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Gary Williams
Mini PAC Conference ,
Melbourne
16-17 November 2012
Plan
Definitions
Guidelines
Epidemiology
Pathophysiology
Management
Outcome prediction
Definition
2002, World Congress on Drowning,
Amsterdam: respiratory embarrassment
from submersion / immersion in a liquid
medium
near drowning
dry or wet drowning
secondary drowning
delayed onset respiratory distress
< 100
350-400
100150
400-450
150200
450-500
200250
500-600
ANZPIC Registry
ANZPIC Registry
ANZPIC Registry
ANZPIC Registry
Submersions > 4 min, age, water temp, deep body temp, duration of submersion
and good neurologic outcome
43 cases, all with water temp documented
Submersion time in 40/43
37/43 initial deep body temp available: < 30C in30/37 (80%)
ED Prediction of outcome ?
Even fixed and dilated pupils, low
GCS, need for CPR in ED have proven
unreliable in individual cases
Christensen et al (Peds, 1997):
composite score based on ED
physical exam (apnoea, coma) +
need for CPR + lowest pH ..best
available but even this 93%
accurate in their hands
ED Prediction of outcome ?
Drowning: PICU
Management
THAPCA
Paed
OHCA
Within 6h
of ROSC
36-37.5C for 5d
Reasons to be
circumspect
1. Fever common, bad for injured brain, often not
controlled to normothermia in control arms
2. TH does have risks
3. Two large retrospective studies in paed cardiac
arrest (Pittsburgh n=181, CCTG n=222) have not
shown benefit
4. Data on early prophylactic use of TH in TBI in
children suggesting a worse outcome
Summary
Drowning remains a major cause
death and disability
Accurate outcome prediction in field
and ED problematic
Cold water protection theoretically
feasible but little evidence to support
Therapeutic hypothermia still waiting
for good evidence to support
Questions ?
Pathophysiology: Cardiac
Potential role of molecular autopsy in
unexplained drownings ?cardiac
channelopathy
Mayo Clinic 2011: 35 unexplained drownings,
average age 17y, 23 male 12 female
putative pathogenic mutation in 1/3: 3 LQT S,
6 CPVT
More common in females with 5/8
unexplained swimming-related drownings in
females having mutation
< 10% of drownings, implications for family
In retrospect 50% had warning sign on history