Resus priorities in drowning:

Answer 4

Early rescue breaths
Cspine precautions
Hypothermia Mx
Prolonged ALS
- At least 30mins, even if moribund
- Longer if cold
- Do not resus above 32deg if ARRESTED: therapeutic hypothermia
AIRWAY
- High risk aspiration (water swallowed). Lateral decubitus, suction, NGT
BREATHING
- Compliance massively reduced- early PPV
- ARDS/ lung-protective strategy
- Aim sats >94%
- Consider bronchodilators
-Marine antibiotics
- Aspiration (pseudomonas, aeromonas)
DISABILITY
Electrolyte correction
- Often hypoosmolar from swallowed water
Neuroprotective

Question 5

Period of observation after near-drowning:

Answer 5

WATER RESCUE ONLY: ie. no history of cough, resp Sx
—> discharge without Ix.

MILD: asymptomatic, normal examination
ABG, CXR
Observe 8 hours
Risk of delayed pulmonary oedema

MODERATE: mild hypoxia
Observe overnight
O2 +- CPAP

Question 6

Predictors of poor outcome in drowning:

Answer 6

SCENE
Immersion >10min
Delay to CPR (>10min)
Delay to spontaneous breath (>30min)
Warm water
Arrested/ pre-drowning condition

ED
Asystole
CPR >25mins
Lactate
Dilated, non reactive pupils AND:
- pH <7
or
- GCS <5

Hypothermia generally bad as it just indicates prolonged submersion. If result of brief imm/submersion in very cold water, may be neuroprotective

Question 7

Definition of ‘drowning’?

Answer 7

A fluid/air interface at victim’s airway.
The result of immersion or submersion in liquid. Prevents victim breathing air.

May or may not live subsequently.

Ie. Drowning doesn’t technically mean death.

Question 8

Orlowski Prognosis in drowning:

Answer 8

>3, 5% intact recovery
<3, 90% intact recover

Age <3
Submersion >5mins
>10mins to CPR
Coma on arrival
pH <7.1

Question 9

Modell & Conn Prognosis in drowning:

Answer 9

GCS 2 hours post event.

>15 = 100% recovery
<3 = <20%