Near Drowning

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1. NEAR DROWNING RAHUL. A.P Asst Proff;LIAHS BPT,MPT MIAP (CRD &ICU CARE)

2. Definition "Near drowning" means a person almost died from not being able to breathe (suffocating) under water. A process resulting in primary respiratory impairment from submersion in a liquid medium

3. The majority of near-drowning cases are attributed to accidents that occur near or in the water. The most common causes of near-drowning include: an inability to swim panic in the water leaving children unattended near bodies of water falling through thin ice alcohol consumption while swimming or on a boat concussion, seizure, or heart attack while in water suicide attempt etc…

4. Infant drownings : 55% in bathtubs Age 1-4 years, 56% in artificial pools and 26% in other bodies of freshwater Children 63% of drownings were in natural bodies of freshwater

5. Signs & symptoms cold or bluish skin abdominal swelling chest pain cough shortness or lack of breath Vomiting

6. Rales and Rhonchi An abnormal lung sound that can be heard through a stethoscope. Rales may be sibilant (whistling), dry (crackling), or wet ( sloshy ), depending on the amount and density of fluid refluxing back and forth in the air passages. Rhonchi are continuous low pitched, rattling lung sounds that often resemble snoring. Obstruction or secretions in larger airways are frequent causes of rhonchi . Signs of associated trauma to the head and neck should be sought

7. PATHOPHYSIOLOGY 1. Involuntary submersion Voluntary apnea, hypoxia, hypercarbia 2. Involuntary inspiration Triggered by hypercarbia and hypoxia arterial hypoxemia, tissue hypoxia, tissue acidosis, and tachycardia 3. Water enters lungs Increased peripheral airway resistance, pulmonary vessel vasoconstriction/hypertension, decreased lung compliance, decreased surfactant

8. 4. Decompensation -gasping with further inhalation -swallowing with emesis -loss of consciousness 5. Neuronal dysfunction -blood brain barrier breaks down 6. Cardiac dysfunction - bradycardia, arrhythmias, asystole 7. Brain Death

9. Dry Drowning 10-20% of patients experience a laryngospasm that prevents aspiration of fluid into the lungs Tight spasm often persists until cardiac arrest Lungs remain dry Large volumes of fluid ingested into stomach Major cause for electrolyte abnormalities in children ( hyponatremia from fresh water, hypernatremia from salt water)

10. Wet Drowning 1-3 mL /kg water aspirated hinders gas exchange When fluid is in the lungs, vagus nerve stimulates vasoconstriction of pulmonary vessels and pulmonary hypertension Freshwater diffuses rapidly across alveolar-capillary membrane and saltwater damages the membrane Surfactant is denatured by freshwater and washed away by salt water In both salt water and freshwater aspiration, compliance is decreased

11. WORKUP-Laboratory Studies The following studies are indicated in near drowning: Blood gas analysis with co- oximetry (A CO - oximeter is a device that measures the oxygen carrying state of hemoglobin in a blood specimen, including oxygen-carrying hemoglobin (O2Hb), non-oxygen-carrying but normal hemoglobin ( HHb )to detect methemoglobinemia and carboxyhemoglobinemia

12. Methemoglobin - a stable oxidized form of haemoglobin which is unable to release oxygen to the tissues Carboxyhemoglobin - is a stable complex of carbon monoxide and hemoglobin ( Hb ) that forms in red blood cells upon contact with carbon monoxide (CO). CBC count, prothrombin time and partial thromboplastin time,

13. Serum electrolytes (with glucose) Liver enzymes Renal function tests Drug screen and ethanol level (consider) Continuous pulse oximetry and cardiorespiratory monitoring (may be needed)

14. Imaging Studies Chest radiography Head CT and cervical spine imaging if trauma suspected Extremity, abdominal, pelvic imaging if clinically indicated Echocardiography if myocardial dysfunction present

15. Other Tests Consider electrocardiography if the patient has arrhythmias. Monitor the patient if rewarming is necessary, because dysrhythmias are common when rewarming patients who suffer cold-water immersion injuries.

16. Swan- Ganz catheter for monitoring cardiac output and related hemodynamic parameters may be useful in patients with unstable cardiovascular status

17. Arrival to the hospital General Assessment: Appearance Work of Breathing Circulation Primary Assessment: Airway Breathing Circulation Disability Exposure

18. Management ET intubation if unconscious 100% O2 by face mask Treat hypothermia, hypoglycaemia , seizures, hypovolaemia and hypotension, if they occur If the patient is awake and alert, observe for at least six hours. Pulmonary oedema may develop late

19. continuous positive airway pressure (CPAP), intubation and mechanical ventilation with high positive end expiratory pressure (PEEP), or even extracorporeal membrane oxygenation (ECMO) for severe pulmonary oedema . Rewarming by extracorporeal circulation provides efficient rewarming and full circulatory support

20. Broncoscopy Removal of vomit, debris in lungs Nasogastric tube +/- urinary catheter. Albuterol For bronchospasm

21. Thank you….