Trauma - Drowning

Question 1

Define drowning

Answer 1

Respiratroy impairment following submersion or immersion in a liquid mediumNear drowning: survivors of drowningDry drowning: used to describe drowning victims without aspiration, died prior to submersionWE DONT USE THESE TWO

Question 2

Classification of drowning

Answer 2

1 - No evidence of aspiration2 - Aspiration with adequate ventilation3 - Aspriation with inadequate ventilation4 - Absent vent and circ

Question 3

Process of drownign

Answer 3

Immersion —> panic			   —> breath holding			  —>  laryngospasm			  —> aspiration			  —> swallow water

Leads to Hypoxia, hypercapnia and acidosisMuscles relax and respiration stimulatedASPIRATION —> direct alveolar injury. —> pulmonary oedema —-> surfactant washout —> atelectasis —> bronchospasmV/Q mismatchReduced complianceARDS

Question 4

Pathophysiological changes by system| CVS

Answer 4

CVS —> Diving reflex —> CN V1 from cold water —> brady and apnoea Catecholamine surge —> vasoconstriction, arrhytias, oedema Hypoexamia and hypothermia —> brady, pulmonary hypertension, failure

Question 5

Pathophysiosology by system| Neuro

Answer 5

Hypoxic brain injury Leading cause of mortality Within 5 minutes Hypothermia is NOT protectiveConfusion/disorientated —> Cerebral oedema —> seizures —> coma —> death

Question 6

Pathophysiology by system| Metabolic/Infection

Answer 6

Metabolic Hypothermia No difference if salt or fresh waterInfection Contamination in 50% Oro-pharynx aspiration —> strep. Staph Aerobic gram negative —> pseudomonas, aeromonas, leptospiridia Fungal —> aspergillus. (Immunocomp)

Question 7

Risk factors for drowning

Answer 7

Age -young children - baths/pools, cant swim, no fence etc Young adults - risk takingMale 2-4x more than FIntoxicationJobs/hobbies Scuba Fishing/farmingMedical: IHD, Epilepsy, stroke, DM, depressionPoor water conditions Current, rip tides, waves

Question 8

Management of drowning| Initial

Answer 8

Get person out the water!No need for spinal precautions unless a dive in shallow water.If arrested ALS plus 5 rescue breaths at the start Compressions after that Needs breaths AS WELL AS compressions

Question 9

Management of drowning in hospital

Answer 9

ATLS approachSecure ETT if needed Examine for signs of aspiration Record GCS at the scene Treat life threatening injuriesOxygenate LPV strategy NO STEROIDS Bronch for debrisCardiac output prompy fluid resus often hypovolaemic InotropesNeuroprotection No evidence of ICP monitoring or barbituates?temp to 34CNo prophylactic abx BUT if water is grossly contaminated develops pneumonia

Question 10

ECMO in drowning, evidence?

Answer 10

Cardiac arest with ROSC prior to ECLS —> 34%Overall survival 51%V-V ecmo has better survival than V-A

Question 11

Indictors of poor prognosis

Answer 11

Sumberged by >5-10 minutesNo resus attempted for >10 minutes after rescue>25 mins resusGCS <5Unreactive pupils in hospitalPulseless and apnoeic in hospitalpH<7.10