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Drowning

• Drowning defined as:


death secondary to asphyxia and
within 24 hours of submersion which
may be immediate or follow resuscitation

• Submersion injury:
Survival after more than 24 hr is termed
regardless the victim later dies or recovers
Epidemiology

Age
1-toddler age<5 yr
2-in 15-19 years old.
• Male predominant in All ages .
• Male/ Female
• 2:1 in toddlers 10:1 in teenager
• The site of drowning ,most
common depending on age.
Relevant factors:
• Water Tonicity
• Time submersion
• water Temperature
• symptoms associated injuries .
• Undetected primary cardiac
arrhythmia( long QT)
• response to initial CPR
Drowning begin with:

1. Panic, breath holding, ear


hunger
2. reflex inspiratory and
aspiration.
3. laryngospasm that leads to
hypoxemia
4. hyperventilation followed by
voluntary apnea .
Pathophysiology
• Asphyxia may occur with:
1. pulmonary aspiration
(wet drowning).

2. laryngospasm (10-20%)
until cardic arrest
)dry drowning)
Anoxic-ischemic injury

• All organs may injured from hypoxia


and ischemia .

• CNS injury
(ICP ,cerebral edema)
The most frequent cause of
mortality and long- term morbidity
Anoxic-ischemic injury
• Pulmonary:
wash out surfactant
Pulmonary edema, ARDS
• Cardiovascular:
Arrhythmia( hypothermia ,hypoxemia)
• Acid-base
• Electrolytes
Anoxic-ischemic injury

• Renal
ATN (hypoxemia,shock,
hemoglobinuria)
• Gasterointestinal
hepatic trasaminases and serum
pancratic enzymes are often acutely
elevated
Aspiration and pulmonary injury

• Pulmonary aspiration occurs in the


great majority of submersion .

Pneumonia may result from :


• gastric contents
• water salinity
• pathogenic organisms
• toxic chemical
Fluid and electrolyte alteration
• The great majority of submersion do
not aspirate large volumes of fluid to
result in significant electrolyte
disturbances.
• Sea water
• Fresh water
Hypothermia
• Moderate hypothermia T(32-35)
increase oxygen consumption.

• Below T 32:
(sever hypothermia) shivering ceases and
cellular metabolic rate decreases

• Deep coma with fixed and dilated


pupils and absent reflexes at T (25-29)
may give the false appearance of death
Lab & imaging studies

• ABG
• CBC ,Electrolytes ,U/A
• Chet x Ray - cervical spine X Ray

• non contrast head CT scan???


Imaging
• Head CT scan is not helpful
unless :
1. Suspicion of associated trauma
injury
2. to rule out other possible causes
of coma

• MRI may detect change


associated with hypoxic- ischemic
injuries
Clinical Manifestation

• Victims in cardiac arrest


require aggressive and prolong
CPR.
Pre hospital treatment
• Careful search for pulses.

If pulses presented :
• Chest compression withhold
Sinus bradicardia and atrial
fibrillation require no immediate
treatment
Treatment
• Initial resuscitation:

• CPR
• air way should be clear

• Abdominal thrust should not be


used
• Cervical spine should be protected
Emergency unit management

• All pediatrics should be observed for at


least 8-12 hr even they are
asymtomatic on presentation.

• Serial monitoring of repeated careful


pulmunary and neurologic
assessment.

• Chest X RAY
Emergency unit management

Patients discharge after 8-12


hours if no evidence of :

• significant injury
• bronchospasm
• tachypnea
• inadequate oxigenation
hospitalized Children
• Supplement O2
• NaHCO3
• diuretic for pulmonary edema .
• broncodilators for brochospasme .
• Antibiotic for contaminated water.
• Anticonvolsion treatment for seizure
Treatment

• NG tube
• ECG monitoring for diagnosis and
treatment of arrhythmia.
• Hypothermia treatment
passive,active
• If a child is hypoglycemic 0/5-
1g/kg dextrose
ETT is needed if…

1. apnea ,cyanosis .
2. hypoventilation.
3. hemodynamic istability.
4. protect air way in patient with
depressed Mental
Treatment (con)
• A few patients develop require mechanical
ventilation.
for at least 24-48 hours.

• evaluated of oxigenation with ABG

• Rewarming effort should be continued


until T is at least 32-34c (passive, active)
• Patients should closely evaluated for
The neurological status

• Neurologic examination during the first


24-72hr are the best prognostic of CNS
outcome.
Prognosis (continue)

1.Overall about 75% of pediatric


submersion victims survive.

• Good recovery did not occur in:


Abnormal brainstem function
• Absence of purposeful movement at
24 hr
Poor prognosis

1. Submersion duration>10 minute


2. Age <3 years
3. CPR>25minutes
4. patient core<T33c
5. GCS<5
6. persistent apnea that CPR is
need in an ED.
prognosis
• PH<7.1
• Water temperature >10 c
• Children who remain comatose
24 hr after initiating
resuscitation
Treatment discontinue

• submersion victim in non-icy


water that remain systole
• despite 30-45 min of aggressive
CPR