Submersion Injuries Flashcards
“a process resulting in primary respiratory impairment from submersion or immersion in a liquid medium”
Drowning
Fatal and nonfatal
“survival after aspiration of liquid into the lungs”. Symptom onset can be immediate or delayed as long as 72 hours
Wet non-fatal drowning
“survival after a period of asphyxia secondary to reflex laryngospasm”
Dry non-fatal drowning
Much better prognosis than wet drowning
1st peak age group distribution of deaths due to drowning
1-5 yrs (tubs, buckets, pools - 20% neglect/abuse)
2nd peak age group distribution of deaths due to drowning
Males 15-25 years, high ETOH involvement
Shallow water blackout - 3 steps
- Hyperventilation before submersion (leads to low CO2 levels in blood)
- O2 drops, but CO2 levels are still abnormally low so brain does not trigger to come up for air. Swimmer loses consciousness.
- Drowning - one swimmer loses consciousness, breath intake is triggered and lungs fill with water
Pulmonary pathophys of drowning
Once wet or dry drowning occurs, leads to
- decreased lung compliance
- Ventilation - Perfusion Mismatch
- Intrapulmonary shunting
(4. Diffuse hypoxemia / ischemia)
Main cause of morbidity (long term damage) from drowning
Cerebral hypoxia
Neurologic end effects of hypoxemia due to drowning
- Neuronal damage
- Cerebral edema
- Elevated ICP
Pulmonary end effects of drowning
- Fluid aspiration washes out surfactant > leads to non cardiac pulmonary edema and ARDS
What component of drowning can lead to ARDS
Fluid aspiration washing out surfactant
Cardiovascular end effect of drowning
Hypothermia / hypoxia leads to»_space;
Arrhythmias
- Sinus tachy
- Sinus brady
- A fib
Acid-base imbalance caused by drowning?
Metabolic and/or respiratory acidosis is common
Renal end effects of drowning?
Rare - but can have acute tubular necrosis / acute renal failure
Hematologic end effects of drowning?
Rare - but coagulopathies and/or hemolysis can occur
Pre-hospital care for drowning (4 steps)
- Immediate CPR, starting with ventilation and 2 rescue breaths
- Administer high-flow O2 via face mask to spontaneously breathing patients
- Intubate apneic patients
- Initiate rewarming of hypothermic patients
Is C-spine immobilization recommended in pre-hospital care for drowning?
Only if :
- pt has clinical signs of cervical injury
- concerning mechanism (shallow dive)
- altered mental status (i.e. intoxication)
Should one attempt maneuvers / positions to remove water from lungs?
No.
ED management of drowning
- Continue resuscitative efforts
- Continue high-flow O2 to maintain 94% O2sat
- CPAP/BiPAP to improve oxygenation and correct Ventilation/Perfusion mismatch
- Trauma evaluation (focued PE / neuro?)
- Remove wet clothing
- Rewarming for hypothermic patients
- Check blood glucose
- Consider whether there is opioid intoxication / naloxone needed
- Monitor (cardiac, O2, end tidal CO2, frequent vitals/neuro checks)
In patients who are not hypothermic, how long until resuscitative efforts are associated with poor neurologic outcomes
> 30 mins
What can be used to correct ventilation/perfusion mismatch?
CPAP/BiPAP
What must be monitored for patients on CPAP/BiPAP
Hypotension secondary to increased intrathoracic pressure
decreased preload due to decreased blood return because of the increased intrathoracic pressure
Indications for intubation
- Inability to protect airway / neurologic deterioration
- PaO2 < 60mmHg or O2sat < 90% on high flow O2
- PaCO2 > 50mmHg
What should be placed along with intubation to prevent gastric distention
Place orogastric tube
How should a drowning patient be monitored once ED workup has been done?
- Cardiac telemetry
- Continuous O2 /end-tidal CO2
- Frequent vitals and neuro checks
Diagnostic tests indicated for ED workup of drowning
Cardiac:
EKG
CXR
CMET
Heme:
CBC
PT/PTT
Pulm:
ABG/VBG
Other:
ETOH / drug screen
- Cardiac enzymes as needed*
- Imaging studies as indicated by trauma eval*
Four pulmonary problems to consider in continued treatment of drowning
- Bronchospasm
- Pneumonia
- Mechanical ventilation
- ARDS
Tx for bronchospasm
Inhaled beta agonists
High suspicion organisms for post-drowning pneumonia
Pseudomonas Proteus Pseudallescheria boydii (fungus from contaminated waters)
Potentially helpful treatment for ARDS due to drowning
Surfactant treatments
Why be cautious in use of diuretics for hypervolemic patients (in drowning management)
Volume depletion > decreased cardiac output > decreased cerebral perfusion
How long do you observe / monitor asymptomatic drowning patients
minimum 8 hours
What must be repeated before discharging asymptomatic patients after 8 hours of observation
CXR and vitals / physical exam
Submersion of more than ____ mins indicates poor prognosis
5 mins
Delay of BLS of more than ____ mins indicates poor prognosis
10 mins
Age of ____ indicates poor prognosis
> 14 yrs
Glasgow coma scale of ___ indicates poor prognosis
< 5
Arterial blood pH of ____ on arrival indicates poor prognosis
< 7.1 on arrival
Decorticate rigidity, forearms/elbows are ____ and legs are ____
flexed, internally rotated
Damage to cervical spinal tract or cerebral hemisphere
Decerebrate regidity, forearms / elbows are ___
extended
Damage to midbrain or pons
