Drowning Justin Sempsrott, MD

Executive Director

Lifeguards Without Borders

Justin@LifeguardsWithoutBorders.org

22

Disclosure

•Air Travel Paid by DAN

•Honorarium paid to LWB

•Graphic images of fatal and non-fatal drowning patients

Who am I?

The “Great of Aleppo” held upside down after drowning. 1237 B.C. From the Pylon of the Ramesseum, Thebes. Photographed by Mr. W. M. F. Petrie

History of drowning treatment

History of drowning treatment

History of drowning treatment

Dr. Frank Eve

Popular Science July 1946

9999

History of drowning treatment

Objectives

• Understand definition of drowning

• Appreciate epidemiology

• Management

• Disposition of drowning patients

• Don’t blow smoke up pt’s (or colleagues) asses

Definition

•Before 2002– 33 Different Definitions

Definition

•“The process of experiencing respiratory impairment from submersion/immersion in liquid”

•Only 3 outcomes – – Death– No Morbidity – Morbidity

Bangladesh, Lifeguards Without Borders, Aug2009

Definition• Old terms that should NOT be used

– Dry – Wet– Active– Passive– Secondary– Near Especially

• No difference between salt, chlorine, and freshwater

Lima, Peru, 2009

Who is Drowning?

•WHO Global Burden of Disease– 388,000 Drowning Deaths*

• 97% in low to middle income countries+1.55 million unreported drowning deaths+6.08 million drowning “incidents”

7.63 million Drowning persons*

Who is Drowning?

•2nd leading cause of unintentional injury death (1st is MVC’s)

•~10 Deaths/Day in US– 40 Drown and survive– ½ with, ½ w/o morbidity

•Male:Female 4:1

Who is drowning?•Disease of youth– 64% of deaths are<30 yrs– 25% of deaths are < 5 yrs

•Alaska, Arizona, California, Florida, Hawaii, Montana, Nevada, Oregon, Utah, & Washington

• Drowning surpasses all other causes of death to children age 0-14

Who is Drowning?

•Excludes Floods/Boating/Natural Disasters

http://nicedeb.files.wordpress.com/2008/05/sinking-boat.jpg

– 2009 USCG Responded to 4,730 incidents

• 3,358 injuries

• 736 deaths– 72% Drowning 90% without lifejackets 50% (+) EtOH

Who is Drowning?

• Hurricane Katrina– USCG– 33,544 Rescues

• 4/6 Rio Flood– 200+ dead

• 8/1 Pakistan Flood– 1100+ dead

• Indonesia Tsunami– 169,752 dead– 127,294 missing

http://www.gearbits.com/images/banda_aceh_tsunami.jpg

CDC MMWR March 10, 2006 / 55(09);239-242

•16 y/o ♀– HPI

• Pulled from ocean

• No LOC

• + Submersion

– PEA- Small foam at

mouth/nose

B-Active cough

C- +Radial Pulse

•15 y/o ♂– HPI

• Pulled from ocean

• No LOC

• + Submersion

– PEA- Large foam at

mouth/nose

B-Active cough

C- +Radial Pulse

Maldito!!

•What next?– Sick or Not Sick– Transport or

No Transport

•First, a review of physiology

Lima, 2012

Physiology of Drowning

• Breath holding during struggle

• Attempt to inhale water results in ?laryngospasm–Usually little (<30mL) or NO fluid in lungs

–Reflex Swallowing

Physiology

•Water may enter (1-3mL/kg)– Relaxation after unconsciousness

© 2009 Nucleus Medical Art, Inc.

Mechanism

•Surfactant wash-out

•Direct cellular injury

•Hypoxic Vasoconstriction

•Bronchospasm

• Inflammation

Physiology

• Compliance

• O2 Delivery to brain

Physiology

•Cause of death or morbidity – Anoxic Brain

Injury – Acidosis

•Treatment Oxygen to the

Brain

Physiology

Alive

DeadDose Response Curve

Res

pons

e

Dose

When to Transport?

•41,729 oceanfront lifeguard rescues in

Rio de Janeiro from 1972 – 1991– 93% Released at scene without further

treatment– 2,304 required additional medical care

•89% lived

•11% died

When to Transport?Grade Signs/Symptoms (s/sx) Mortality Treatment

1 Cough, no foam at mouth/nose -LCTAB

0% Thorough history – Release home with education

2 Small amt foam in mouth or nose, +Rales

0.6% N/C O2 - Hospital

3 Large amt foam, normal BP (+radial pulse)

5.2% ETT/NRB O2 - Hospital

4 Large amt foam, LOW BP (-radial pulse)

19.4% ETT/NRB O2 , IV Fluids - Hospital

5 Respiratory Arrest 44% ETT/NRB O2 , IV Fluids - Hospital

6 Cardiopulmonary Arrest 93% ETT/NRB O2 , IV Fluids, AED – HospitalDo not resuscitate if down >1 hour

When to Transport?Grade Signs/Symptoms

(s/sx)Mortality Treatment

1 Cough, no foam at mouth/nose -LCTAB

0% Thorough history – Release home with education

2 Small amt foam in mouth or nose, +Rales

0.6% N/C O2 – Hospital

3 Large amt foam, normal BP (+radial pulse)

5.2% ETT/NRB O2 - Hospital

Do we transport?•16 y/o ♀

– HPI• Pulled from ocean• No LOC• + Submersion– PEA- Small foam at mouth/nose B-Active coughC- + Radial Pulse

•15 y/o ♂

– HPI• Pulled from ocean• No LOC• + Submersion– PEA- Large foam at mouth/noseB- Active coughC- +Radial Pulse

• 15 y/o ♂– “Emergency Dept”

“Treatment”– O2 N/C @ 2 LPM

– 4 mg IM Dexamethasone– B12 – 10,000 μg IM– N-Acetylcysteine 20% IV– 30 mL (200mg/mL)

You assume care of 16 y/o

• A- Patent, copius foam

• B- Tachypneic, RR 36, tiring out

• C- ST 130 bpm, thready radial pulse

• Critical Actions?

Airway

• Intubate / Oxygenate– Pediatric– Laryngospasm

• RSI, PPV, Jaw thrust

Cricothyrotomy, Lidocaine

– Airway obstruction?• Foam, Sand, Mud, Del Taco

– Dec Compliance– Vomitus

• 86% of Drowning resuscitations

http://www.emsresponder.com/article/photos/1130360989690_10.jpg

Hypoxic Arrest

•Cardiac BLS/ACLS– Heart stops, oxygen in blood needs

circulating– C,A,B

•Drowning, Peds, Traumatic BLS/ACLS– Heart stops because no oxygen in blood– A,B,C

What about sending them home?

OK to send home after 4-6 hours

•Asymptomatic– GCS ≥14– Normal Respiratory Efforts

– SpO2 ≥ 96% on room air 

– No ACLS

Special considerations

In Water Resuscitation

•3X Increased Survival

Special considerations

Special considerations

Special considerations

• Immersion / Swimming Pulmonary Edema– Overhydration– Cold Water– Healthy

•Treatment– Oxygen, Oxygen, Oxygen– ?Antibiotics

4455

C-Spine

•Less than 1% of Drowning patients, all with significant mechanism of injury– Routine C-Spine

immobilization is unnecessary

Special considerations

4466

AED’s in Drowning

•V-Fib/V-Tach?

•Rescuer Safety

•Do not delay Oxygenation / Ventilation

•Minimize interruptions

5858

Special considerations

4477

Heimlich Manuever

• Increased risk of aspiration– Delays

ventilation– Usually <30mL

fluid in lungs– Watch for

vomiting !!!

Special considerations

Hypothermia

• Hypothermia?– Is it protective? Harmful? What about post-resus?

•Water at 91.4°F is thermally neutral

•Conductivity is 25-30 x air

•All have some degree of hypothermia

– Case Reports?•21 y/o ♀, 45 min 4°C•5 y/o ♂, 40 min 0°C•3 y/o ♀, 30 min 8°C•2.5 y/o ♀, 66 min (19°C)

Special considerations

Hypothermia

– Mammalian Diving Reflex•15%-30% of Humans

– Cold and Dead?•Continue resus and rewarm to 94°F

– What about post-resus?•Therapeutic Hypothermia has been shown to

decrease cerebral oxygen demand and improve neurologic outcomes

•Area of active research

Special considerations

Hypothermia

•Bottom line– Warm pt to

94°F•If dead, their

dead

•If not dead, stay there *

*Only if hospital protocols are in place

Special considerations

5511

Antibiotics

•No evidence to support routine use– CXR usually abnormal on admission– Febrile response to drowning– Use cultures to guide abx use

6363

Special considerations

Summary

• Understand definition of drowning– Process, not an outcome

• Appreciate epidemiology – Highly prevalent worldwide, children <4

• Management– Rapid O2 O2 O2, warm pt to 94°F, vomitus, ignore foam

– Hypoxic vs Cardiac cause of arrest

• Disposition of drowning patients– Home or ICU

• Don’t blow smoke up pt’s (or colleagues) asses– Bring your “A” game, be able to back it up

Discussion

Justin@LifeguardsWithoutBorders.org