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Drowning, Emergency Medicine

Basics

Description

- Scenario of drowning: - Now thought all drowning victims aspirate some amount of liquid - Previously classified as "wet" and "dry" drowning: - "Wet" drowning (90%): Aspiration of small amount of liquid into the lungs - "Dry" drowning (10%): Laryngospasm secondary to the presence of liquid in the oropharynx or larynx

- Pathophysiology: - Aspiration: - Small volume of water - Decreased lung compliance causing ventilation/perfusion mismatch and intrapulmonary shunting - No significant electrolyte changes - Grossly contaminated water: Risk for pulmonary infection

- Hypoxemia: - Metabolic lactic acidosis - Multisystem organ dysfunction - Noncardiogenic pulmonary edema - Myocardial dysfunction (arrhythmias) - Coagulation abnormalities (disseminated IV coagulation) - Renal failure (usually acute tubular necrosis) - Cerebral hypoxia: Cerebral edema, increased intracranial pressure

- Hypothermia: - More common in young children - Larger body surface-to-mass ratio - Decreases the metabolic rate - Survival with full recovery is possible (neuroprotective)

- Diving reflex: - Young children are more susceptible - Triggered by submersion of face in cold water - Bradycardia ensues: Redistribution of blood flow to the heart and brain - Delays onset of hypoxia-related damage

- ECG: - Long QT interval - Sinus bradycardia - Sinus tachycardia - Atrial fibrillation

- Consider reason for submersion: - Dysrhythmia (long QT syndrome, familial polymorphic ventricular tachycardia) - Myocardial infarction - Seizure - Syncope - Trauma - Suicide attempt

- Attention to ABCs: - Avoid further aspiration - Secure airway-intubate - Early CPR

- Evaluate and treat traumatic injuries - Correct acidosis - Cardiopulmonary arrest: - Initiate advanced cardiac life support measures - Continue rewarming efforts: - Passive: Blankets, insulators - Active external: Warm blankets, radiant heat, warm baths - Active internal: Pleural or peritoneal lavage, cardiopulmonary bypass

- No value to steroids - Poor prognostic signs: - Prolonged submersion time - Severe acidosis (pH â¤7.0) - Need for CPR - Low oxygen saturation - Low Glasgow Coma Score (GCS)

- ICU: - Patients who required CPR or artificial ventilation - Abnormal chest radiograph - Arterial blood gas abnormalities - GCS <13

  • Definitions:Drowning: "A process resulting in primary respiratory impairment from submersion or immersion in a liquid medium"Fatal drowning: Death at any time as a result of drowningNonfatal drowning: If the victim is rescued at any time and the process of drowning is interruptedWater rescue: Any submersion or immersion incident without evidence of respiratory impairment
  • Scenario of drowning:Now thought all drowning victims aspirate some amount of liquidPreviously classified as "wet" and "dry" drowning:"Wet" drowning (90%): Aspiration of small amount of liquid into the lungs"Dry" drowning (10%): Laryngospasm secondary to the presence of liquid in the oropharynx or larynxEnd result: HypoxiaNo significant difference between freshwater and saltwater submersion
  • Pathophysiology:Aspiration:Small volume of waterDecreased lung compliance causing ventilation/perfusion mismatch and intrapulmonary shuntingNo significant electrolyte changesGrossly contaminated water: Risk for pulmonary infectionHypoxemia:Metabolic lactic acidosisMultisystem organ dysfunctionNoncardiogenic pulmonary edemaMyocardial dysfunction (arrhythmias)Coagulation abnormalities (disseminated IV coagulation)Renal failure (usually acute tubular necrosis)Cerebral hypoxia: Cerebral edema, increased intracranial pressure
  • Hypothermia:More common in young childrenLarger body surface-to-mass ratioDecreases the metabolic rateSurvival with full recovery is possible (neuroprotective)
  • Diving reflex:Young children are more susceptibleTriggered by submersion of face in cold waterBradycardia ensues: Redistribution of blood flow to the heart and brainDelays onset of hypoxia-related damage

Risk factors:

  • Lack of proper supervision
  • Alcohol or other drug abuse
  • Limited swimming ability or exhaustion
  • Trauma
  • Seizure disorder
  • Risky behavior
  • Pre-existing medical problem
  • Attempted suicide
  • Poor education

Diagnosis

Signs and Symptoms

  • Cardiopulmonary arrest
  • Cyanosis
  • Dyspnea
  • Copious pulmonary secretions
  • Loss of consciousness
  • Cerebral edema/injury
  • Evidence of trauma:Intracranial hemorrhageCervical spine injury rare (<0.5%)
  • Hypothermia

Essential Workup

  • Information from witnesses or emergency medical services personnel at the scene
  • Early airway management and CPR
  • Rectal temperature for hypothermia

Diagnosis Tests & Interpretation

Lab

  • Arterial blood gas (pH)
  • CBC
  • Electrolytes, BUN, creatinine, glucose:Usually normal (>85%)Hypernatremia or hyponatremia
  • Alcohol and toxicology screen

Imaging

  • CXR:Diffuse or focal infiltrates, acute respiratory distress syndromeMay be normal initially
  • ECG:Long QT intervalSinus bradycardiaSinus tachycardiaAtrial fibrillation
  • CT scan:Brain: Abnormality at any time during hospitalization is associated with poor neurologic outcomeCervical spine: Traumatic injury

Differential Diagnosis

  • Consider reason for submersion:Dysrhythmia (long QT syndrome, familial polymorphic ventricular tachycardia)Myocardial infarctionSeizureSyncopeTraumaSuicide attempt

Consider child abuse/neglect:

  • Especially infants in bathtub near drowning

Treatment

Pre-Hospital

  • Attention to ABCs:Avoid further aspirationSecure airway-intubateEarly CPR
  • Cervical spine precautions if injury suspected or concerning mechanism
  • Early rewarming attempts
  • 90% survival with appropriate intervention
  • All drowning victims need ED evaluation
  • Abdominal thrust to remove water not recommended:Useful only if foreign body in airwayIncreases risk for aspirationDelays effective CPR

Initial Stabilization/Therapy

  • ABCs
  • Core temperature:Initiate rewarming (see "Hypothermia")Remove wet clothing

Ed Treatment/Procedures

  • Correct hypoxemia:Titrate to oxygen saturationIntubate and provide mechanical ventilation with positive end-expiratory pressure
  • Evaluate and treat traumatic injuries
  • Correct acidosis
  • Cardiopulmonary arrest:Initiate advanced cardiac life support measuresContinue rewarming efforts:Passive: Blankets, insulatorsActive external: Warm blankets, radiant heat, warm bathsActive internal: Pleural or peritoneal lavage, cardiopulmonary bypassContinue resuscitation until core temperature >32 °C or until spontaneous pulse and respirations return
  • No value to steroids
  • Poor prognostic signs:Prolonged submersion timeSevere acidosis (pH â¤7.0)Need for CPRLow oxygen saturationLow Glasgow Coma Score (GCS)

Medication

  • Epinephrine: 1 mg (peds: 0.01 mg/kg) IV
  • Vasopressin: 40 U (peds: 0.04 U/kg) IV
  • Lidocaine: 1 mg/kg IV
  • Sodium bicarbonate: 1 mEq/kg IV
  • Hypothermia may be protective:Aggressive rewarmingAggressive resuscitation
  • Evaluate for abuse/neglect
  • Family history: Sudden death, similar episode:Long QT syndromeFamilial polymorphic ventricular tachycardia
  • Prevention is key to treatment:Supervision around waterEmpty pails and buckets

Controversial: Therapeutic hypothermia

  • Widely accepted in adult population after cardiac arrest with return of spontaneous circulation, still controversial in pediatrics
  • Optimize neurologic outcome
  • Suppress reperfusion injury

Follow-Up

Disposition

Admission Criteria

  • Delayed symptomatology occurs:Pulmonary edema (up to 12 hr later)Neurologic abnormalities
  • ICU:Patients who required CPR or artificial ventilationAbnormal chest radiographArterial blood gas abnormalitiesGCS <13
  • Admit observation status:All symptomatic patientsSubmersion for >1 minHistory of cyanosis or apneaPatients who required brief assisted ventilation

Discharge Criteria

  • Questionable history of submersion:Observe in ED for 8 hr:No respiratory distressNo neurologic impairment
  • Discharge to reliable home
  • Home-going instructions:Return for shortness of breath or mental status changes

Followup Recommendations

Close primary care follow-up for all patients discharged from ED

Pearls and Pitfalls

  • All patients with drowning incident require at least 8 hr of observation
  • Indicators of poor prognosis:Acidemia (pH <7.1 on presentation)Age <3 yrSubmersion >10 minTime to basic life support care >10 minGCS ⤠5Long transportation time to EDPersistent apnea or need for cardiopulmonary resuscitation in the EDWater temperature >10 °C

Additional Reading

  • Burford AE, Ryan LM, Stone BJ, et al. Drowning and near-drowning in children and adolescents: A succinct review for emergency physicians and nurses. Pediatr Emerg Care. 2005;21(9):610-619.
  • Layon AJ, Modell JH. Drowning: Update 2009. Anesthesiology. 2009;110(6):1390-1401.
  • Szpilman D, Bierens JJ, Handley AJ, et al. Drowning. N Engl J Med. 2012;366(22):2102-2110.
  • Wagner C. Pediatric submersion injuries. Air Med J. 2009;28(3):116-119.
  • Youn CS, Choi SP, Yim HW, et al. Out-of-hospital cardiac arrest due to drowning: An Utstein Style report of 10 years of experience from St. Marys Hospital. Resuscitation. 2009;80(7):778-783.

See Also (Topic, Algorithm, Electronic Media Element)

Hypothermia

Codes

ICD9

  • 507.0 Pneumonitis due to inhalation of food or vomitus
  • 991.6 Hypothermia
  • 994.1 Drowning and nonfatal submersion
  • 799.02 Hypoxemia

ICD10

  • J69.0 Pneumonitis due to inhalation of food and vomit
  • T68.XXXA Hypothermia, initial encounter
  • T75.1XXA Unsp effects of drowning and nonfatal submersion, init
  • R09.02 Hypoxemia

SNOMED

  • 87970004 Nonfatal submersion (disorder)
  • 116277006 Pulmonary aspiration of fluid (finding)
  • 241968001 Immersion hypothermia (disorder)
  • 389086002 Hypoxia (disorder)