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Casey 17 year old previously healthy boy was on a raft in a

homemade pond at his home partying with friends,

dove in and did not come up.

y Friends jumped into the water and pulled him ontothe shore, then called 911

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Scene/Initial Surveyy Pond is approximately 100 meters from any paved

road/path. There is a narrow path cut through grass.

y Ambient temperature is 76 degrees F.

y Patient is now on the shore, lying on the ground,

covered with towels.

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Scene/Initial Surveyy Primary Survey 

y  Airway intact, pt talking, occasional gasping breaths.

y

Breathing diaphragmatic breathing with use of accessory muscles of neck, coarse breath sounds. Diminishedposteriorly.

y Circulation heart tones S1S2, rate 50s, weak central pulses.

y Disability alert and oriented, unable to move arms and legs,

no sensation below the clavicles.y Exposure gaping laceration of scalp, priapism, no deformity 

or other apparent trauma. Pts breath smells of alcohol.

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Initial Actions?

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Secondary Survey/Interventionsy  ABCs unchanged, pt placed in full spine immobilization.

y BP 82/40, HR 54, regular, RR16, O2 sat 96% on ambient air

yOxygen applied via NRB

y IV started, NS bolus administered without change in BP.

y Dressing applied to scalp laceration. No other signs of  visible trauma.

yPt carried to ambulance on board by paramedics andfirefighters.

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Problem listy W hat is wrong here?

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Problem listy Slightly labored respirations Does not have hypoxia

at this point and is talking. Is there a need to

administer positive pressure ventilation? W 

hat willpositive pressure ventilation do to his hemodynamics?

y Hypotension possibly multifactorial

y Neurogenic shock

y Hemorrhagic shock scalp woundy Initial treatment

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Problem listy Paralysis and total sensory deficit?

y W hat is the cause?

y Does this affect his disposition?

y How can you optimize chances for a better outcome?

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Transporty Pts blood pressure falls to 60/30 despite initial IV NS

bolus, HR remains in the 50s

yO2 saturation begins to fall to low 90s/upper 80s onNRB mask, pt breathing becomes more labored.

y Pt remains lucid, but is becoming anxious

y W hat next (you are 15 minutes out from your receiving

hospital)?

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Near Drowning/Submersion Injuryy Occurs when a person is submerged in water, attempts

to breathe (wet drowning) or has largyngospasm (dry 

drowning), and sustains neurologic deficit secondary to impaired oxygen delivery.

y Drowning is defined as death from asphyxia within 24hours from a submersion episode.

y

Near drowning refers to survival (even with eventualdeath) greater than 24 hours from the submersionepisode.

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Epidemiologyy 3rd most common accidental death (2nd in children 1-14

 yrs)

yChildren under 4, teenagers (15-19 yrs), elderly 

y Swimming pools 15 times more likely involved thanauto accident in children under age 5

y Males, particularly adolescents, higher risk (4:1 M:F).

Males 12 times more likely to be involved in boat related drowning.

y Risk factors include water sports and boating,particularly when mixed with alcohol.

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Mechanism of Injuryy Death from respiratory failure and anoxic brain injury 

y Electrolyte abnormalities, hemolysis and disseminatedintravascular coagulation are rare

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Mechanism of Injuryy CNS effects:

y Cerebral hypoxemia, cerebral edema, reperfusion injury.

y Injury may be limited by hypothermia at the time of thesubmersion event.

y  Autonomic instability (diencephalic/hypothalamicstorm) may result as demonstrated by tachycardia,hypertension, tachypnea, diaphoresis, muscle rigidity.

y May have delayed CNS infection with atypical soil and water borne pathogens.

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Mechanism of Injuryy Pulmonary effects:

y Fluid aspiration as little as 1-3 ml/kg can result insignificantly impaired gas exchange, often due to alteredalveolar surfactant (hypotonic fresh water causeddisruption and hypertonic salt water causes osmotic washout).

y Injury to the alveolar capillary unit results in lowerFRC and pulmonary edema, and may progress to ARDS.This may also occur with anoxic brain injury due toneurogenic pulmonary edema.

y Pneumonia is a rare, delayed consequence of submersion injury.

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Mechanism of Injuryy Cardiovascular impairment may be caused by:

y Direct coronary ischemia secondary to hypoxemia from

lack of ventilation and subsequent decreased cardiacoutput (decreased EF or arrhythmia)

y Hypotension of rewarming secondary to vasodilatation

y These effects are usually transient unless there issustained hypoxic stress

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Dry vs Wety Dry drowning may account for as much as 15% of near

drowning

y

Caused by largyngospasm and glottic closure causingasphyxiation

y Some recent literature questions the incidence andpathophysiology however

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Wet drowning

y Flooded alveoli impairing oxygenation and ventilation

y Pulmonary edema caused by flooding, fluid shifts,neurogenic edema, altered capillary permeability 

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Diving reflexy Occurs when face submerged in cold water

y Produces bradycardia, breath holding, central

redistribution of blood flow (may mimic death inprofound cases even after the pt is removed from the

 water)

y May improve cerebral outcome, particularly when the

 water is colder and the body temperature is rapidly lowered or hypothermia present at the time of submersion.

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Important HPIy W itnessed/unwitnessed, time of event or time person

last seen

y

Known traumay PMH (seizures, cardiac problems, DM)

y Drug or alcohol use

y Environmental (air and water temp)

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Clinical Examy Respiratory distress, tachypnea, use of accessory 

muscles. This can progress to failure, even hours out

from the submersiony May hear wheezing, rales, rhonchi

y Neurologic impairment

y Hypothermia, even in warm weather

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Pre-hospital carey  Airway: All should receive O2

y Rescue breathing/assisted ventilation ASA P (even in water)y ETT for hypoxia, airway protection

y CP A P if airway and neurological exam intacty C-spine immobilization as indicated

y Breathing: May use PEEP valve or higher vent pressuresettings to overcome poor compliance due to pulmonary edema and atelectasis

yCirculation: IV, monitor. No chest compressions while in water

y Exposure: Keep warm. Hypothermia is only protectiveduring the exposure. Extricate the patient from the water asquickly as possible.

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Additional Concernsy Dont forget c-spine immobilization

y May see paralysis, weakness, hypotension, bradycardia

 with associated low cervical spine injuries (may mimicdiving reflex)

y  Always protect c-spine if submersion unwitnessed

y Evaluate for associated injuries

y

Evaluate for causative illnesses (cardiac event, stroke,hyper/hypoglycemia, seizure, suicide attempt,ingestion)

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Be Aggressivey W hile cardiac and respiratory arrest present a worse

outcome, as may as 20% of these patients will survive

neurologically intact

y Poor outcomes are associated with requirement of sustained CPR on arrival at the hospital, particularly 

 with warm water drowning

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Special Considerationsy Resuscitation of the pulseless and apneic patient

y C-spine immobilization

y Heimlich Maneuvery Tracheal intubation

y Treatment in the ED

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Pulseless and apneic drowning pty RESUSCITATE! Begin ventilations and compressions

as soon as practicable

y

Bystander estimates of immersion time ofteninaccurate

y Case reports document functional recovery after anhour of submersion

y No prognostic scale or clinical findings accurately predict long-term neurologic outcome

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C-Spine immobilization?y A 2001 Journal of Trauma review of 2244 cases from W ashington state identified only 11 (.5%) with a

cervical spine injury y Each case had either clinical signs of trauma, or

history of MVA, fall from height, or diving accident

y Thus, routine immobilization absent such factors may 

be unnecessary 

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Heimlich: Yes or No?y This maneuver has been suggested as a way to remove

fluid from the lungs

y

Ineffective and dangerous, as it may delay ventilationand precipitate vomiting and aspiration

y No Heimlich

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Aspiration Risky Submersion victims swallow much more water than

they aspirate

y

If you use BVM or CP A P, remember the increased riskof gastric distention and subsequent vomiting andaspiration

y Submersion in sewage or water with high particulate

content increases risk of infection from subsequentaspiration

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Aspiration Risk contdy Inability to maintain O2 sats greater than 90% on high

flow

y

Capnometry of 50 or greatery These findings would normally indicate CP A P

y Because of increased risk of aspiration in the drowning victim, RSI may be preferred

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Emergency Department Carey For normal exam on arrival, pts may be discharged after 6

hour observation period if no deteriorationy  Admit any patient with respiratory symptoms or

dysfunctiony  Airway, oxygen, management of arrhythmias (which are

often due to hypoxia)y  Volume repletion in patients with severe respiratory 

involvement due to fluid shiftsy

Rewarm aggressively (unless VT/VF may wish to followhypothermia protocol)y Identify other injuries/medical issuesy Steroids and prophylactic antibiotics not helpful

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In Hospital Carey Hospital care is directed toward optimizing CNS

oxygenation and perfusion

y

 Aggressive ventilatory supporty Correct arrhythmias and use dopamine/dobutamine for

hemodynamic support as needed

y Monitor and manage serum glucose

y

 Appropriate consultation (surgery, neurosurgery,orthopedic surgery) for management of traumaticinjuries

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Prevention Effortsy EMS can play a major role in prevention

y Inadequate supervision of children playing in or

around water is chief cause of pediatric submersiondeath

y Mortality rate from drowning has declined in the USsince 1990, probably in part due to increased public

awareness of prevention, ETOH risks, and CP

R 

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Back to our case

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Transport (part 2)y Pt is started on CP A P

y Dopamine is started through his large-bore peripheral

IV and BP

and HR improvey Pt has some recurrent bleeding through the dressing

on his scalp wound after his hemodynamics improve controlled with direct pressure for the remainder of 

transport

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ED Coursey Pt switched to BiP A P ventilation and hypoxia further

improves

y

Trauma line placed for vasopressor support.Phenelephrine added

y Pt started on methylprednisolone protocol

y Raney clips used to temporize scalp bleeding

y Trauma evaluation significant for unilateral facetdislocation at C5-6

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SICU Coursey Pt placed in  W ells tongs and traction with eventual

reduction of his facet dislocation

y Scalp wound debrided and repaired at bedside

y Neurological exam does not improve

y MRI shows cord disruption with extension of hematoma and edema to the C3 level

y Eventually weaned from pressors and positive pressure ventilation

y Transferred to rehabilitation with persistentquadriplegia

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After dischargey Pt eventually able to manage powered wheelchair

independently. Continues to need total assistance for ADLs.

y Commits suicide by driving his wheelchair off a dock within months of moving back home

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Q uestions?