1. Drowning David Slocum MD Albany Medical Center

2. Miracles Matthew Granger 14 month old 14 month old 20-40 minutes 20-40 minutes

3. Vocabulary Drowning – death within 24 hours Near-drowning – survival past 24 hours

4. Who? Usually young, healthy individuals

5. 2006 Drowning U.S.A. – 5000 died Worldwide – over 100,000 died

6. Epidemiology 500,000 submersion events annually 2nd cause of death – children under 15 Injury ranges Transient Transient Profound neurological deficit Profound neurological deficit

7. Three Peaks ToddlersAdolescentsElderly

8. Toddlers ToiletsBathtubsBuckets

9. Coastal Areas Swimming pools more likely

10. Adolescents Stupidity

11. Young Adults Alcohol 40% adult drownings 40% adult drownings 75% boat drownings 75% boat drownings

12. Elderly

13. Complicating Factors Spinal cord injury HypothermiaPanickingSyncopeSeizures

14. Pathophysiology Central Nervous System Injury Pulmonary Injury

15. Dry-drowning 10-20% of submersions LaryngospasmHypoxia Loss of consciousness

16. Wet-drowning Aspiration of water Dilution of surfactant Diminished gas transfer Atelectasis Ventilation perfusion mismatch

17. Pulmonary Injury Contaminated foreign material Particulate matter BacteriaVomitus Chemical irritants

18. Prognosis Submersion time Physiological scoring systems

19. Two extremes Fair cardiovascular and neurological function Minimal disability Minimal disability Unstable cardiovascular function and coma Poorly Poorly Hypoxic CNS injury Hypoxic CNS injury

20. End Organ Damage Renal injury Hypoxia Hypoxia Myoglobinuria Myoglobinuria Hemoglobinuria HemoglobinuriaHematologic Hemolysis Hemolysis DIC DIC

21. Treatment

22. Prehospital Care Resuscitation Time optimizes outcome Time optimizes outcome Removal from water C-spine protection C-spine protection CPR ASAP

23. Airway Breathing High flow oxygen by facemask High flow oxygen by facemask Not Breathing Bag valve mask Bag valve mask Endotracheal tube Endotracheal tubeUnconscious Protect from aspiration

24. Who to transport? Amnesia Loss or depressed consciousness Period of apnea Period of artificial respirations Even if asymptomatic

25. Don’t Forget Warm patient Hypothermia HypothermiaMonitor IV access Warm isotonic fluids Warm isotonic fluids

26. Summary Rapid, cautious rescue Spine precautions Cardiopulmonary resuscitation Supplemental Oxygen Transport

27. ED Treatment Continue EMS care Airway Airway Oxygen Oxygen Ventilation Ventilation Warmed fluids Warmed fluids Warming adjunts Warming adjunts Treat associated injuries Treat associated injuries

28. GCS > 12 Oxygen to keep sat > 95% Observe 4-6 hours Pulmonary exam normal Saturation normal Discharge home No xray or labs needed

29. GCS > 12 Oxygen to keep sat > 95% Observe 4-6 hours Pulmonary exam abnormal Requires oxygen Deteriorates Admit to Monitored bed

30. GCS < 13 High flow oxygen Intubation for low PaO2 CXR, Labs Continuous cardiac monitoring Frequent reassessments

31. Seizure Dilutional hyponatremia Control seizures Correct electrolytes Residual disorder uncommon

32. ED Arrest Warm water drowning Recovery doubtful Consider early discontinuation of efforts Risk profound neurological handicaps

33. Hospital Management Supportive Avoid ARDS Pneumonia rare Dopamine, epinephrine drips 48 hour window

34. No benefit Mannitol Loop diuretics Hypertonic saline Fluid restriction Hyperventilation Controlled hypothermia Barbiturate coma

35. Prognosis No CPR Full recovery within 48 hours Full recovery within 48 hours May develop ARDS May develop ARDS Bystander CPR Steady recovery Steady recovery Steady decline Steady decline ED CPR Very poor prognosis Very poor prognosis

36. Pediatric Warm Water Drowning 500 victims 100% received ED CPR 84% died 16% severe hypoxic encephalopathy

37. Diving Reflex MammalsBradycardia Peripheral Vasoconstriction Greatest in cold water Preserves oxygen

38. ICE water submersion Asystole Children and Adults Complete Recovery Rare Resuscitate until normothermic

39. Prevention Infants Parental vigilance Parental vigilanceToddler Pool fencing Pool fencing Adolescent/Young Adult Control Alcohol/Drug Use Control Alcohol/Drug Use Swimming lessons Swimming lessonsElderly Same as infant/toddler Same as infant/toddler