1. Resident Rounds June 26, 2003 Robbie N. Drummond
Near Drowning
Resident Rounds
June 26, 2003
Robbie N. Drummond

2. Not Waving but Drowning Stevie Smith
Nobody heard him, the dead man,
But still he lay moaning:
I was much further out than you thought
And not waving but drowning.
Poor chap, he always loved larking
And now he's dead
It must have been too cold for him his heart gave way,
They said.
Oh, no no no, it was too cold always
(Still the dead one lay moaning)
I was much too far out all my life

3. IV. DEATH BY WATER (from the Wasteland, T.S. Eliot)
PHLEBAS the Phoenician, a fortnight dead,
Forgot the cry of gulls, and the deep seas swell
And the profit and loss.
A current under sea
Picked his bones in whispers.As he rose and fell
He passed the stages of his age and youth
Entering the whirlpool.
Gentile or Jew
O you who turn the wheel and look to windward,
Consider Phlebas, who was once handsome and tall as you.

4. The Tempest by Willy Boy the Spear Shaker Act I Scene ii
ARIEL sings]
Full fathom five thy father lies;
Of his bones are coral made;
Those are pearls that were his eyes:
Nothing of him that doth fade
But doth suffer a sea-change
Into something rich and strange.
Sea-nymphs hourly ring his knell
Hark! now I hear them,--Ding-dong, bell.
FERDINAND The ditty does remember my drown'd father.

5. YODA’s 7 QUESTIONS ABOUT DROWNING
There are a lot of terms to describe drowning how do I wade through them all?
What is the real difference between fresh and salt water drowning?
How common is drowning are there any preventative measures to be taken to avert death by water?
There is a drowning victim in the ED what are the factors that suggest he will survive?
What is the best approach to resuscitating a drowning victim?
What about the prophylaxis measures previously taken, steroids, hyper therapy, antibiotics....etc.?
Survivors of drownings usually are hypothermic what is the relation between hypothermia and drowning?

6. There are many terms to describe drowning how do I wade through them all?
gets complicated..... Drowning, near-drowning, drowning with/without aspiration, dry drowning, wet drowning, secondary drowning, submersion vs immersion, immersion syndrome,
ORLOWSKI feels too complicated was supposed to imply prognosis but does not
Drowning “ suffocation by immersion or submersion in any liquid medium, caused by the entrance of liquid in the airways that partially or fully compromises ventilation or oxygen exchange”

7. basic definitions drowning death within 24 hours of submersion
near drowning death after 24 hours of submersion
secondary drowning death from a complication of submersion
one author secondary drowning cause of death not related to water (eg MI)
drowning with or without aspiration
immersion vs submersion partially vs totally covered
aspiration of other fluids bodily etc

8. wet vs dry drowning 10% no fluid found in lungs
severe laryngospasm, hypoxia, convulsion and death
one author “dry drownings probably do not exist.... if there is no water in lungs victim probably not alive when entered water”..... A la Brian Jones of the Stones.... It was Mick and Keith, the glimmer twins, don’t you know it?

9. 13 % of all drownings happens after precipitating event
drugs 36% (usually alcohol)
convulsion 18 %
trauma 16 %
cardiopulmonary 14%
SCUBA 3 %
others 11 %

11. My mother told me to splash water on my face before.....
Immersion Syndrome
syncope provoked by arrhythmia
sudden contact with water at least 5 degrees less than body temperature
syncope loss of consciousness and secondary drowning
massive release of adrenaline
reduced by wetting face and head before entering water

12. How common is drowning are there any preventative measures to be taken to avert death by water?
90 % of all drowning deaths occur within 10 meters of safety

13. Some watery numbers 500,000 per year worldwide
third most common cause of unintentional death
10 saves and five near drownings for every drowning
,747 rescues
55-60% less than 20 years of age
African-Americans two time rate of Caucasians
males five times as often as females
costs 6.5 billion buckaroos in US alone

14. bimodal distribution
toddlers less than 2 and teenage boys years
teenager (boys) risk taking, alcohol factor 60% of time
bathtubs usual site under one year of age
many as a result of abuse
bucket- related deaths
older toddlers pools
children and adolescents fresh water

16. POOLS 50, 000 new pools built every year in USA
2.2 million residential pools
2.3 million nonresidential pools already in existence
in temperate areas of USA % of drowning occur in pools

17. PUBLIC HEALTH proper pool fencing and supervision
training in swimming and water safety essential
not leaving child unattended near tub or pool
personal flotation devices while boating
proper training, SCUBA boating etc
solar blankets support weight of toy not children hides drowning child
citizens trained in CPR
avoidance of alcohol

19. PREVENTION the key to minimizing morbidity is successful prevention
AAP 23 recommendations
swimming lessons a good idea
but sometimes children not aware of their skill level and
parents not cautious enough

20. RISK FACTORS FOR SUBMERSION ACCIDENTS
, seizures, trauma, Etoh, hyperventilation,
drugs of abuse, hot tubs, hypothermia,
cvs disease, child abuse, diabetes, suicide
inability to swim
53% of individuals with a submersion incident over age 26 blood etoh >100
9% of suicides due to drowning
Time of day: toddler drowning :
meal preparation times early evenings

21. What is the real difference between fresh and salt water drowning?
animal models (ie threw man’s best friend in water to see what happens)
struggle small amounts fluid hypopharynx laryngospasm
swallowing water
laryngospasm abates aspiration large amounts water
vomiting aspiration of gastric contents
evolving hypoxemia , circulatory collapse
myocardial damage, and multiorgan failure
ischemic brain injury....death

22. the Pacific vs Georgian Bay
for many years suggested difference between fresh and salt water drowning
give dogs 44 ml /kg fresh water causes potassium disturbance
previous theory was fresh water more hypotonic
hemodilution hyper volemia, red cell rupture
dilution of pulmonary surfactant alveolar collapse
sea water hypovolemia, and increased electrolyte hemoconcentration
fluid movement from intravascular to alveoli

23. In reality.... more than 11 ml per kg for change in blood volume
only 15% who die in the water aspirate more than this quantity most less than 4ml/kg
22 ml/kg for changes in electrolytes
in a study by spilzman drowning victims had no electrolyte abnormality
seawater drowning does not cause hypovolemia
freshwater drowning does not cause hypervolemia, hemolysis, or hyperkalemia

24. no difference
from clinical point of view no difference fresh vs salt water
most immediate cause is hypoxia and metabolic acidosis
both produce surfactant destruction alveolitis, noncardiogenic pulmonary edema
disruption of gas exchange increased shunt leading to profound hypoxia
as little as 1 ml /kg aspiration profound alterations in gas exchange decreased compliance
cerebral hypoxia is the final common pathway
resp disturbance more on amount than type of water

25. 2 small points sometimes physiologic changes many hours after insult
water may be contaminated with chemicals, bacteria, sand etc.

26. DEAD SEA

27. Dead Sea
unless you drown in the dead sea (Yagil et al arch In Med 1985)
one case hypercalcemia and hypermagnesemia

28. What is the best approach to resuscitating a drowning victim?
drowning victims present risk to rescuer
approach with caution or intermediate object
instinctive drowning response
drowning victims unable to call for help
upright position slapping or thrashing water
children seconds
adult up to 60 seconds

29. always remember underlying causes for drowning
CPR ASAP SVP
first description of CPR 1600’s : Paracelcus a Swiss physician inserting fireplace bellows in the victim’s mouth or nostrils
always remember underlying causes for drowning
caution re neck injuries
citizens trained in CPR
in water CPR usually ineffective and dangerous
delay in CPR prolongs hypoxia
because circumstance are never clear
resuscitation should always be initiated in the field

30. drowning victims swallow much more water than they inhale
no attempt to remove water from lung
great quantities of water in stomach likely to aspirate
Heimlich himself suggested his maneuver to expel water from lungs,,,, counterproductive
gastric acid aspiration from abdominal pressure
lots of fluid in stomach
up to 60 % of drowning victims vomit
right lateral decubitus head down ? Sellick’s maneuver
high risk for vomiting spontaneously or on resuscitation

31. There is a drowning victim in the ED what are the factors that suggest he will survive?

32. ORLOWSKI’s 5 unfavourable prognostic factors
age of 3 or less
submersion > 5 minutes
no attempts at resuscitation for 10 minutes
coma on admission to ED
severe acidosis pH <7.1
lack of controlled studies which factors greatest impact < % recovery
> % likelihood of recovery

33. Check out the GCS GCS adds predictability
2-6 hours after if no improvement unlikely to improve
if some increase GCS 50%
if alertness normal sequelae limited

34. other factors resuscitation > 25 minutes
asystole on arrival at hospital GCS < 5
elevated ICP, coma or CPR needed in ED
some survival in some individuals with some or all of these factors
water temperature, duration and degree of hypothermia
the diving reflex, the victim’s age, water contamination,
duration of cardiac arrest
the speed and effectiveness of initial treatment cerebral resuscitation

35. success of resuscitation major determinant of outcome
prognosis response to serial neurologic exams
3 point improvement on GCS on arrival to ICU portends
100 % full recovery in pediatric population
conscious on arrival excellent chance of survival
CONN scale alert 100%’
blunted mortality rate 10%
comatose greater than 35%

36. The Opposite of Drowning?

37. What is the best approach to resuscitating a drowning victim in ED?
continuous cardiac monitoring
observation for 4-6 hours if asymptomatic
serial ABG measurements (Arterial line)
oxygen therapy
NGT and FOLEY
ETT degree of respiratory distress pa o2 below 50 paco2 greater than 50%

38. Read my lips “it’s the anoxia, stupid!!!”
grading system from 1 to 7 based on need for aggressive airway intervention
grade 2 only by cannula, grade 4 mechanical
pneumothoraces usually as result of baro trauma
most significant implication is anoxic ischemic cerebral insult
most common cause of late death
every effort to maintain oxygenation and prevent cerebral edema

39. r/o other cause of injury
toxicological insult spinal injury
evaluate and treat associated conditions,
hypovolemia, hypothermia, hypoglycemia
careful neurological assessment and reassessment

40. both respiratory and metabolic acidosis
may still need fluid resuscitation despite pulmonary edema
shock is uncommon in drowning
do not use furosemide to treat pulmonary edema may need volume
in ICU many patients will need PEEP
ARDS common in drowning same management as any ARDS patient
delayed onset of pulmonary edema (up to 12 hrs)

41. PATHOPHYSIOLOGY
although some difference drowning is an asphyxia injury like like hanging, foreign body aspiration, apnea etc
noncardiac pulmonary edema, noncardiogenic pulmonary injury, surfactant loss, inflammatory contaminants, and cerebral hypoxia
global hypoxic ischemic event affecting brain, lungs, and heart
cardiovascular function usually preserved
aggressive pulmonary support is required to prevent long term sequelae of hypoxia
optimal treatment for anoxic brain injury remains unclear
no prognostic scale accurately predicts long term neurologic outcome

42. Consequences global hypoxia
cns dysfunction from initial hypoxic injury increased ICP edema
aggressive control of cerebral perfusion pressure
does not improve out come
CNS damage progresses after circulation reestablished
cardiac dysrhythmias : a result of hypoxemia/acidosis
low cardiac index elevated right and left heart filling pressures increased SVR
renal failure uncommon
coagulopathies esp DIC and hemolysis

43. What about the prophylaxis measures previously taken, steroids, hyper therapy, antibiotics....etc.?
prophylactic antibiotics of limited use
treat when infection
antibiotics only if grossly contaminated water
contributing to injury is aspiration of sand bacteria algae or particulate matter emesis and chemical irritant
corticosteroids of limited use

44. HYPER THERAPY early theory (BOHN Critical care medicine 1986)
hyperhydration, hyperventilation, hyperpyrexia, hyper- excitability, hyperrigid
suggested use of diuretic, hypothermia, barbituates glucocorticoids barbituate coma, muscle paralysis and monitoring and treating of ICP
subsequent reviews failed to show improvement with these protocols
most centers no longer use hyper therapy
current approach supportive care

45. disposition four groups
1) no evidence of sig. submersion d/c’d quickly
cxray and abg unnecessary serial sats reassuring
pts without any symptoms and completely normal respiratory status may be discharged with instruction to return immediately if respiratory distress developed
2) asymptomatic after sig. episode observed for four to six hours then d/c’d
3) poor oxygenation mod hypoxemia admitted followed once o2 resolved ....home

46. ??? ICU final group... Intubated: depends on neurological status
any respiratory complaints or symptoms, cxray abnormalities, demonstrated oxygen requirement monitored for 24 hours usually in ICU
any patient with LOC, cyanosis, or apnea, CPR or resuscitative efforts need to be monitored closely
GCS needs to be done sequentially

47. CXRAY 20 % of severe drowning normal cxray
typical findings perihilar infiltrates, pulmonary edema

49. Pediatrics peds use fairly aggressive PEEP protocol
increased risk of nosocomial infection
children larger surface area less fat more prone to hypothermia
hypothermia some degree of protection
rapid cooling necessary in icy water <5 deg to offer benefit
usually severe hypothermia increased mortality
large costs realistic goal re prognosis
families need time to adjust

50. POOR PROGNOSIS IF:
absence of cognitive function / recovery hours
seizures beyond 12 hours
despite early enthusiasm, ICP monitoring: no benefit
CT only helpful if ass’d with other injury
MRI day 1 and day 3 change helpful in predicting outcome
EEG often obscured by drugs and resuscitation
persistent flat tracing attenuated record without med or burst suppression poor prognosis
brainstem evoked potential: controversial many confounding factors
most useful for predicting outcome is repeated clinical neurological examination

52. Survivors of drownings are often hypothermic what is the relation between hypothermia and drowning?
continue resuscitation till core temperature degreesC
one child recovered successfully after minute immersion in cold water
hypothermic protection dependant on slowing cerebral metabolism before irreversible damage
works with sudden immersion in very icy water or in victims above water cooling before immersion

53. HYPOTHERMIA definition core temperature less than 35 degrees
significant pathophysiology develops below 35 degrees
primary direct exposure to cold
secondary systemic disorders
heat preservation shivering, autonomic and endocrinologic responses.... adaptive behavioral responses

54. 35-32-27....mild, moderate, severe
shivering stops, hr and bp decline, oxygen consumption declines
depressed CNS increase metabolic rate & pulse , dysarthria, amnesia, ataxia, apathy
moderate
decreased loc and vitals, shivering extinguished, arrhythmias, qt prolonged, j wave (Osborne) cannot rewarm spontaneously
cold diuresis

55. Severe Hypothermia severe less than 27 degrees coma and areflexia with
profoundly depressed vital signs
co2 production decreases 50% for each 8 degrees fall in temperature
increase heat loss impaired thermoregulation
extreme bradycardia spont VF or asystole
coagulopathy prolonged clotting times and platelet dysfunction

56. physiologic changes
protein binding increases temp drops drugs ineffective
wait with monitoring 60 second before initiating CPR
most recommend CPR with PEA even with profound hypothermia
pulse oximetry accurate in hypothermic patients
caution irritating heart in central line insertion
most rhythms revert spontaneously with rewarming
most VF refractory until rewarmed
three shocks trial if unsuccessful rewarm CPR attempt at higher temperature

57. changes in hypothermia
tachycardia disproportionate to temperature suspect hypoglycemia hypovolemia or OD
hyperventilation suggests A CNS system lesion systemic acidosis DKA or lactic acidosis
cold induced rectus spasm and ileus may mask or mimic an acute abdomen
need core temperature
anemia is masked because hematocrit increase 2% per 1 degree drop in temperature
leukocytes sequestered

58. active rewarming passive vs active warming passive noninvasive
involves simply covering the patient in a warm environment
active rewarming if cvs instability
temperature less than 32.2
active core rewarming heated humidified air inhalation, heated infusion lavage, extracorporeal rewarming

59. Invasive techniques thorocostomy tube irrigation
IV fluids degrees
double catheter peritoneal lavage
2 liters of degrees NS suction after 20 minutes
extracorporeal rewarming
cardiopulmonary bypass arteriovenous and venovenous rewarming hemodialysis lifesaving in cardiac arrest situations

60. caution: drop in core temp after initiation of rewarming
temperature equilibration circulatory
return of cold peripheral blood to the core
overwhelms a depressed cvs system
vasoconstricted skin prone to burning caution with warming extremities

61. What is the Diving Reflex?
mammalian response
protective bradycardia shunting blood to brain and heart
victims age ration of body mass to surface area development of hypothermia
hypothermia more protective in children than the diving reflex
water must be 10 degrees or colder
sudden immersion in cold water can cause ventricular fibrillation
controversy over diving reflex
breath holding intense vaso constriction bradycarda decreased Cardiac output and increased MAP selective vasoconstriction and heart and CNS perfused
breath holding reduced when children submerged in cold water

62. Answers to Yoda’s seven questions
drowning is a form of asphyxia main injury is anoxia and its consequences
there is no clinical difference between fresh and salt water drowning
90% of drowning occurs within 10 meters of safety prevention is the key
level of consciousness on presentation to the ED best prognostic indicator followed by sequential neurologic assessments
main features of management is aggressive respiratory support
prophylaxis is not indicated
the usual dicturm applies the patient is not dead till he is warm and dead

63. Yoda’s real feeling about water
Nothing in the world is more flexible
and yielding than water.
Yet when it attacks the firm and strong
none can withstand it,
because they have no way to change it.
So the flexible overcome the adamant,
the yielding overcome the forceful.
Everyone knows this,
but no one can do it.
This is why the sages say
those who can take on the disgrace of nations
are leaders of lands;
those who can take on the misfortune of nations
are rulers of the world.
True sayings seem paradoxical.

64. References
DROWNING Pediatric clinics of North America June 2001Orlowski et al
EMR June 1997Schwab et al Emergencies of Summer
NEAR DROWNING Critical Care Clinics April199 Sachdeva
SUBMERSION AND ASPHYXIAL INJURIES Ibsen and Kock Critical Care medicine Nov 2002
TINTINELLI’s 2002
Rosen’s 2002
EMERGENCY MEDICINE SECRETS THIRD EDITION Markovchick 2003+

66. the (deep) end