Drowning, near drowning Definition •drowning- death from asphyxia due to suffocation caused by water entering lungs and preventing the absorbtion of oxygen leading to cerebral hypoxia •WHO: the process of wxperiencing respirátory impairment from submersion/ immersion in liquid •near drowning- survival of drowning event involving uncouciousness or water inhalation, can lead to serious complications, even death, after event Epidemiology •3rd leading cause of unintentional injury death worldwide (WHO) •96% of deaths occures in low- and middle- income countries •one of the leading causes of death in children under 12 years •more frequent in males and the young Etiology •Primary causes •infants: bathtubes, bucket of water, mostly during briefe lapse of adult supervision (less than 5 min) •children 1-5 y: residential swimming pools (no physical barrier) •young adults: ponds, lakes, rivers, ocean (alcohol, drugs frequently involved) •Non-swimmers, exhaustion • Etiology •Secondary causes •seisure •MI, syncopal episode •anxiety/panic •diabetes, hypoglycaemia •water sport hazards •substance abuse •cervical spine injury, head trauma •natural disasters • • • • • • Classification •Wet drowning: •Inhalation of water, which interferes with respiration and causes the circulatory systeme collapse •Dry drowning: •around 10% drownings, often due to immersion in cold water •muscle spasms around the voice box block the airway, no water enters the lungs •leads to negative pressure pulmonary edema (forced inspiration against closed glottis)- increased capillary endothelium permeability with surfactant disturbance- ARDS or acute lung injury • Dry drowning- pathophysiology •Laryngospasm •Low O2 in blood, increased CO2 •Cardiac arrest •Brain damage caused by hypoxia (longer period in cold water) Wet drowning- pathophysiology •Intentional breath holding (about 1 min.), then overcome onf inspiration drive and aspiration of some liquid, which leads to cough reflex and laryngospasm •Hypoxemia, acidosis- if drowning continues, lead to relaxation of laryngospasm and aspiration •Unconciousness within 2 min., apnoe •Cardiac arrest Pre-hospital management •On scene: •airways check for foreign material/ vomitus (patient with altered mental status) •immediate rescue breathing (even in water) •Heimlich maneuver- not effective in removing aspired water, delays start of resuscitation •wet clothing removal (hypothermia), external rewarming •CPR- initially 5 rescue breaths ! (cardiac arrest usually secondarily due to hypoxia) •oxygen administration once possible •consider trauma- C-spine precautiouns Emergency department •ABCDE evaluation, trauma survey •C-spine stabilisation •vital functions monitoring •warm IV fluid administration, passive rewarming (nobody is dead until warm and dead) •O2 supplementation/ OTI, mechanical ventilation •bronchoscopy in selected cases •correction of heart arrythmias • • Investigations •ECG for dysrhytmias •ABG •Labs: electrolytes, renal functions, CBC, glucose •CXR Hospital care •ICU/CCU monitoration •Airway management, maintaining SpO2 >94%, bronchodilators •Nasogastric tube •Prevention of cerebral edema (secondary brain damage): upper body elevation, diuretics administration, normoglycaemia, normotension, controled hyperventilation • • Complications •Hypoxic/ischemic events effecting lungs/brain/heart •Hypoxic encephalopathy •Pulmonary edema •Dysarythmia •Acidosis •Hemodilution (?) •Late: pneumonia, ARDS, empyema • Morbidity/ mortality •Drowning time > 5 min •Start of BLS > 10 min •Prolonged resuscitation > 25 min •Age > 14 years •GCS < 5 •Drowning in contaminated water •