Drowning ( Submersion Injuries )

Uptodate till Jan'18

1. Drowning ( Submersion injuries ) Dr Ashutosh Bhardwaj MD,IDCCM,EDIC Clinical Lead & Senior Consultant , Critical Care Medicine , Dharmshila Narayana Superspeciality Hospital , Vasundhara Enclave, Delhi -96

2. Introduction Every year, drowning accounts for at least 500,000 deaths worldwide Low and middle-income countries-highest rates of fatal drowning (over 90 percent of such fatalities) M ajor cause of accidental death- under the age of 45 years and in children under five years of age The age distribution of submersion injury is bimodal Statistics for nonfatal drowning - difficult to obtain, may occur several hundred times as frequently as reported drowning deaths Papa L, Hoelle R, Idris A. Systematic review of definitions for drowning incidents. Resuscitation 2005;65:255 Bierens JJ, Knape JT, Gelissen HP. Drowning. Curr Opin Crit Care 2002; 8:578 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477 2

3. < 100 350-400 100-150 400-450 150-200 450-500 200-250 500-600 250-300 600-700 300-350 >700 Age-standardised Disability-Adjusted Life Year (DALY) rates from Drownings by country (per 100,000 inhabitants) DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477 3

4. Terminology Multiple definitions of drowning, nonfatal drowning, and submersion injury - creating confusion Nonfatal drowning - survival, at least temporarily, after aspiration of fluid into the lungs ("wet nonfatal drowning") or after a period of asphyxia secondary to laryngospasm ("dry nonfatal drowning") The Utstein definitions & methods of data reporting for drowning and related event - to improve consistency Idris AH, Bierens JJLM, Perkins GD, et al. 2015 revised Utstein -style recommended guidelines for uniform reporting of data from drowning-related resuscitation: An ILCOR advisory statement. Resuscitation 2017;118:147 . Youn CS, Choi SP, Yim HW, Park KN. Out-of-hospital cardiac arrest due to drowning: An Utstein Style report of 10 years of experience from St. Mary's Hospital. Resuscitation 2009; 80:778. 4

5. Terminology Utstein guidelines, drowning refers to: "a process resulting in primary respiratory impairment from submersion or immersion in a liquid medium" S uggest to remove ambiguous or confusing terms such as "near-drowning," "secondary drowning," and " wet drowning " Idris AH, Bierens JJLM, Perkins GD, et al. 2015 revised Utstein -style recommended guidelines for uniform reporting of data from drowning-related resuscitation: An ILCOR advisory statement. Resuscitation 2017;118:147 . Youn CS, Choi SP, Yim HW, Park KN. Out-of-hospital cardiac arrest due to drowning: An Utstein Style report of 10 years of experience from St. Mary's Hospital. Resuscitation 2009; 80:778. 5

6. Risk factors Inadequate adult supervision Inability to swim or overestimation of swimming capabilities. Risk-taking behavior  ,Use of alcohol and illicit drugs DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477 Olshaker JS. Near drowning. Emerg Med Clin North Am 1992; 10:339 Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics 1993;91:612 . 6

7. Hypothermia,Concomitant trauma, stroke, or myocardial infarction Seizure disorder or developmental/behavioral disorders in children Undetected primary cardiac arrhythmia Hyperventilation prior to a shallow dive DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477 Olshaker JS. Near drowning. Emerg Med Clin North Am 1992; 10:339 Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics 1993;91:612 . 7

8. 8 Causes Salt Water 1-2% Fresh water 98% swimming pools: public 50% swimming pools: private 3% lakes, rivers, streams, storm drains 20% bathtubs 15% buckets of water 4% fish tanks or pools 4% toilets 1% washing machines 1% DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477 Olshaker JS. Near drowning. Emerg Med Clin North Am 1992; 10:339 Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics 1993;91:612 .

9. Pathophysiology Fatal and nonfatal drowning- begins with a period of panic, loss of the normal breathing pattern, breath-holding, air hunger Reflex inspiratory efforts - hypoxemia by means of either aspiration or reflex laryngospasm Hypoxemia-affects every organ system especially brain Kenny D, Martin R. Drowning and sudden cardiac death. Arch Dis Child 2011; 96:5. Ibsen LM, Koch T. Submersion and asphyxial injury. Crit Care Med 2002; 30:S402. Karpovich , PV. Water in the lungs in drowned animals. Arch Pathol 1933; 15:828. Giammona ST. Drowning: pathophysiology and management. Curr Probl Pediatr 1971; 1:1.   9

10. Pathophysiology Kenny D, Martin R. Drowning and sudden cardiac death. Arch Dis Child 2011; 96:5. Ibsen LM, Koch T. Submersion and asphyxial injury. Crit Care Med 2002; 30:S402. 10

11. The event-- part 1 Voluntary breath-holding Aspiration of small amounts into larynx Involuntary laryngospasm Swallow large amounts Laryngospasm abates (due to hypoxia ) Aspiration into lungs Pathophysiology Karpovich , PV. Water in the lungs in drowned animals. Arch Pathol 1933; 15:828. Giammona ST. Drowning: pathophysiology and management. Curr Probl Pediatr 1971; 1:1. 11

12. The event-- part 2 Decrease in sats Decrease in cardiac output Intense peripheral vasoconstriction Hypothermia Bradycardia Circulatory arrest, while VF rare Extravascular fluid shifts, diuresis Karpovich , PV. Water in the lungs in drowned animals. Arch Pathol 1933; 15:828. Giammona ST. Drowning: pathophysiology and management. Curr Probl Pediatr 1971; 1:1. 12

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15. Pathophysiology – Fresh vs Salt water Hypertonic vs hypotonic - No longer considered important More apparent among persons who are dead on arrival Aspiration of >11 mL/kg must before blood volume changes & > 22 mL/kg before electrolyte changes U nusual for nonfatal drowning victims to aspirate more than 3 to 4 mL/kg Both result in decreased lung compliance, V/Q mismatch and intrapulmonary shunting -hypoxemia Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am 2001;48:627 Harries MG. Drowning in man. Crit Care Med 1981; 9:407 Harries M. Near drowning. BMJ 2003; 327:1336. 15

16. End organs effects Tissue hypoxia Pulmonary Fluid aspiration-hypoxemia Both salt water and fresh water wash out surfactant - noncardiogenic pulmonary edema and ARDS Pulmonary insufficiency - shortness of breath, crackles, and wheezing C hest radiograph or CT - normal to localized, perihilar , or diffuse pulmonary edema DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. CritCare Clin 1997;13:477   Olshaker JS. Near drowning. Emerg Med Clin North Am 1992; 10:339. 16

17. Neurologic - Hypoxemia and ischemia - neuronal damage, cerebral edema and elevations in intracranial pressure 20 percent of nonfatal drowning victims sustain neurologic damage Cardiovascular – Arrhythmias secondary to hypothermia and hypoxemia In some pts ECG may show s/o MI I nitial arrhythmias-sinus tachycardia, sinus bradycardia and atrial fibrillation D iving can precipitate fatal ventricular arrhythmias in patients with congenital long QT syndrome End organs effects Sarnaik AP, Preston G, Lieh -Lai M, Eisenbrey AB. Intracranial pressure and cerebral perfusion pressure in near-drowning. Crit Care Med 1985; 13:224 Gonzalez- Rothi RJ. Near drowning: consensus and controversies in pulmonary and cerebral resuscitation.Heart Lung 1987; 16:474 Rivers JF, Orr G, Lee HA. Drowning. Its clinical sequelae and management. Br Med J 1970; 2:157 17

18. Acid-base and electrolytes - Metabolic and/or respiratory acidosis Significant electrolyte imbalances rare in nonfatal drowning survivors except those submerged in unusual media, such as the Dead Sea - extremely concentrated seawater Renal – Rare & due to acute tubular necrosis resulting from hypoxemia, shock, hemoglobinuria , or myoglobinuria Coagulation – Hemolysis and coagulopathy are rare End organs effects Yagil Y, Stalnikowicz R, Michaeli J, Mogle P. Near drowning in the dead sea. Electrolyte imbalances and therapeutic implications. Arch Intern Med 1985; 145:50. Fandel I, Bancalari E. Near-drowning in children: clinical aspects. Pediatrics 1976; 58:573 . Bonnor R, Siddiqui M, Ahuja TS. Rhabdomyolysis associated with near-drowning. Am J Med Sci 1999;318:201 .   18

19. Management Prehospital care and acute interventions Emergency department management Patient disposition Inpatient management 19

20. Prehospital care and acute interventions Rescue and immediate resuscitation by bystanders improves the outcome of drowning victims CPR - as soon as possible without compromising the safety of the rescuer or delaying the removal of the victim from the water Ventilation is the most important initial treatment Follow ABC & NOT CAB Cervical spinal cord injury is uncommon Unless clinical signs or history suggestive As per ACLS- routine cervical spine immobilization not recommended Venema AM, Groothoff JW, Bierens JJ. The role of bystanders during rescue and resuscitation of drowning victims. Resuscitation 2010; 81:434 . Watson RS, Cummings P, Quan L, et al. Cervical spine injuries among submersion victims. J Trauma 2001 ; 51:658. 20

21. Pulses may be very weak and difficult to palpate May be because of hypothermia or arrythmias Check for at least one min before initiating chest compressions The Heimlich maneuver or other postural drainage technique – no proven value Don’t delay rescue breaths Give supplemental oxygen Initiate rewarming in hypothermic pt ( <33⁰C) Rosen P, Stoto M, Harley J. The use of the Heimlich maneuver in near drowning: Institute of Medicine report. J Emerg Med 1995; 13:397. Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S501.   Prehospital care and acute interventions 21

22. Immediate hospital management Assess and manage ABC 100 % oxygen Pulse oximetry (watch for false readings caused by peripheral shutdown and acidosis) ABGs , FBC, U&E CXR Observation Management of associated hypothermia 22

23. Emergency department management Prehospital resuscitative efforts to be continued I ndications for O2,NIV & intubation – GCS,PaO2,PaCO2 F requent vital sign measurements and clinical reassessment T rauma evaluation and appropriate imaging studies Rewarm the hypothermic patients Importance of prolonged resuscitative efforts Jolly BT, Ghezzi KT. Accidental hypothermia. Emerg Med Clin North Am 1992; 10:311 . Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome. Resuscitation 2014; 85:790. Kieboom JK, Verkade HJ, Burgerhof JG, et al. Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study. BMJ 2015;350:h418 . 23

24. Predicting Ability for ED Discharge Several studies support selected ED discharge Observe in ED for minimum 4-6 hours if: Submersion > 1 min. Cyanosis on extraction CPR required Admit if: CNS or respiratory symptoms Child can safely be discharged home if at 6 hours after ED presentation: GCS > 13 Normal physical exam/respiratory effort Room air pulse oximetry oxygen saturation > 95% Jolly BT, Ghezzi KT. Accidental hypothermia. Emerg Med Clin North Am 1992; 10:311 . Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome. Resuscitation 2014; 85:790. Kieboom JK, Verkade HJ, Burgerhof JG, et al. Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study. BMJ 2015;350:h418 . 24

25. Patient disposition Drowning classification system Adapted from Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation . Pediatr Clin North Am. 2001;48:627-646 . [BMJ Best Practice: drowning classification system 25

26. Inpatient management Respiratory Ventilation Treatment of bronchospasm Steroids: no benefits Bronchoscopy Prophylactic abx : no benefits Pneumonia – Grossly contaminated water, Gastric juices Thinks of water borne bugs Surfactant: no beneficial Cardiovascular Restore adequate oxygen delivery to tissues Hypotension – cold diuresis - Pearn J. Pathophysiology of drowning. Med J Aust 1985; 142:586 .   Anker AL, Santora T, Spivey W. Artificial surfactant administration in an animal model of near drowning . Acad Emerg Med 1995; 2:204.   26

27. Inpatient management Neurological Outcome GCS on presentation, duration of LOC Goal is to prevent secondary neurologic injuries Brain CT – not indicated, unless TBI suspected ICP monitoring - not indicated , typically irreversible hypoxic cellular injury Mild hyperventilation? Osmotherapy – not indicated Corticosteroids (dexamethasone) - no proven benefit - Moler FW, Hutchison JS, Nadkarni VM, et al. Targeted Temperature Management After Pediatric Cardiac Arrest Due To Drowning: Outcomes and Complications. Pediatr Crit Care Med 2016; 17:712 . Tipton MJ, Golden FS. A proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion. Resuscitation 2011; 82:819. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010; 81:1400.   27

28. Inpatient management Shivering or random, purposeless movements can increase ICP Seizures - treat aggressively Hypothermia and barbiturate coma - highly controversial & unlikely to benefit the patient Avoid NMBs Maintain Euglycemia T herapeutic (induced) hypothermia in the postresuscitation period – Equivocal data Moler FW, Hutchison JS, Nadkarni VM, et al. Targeted Temperature Management After Pediatric Cardiac Arrest Due To Drowning: Outcomes and Complications. Pediatr Crit Care Med 2016; 17:712 . Tipton MJ, Golden FS. A proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion. Resuscitation 2011; 82:819. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010; 81:1400.   28

29. Prognosis 29

30. Prognosis predictors Poor outcomes Age >14 yrs Submersion time: > 5 min Time to effective BLS >10 min Serum pH: <7.1 on presentation CPR >25 min Initial core temp <33ºC GCS <5 ie comatose No association between water temperature & outcome - Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome. Resuscitation 2014; 85:790. 30

31. Prognosis predictors - Submersion time survival Fatality 0-5 min 7/67 10% 6-9 min 5/9 56% 10-25 min 21/25 88% >25 min 4/4 100% Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome. Resuscitation 2014; 85:790. 31

32. Neurologic prognosis Absence of spontaneous respiration,Poor GCS, duration of LOC are ominous sign associated with severe neurologic sequelae Permanent neurologic sequelae persist in ~20 % of victims who present comatose Minimal brain dysfunction, spastic quadriplegia , extrapyramidal syndromes, optic and cerebral atrophy, and peripheral neuromuscular damage Orlowski JP. Prognostic factors in pediatric cases of drowning and near-drowning. JACEP 1979; 8:176 .   Biggart MJ, Bohn DJ. Effect of hypothermia and cardiac arrest on outcome of near-drowning accidents in children. J Pediatr 1990; 117:179. 32

33. Safety Recommendations Never leave a child alone in or near water, even for a minute Limit pool access. Children with Epilepsy Child can swim in lifeguard-supervised swimming pool - no open water Older child should shower in a non-glass cubicle - no bath Leave bathroom unlocked Supervision ! O'Flaherty JE, Pirie PL. Prevention of pediatric drowning and near-drowning: a survey of members of the American Academy of Pediatrics. Pediatrics 1997; 99:169 . Modell JH. Prevention of needless deaths from drowning. South Med J 2010; 103:650. 33

34. Safety Recommendations Learn CPR Use approved personal flotation devices Teach safe water behaviour The Best Approach Therefore: P revention ! P revention ! P revention ! O'Flaherty JE, Pirie PL. Prevention of pediatric drowning and near-drowning: a survey of members of the American Academy of Pediatrics. Pediatrics 1997; 99:169 . Modell JH. Prevention of needless deaths from drowning. South Med J 2010; 103:650. 34

35. Summary Ventilation is the most important initial treatment for victims of submersion injury – ventilation strategies are standard Rescue breathing should begin as soon as the rescuer reaches shallow water or a stable surface In critically ill patients, standard practices are employed to reduce the risk of brain injury The role of therapeutic hypothermia remains unclear There is no good evidence to support the routine use of glucocorticoids or prophylactic antibiotics in nonfatal drowning victims 35

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