Near Drowning

Question 1

• Common cause of accidental death in the United States and an important cause of childhood fatalities worldwide
• Low and middle-income countries have the highest rates accounting for over 90 percent of such fatalities.

Answer 1

Drowning

Question 2

Generally is defined as survival, at least temporarily, after suffocation by submersion in a liquid medium.

Answer 2

Nonfatal Drowning

Question 3

Factors that increase risk of drowning

Answer 3

(a) Inadequate adult supervision.
(b) Inability to swim or overestimation of swimming capabilities.
(c) Risk-taking behavior.
(d) Use of alcohol and illicit drugs (more than 50 percent of adult drowning deaths are
believed to be alcohol-related).
(e) Hypothermia, which can lead to rapid exhaustion or cardiac arrhythmias.
(f) Concomitant trauma, stroke, or myocardial infarction.
(g) Seizure disorder or developmental/behavioral disorders in children

Question 4

Pulmonary sx of Hypoxia

Answer 4

(a) Fluid aspiration results in varying degrees of hypoxemia.
(b) Both salt water and fresh water wash out surfactant, often producing noncardiogenic pulmonary edema and the acute respiratory distress syndrome (ARDS)
(c) Pulmonary insufficiency can develop insidiously or rapidly;
(d) Signs and symptoms include shortness of breath, crackles, and wheezing.
(e) The chest radiograph or computed tomography at presentation can vary from normal to localized, perihilar, or diffuse pulmonary edema.

Question 5

Neurologic sx of hypoxia

Answer 5

(a) Hypoxemia and ischemia cause neuronal damage, which can produce cerebral
(b) Edema and elevations in intracranial pressure.
(c) Some authors consider the progressive rise in intracranial pressure that is sometimes observed approximately 24 hours after injury to reflect the severity of the neurologic insult rather than its cause. Approximately 20 percent of nonfatal drowning victims sustain neurologic
(d) Damage, limiting functional recovery despite successful cardiopulmonary resuscitation.

Question 6

Cardiovascular sx of hypoxia

Answer 6

(a) Arrhythmias secondary to hypothermia and hypoxemia are often observed in nonfatal drowning victims.
1) The initial arrhythmias described following nonfatal drowning include sinus tachycardia, sinus bradycardia, and atrial fibrillation.
2) In addition, swimming (including diving) can precipitate fatal ventricular arrhythmias in patient with congenital arrhythmias.

Question 7

Hypoxia acid-base and electrolytes

Answer 7

(a) A metabolic and/or respiratory acidosis is often observed.
(b) Significant electrolyte imbalances generally do not occur in nonfatal drowning survivors except those submerged in unusual media, such as the Dead Sea, where the extremely concentrated seawater can produce life- threatening hypernatremia, hypermagnesemia, and hypercalcemia due to absorption of swallowed seawater.

Question 8

Renal effects of hypoxia

Answer 8

(a) Renal failure rarely can occur after submersion, and is usually due to acute tubular necrosis resulting from hypoxemia, shock, hemoglobinuria, or myoglobinuria.

Question 9

3 phases of management of a drowning victim

Answer 9

• Pre hospital care
• Emergency Department
• Inpatient care

Question 10

Acute interventions for drowning

Answer 10

(a) Rescue and immediate resuscitation by bystanders improve the outcome of
drowning victims.
(b) The need for cardiopulmonary resuscitation (CPR) is determined as soon as possible without compromising the safety of the rescuer or delaying the removal of the victim from the water.

Question 11

Does the Heimlich maneuver or other postural drainage techniques to remove water
from the lungs help a drowning victim

Answer 11

Are of no proven value

Question 12

Indications for intubating a drowning patient

Answer 12

1) Signs of neurological deterioration or inability to protect the airway.
2) Inability to maintain a PaO2 above 60 mmHg or oxygen saturation (SpO2) above 90 percent despite high-flow supplemental oxygen.
3) PaCO2 above 50 mmHg.

Question 13

When should supplemental oxygen be provided

Answer 13

if below 94% SpO2

Question 14

How do you prevent hypothermia in a drowning patient

Answer 14

• remove wet clothing
• initiate rewarming

Question 15

Factors that have been associated with poor prognosis with drowning

Answer 15

a) Duration of submersion > 5 minutes (most critical factor)
b) Time to effective basic life support > 10 minutes
c) Resuscitation duration > 25 minutes
d) Age > 14 years
e) Glascgow coma scale < 5 (i.e., comatose)
f) Persistent apnea requirement of cardiopulmonary resuscitation in the emergency department.
g) Arterial blood pH<7.1 upon presentation