POTD: Drowning

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POTD: DROWNING

 

Causes:

·     misadventure

·     inadequate supervision of small children

·     neurological event e.g. epilepsy, stroke

·     cardiac event e,g, MI, HCM, dysrhythmia, long QT, short QT

·     impaired judgement e.g. intoxication

·     trauma

·     overdose

·     foul play

 

Pathophysiology:

·      Water enters the mouth

·      Voluntarily spat out or swallowed

·      One hold’s their breath until inspiratory drive is too high.

·      Water is aspirated in the lungs, and coughing occurs as a reflex

·      Continued aspiration leads to hypoxemia, loss of consciousness and apnea

·      Death usually occurs from seconds to a few minutes

 

Long term sequela are determined by:

Surfactant dysfunction and washout

Osmotic gradient damaging alveolar capillary membrane

Massive bloodstained pulmonary edema

Decrease in lung compliance, VQ mismatch atelectasis and bronchospasm

 

There is no significant difference in sea water vs fresh water, although fresh water has greater antibiotic prevalence.

 

HOSPITAL MANAGEMENT:

 

The Heimlich or other expiratory maneuvers are not believed to be of use in these patients.

 

Rewarm to 34C as quickly as possible; remove wet clothes, insulate with blankets, forced air warmer, warmed IVF, warmed lavage bladder, peritoneal, and chest lavage.

 

Early invasive ventilation as indicated by respiratory distress.

 

RESPIRATORY SUPPORT: ARDS lung protective ventilation, bronchodilation, consider proning and possibly ECMO.

 

KEY POINTS:

·      consider ECMO to aid in both respiratory and hypothermic management.

·      Resuscitation focus should be on ventilation due to loss of surfactant.

·      Hypothermia can be neuroprotective: hours of resuscitation may still lead to complete recovery.

·      Antibiotics should only be given if water was grossly contaminated, glucocorticoids are not recommended, and there is no strong data on the use of surfactant.

·      Symptomatic patients, those with shortness of breath, chest pain, cough, nausea or vomiting, should be monitored in the ED for a minimum for 6 hours and should be counseled on prevention and risk factors for drowning.

 

 

REFERENCES:

https://litfl.com/drowning/

https://www.aliem.com/resuscitation-of-a-drowning-victim/

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