Drowning

/ Maninder Singh, M.D.

Wednesday Conference
11/11/15
Article Inspired by: Dr. Sui Fai Li and Dr. Andrew Chertoff

THE CASE

20 y/o M BIBEMS after falling into the river. He is pulseless, apneic and cold. He is intubated, and his temperature is 80F. CPR has been in progress for 2 hours. Monitor shows VFib throughout CPR. What do you do?

  • Controversial but keep resuscitating until normothermic (possible neuroprotective effects with hypothermia)

THE TALK

Drowning = “process of experiencing respiratory impairment from submersion/immersion in liquid” as per World Congress on Drowning in 2002

Why is drowning harmful?

  • Initially you can hold breath
  • As some point, due to need for oxygen, will take a deep breath and water will enter airway
  • Clinical picture determined mostly by the amount of water that has been aspirated
    • Water in the alveoli causes surfactant dysfunction and washout
    • Increased permeability of the alveolar-capillary membrane
  • Result = hypoxemia
    • Decreased lung compliance
    • Increased regions of low ventilation to perfusion in the lungs (V/Q mismatch)
    • Atelectasis
    • Bronchospasm

What should I do if I see someone drowning and I am the first person on the scene?

  • Cardiac arrest from drowning is due primarily to lack of oxygen
  • CPR should follow traditional ABC sequence- 5 initial rescue breaths, followed by 30 chest compressions and continuing with 2 rescue breaths and 30 compressions

Should I do the Heimlich maneuver?

  • NO, most frequent complication is vomiting and it delays the initiation of ventilation

How about when the patient is in the Emergency Department?

  • Focus on reversing hypoxemia
    • Non-rebreather mask or nasal cannula if patient is protecting airway
    • If no improvement in 10-30 minutes, intubate
  • If hypothermic, warm them to achieve ROSC and then make a treatment decision
  • ECMO is single most effective way to warm someone, especially if cardiac dysrhythmia
  • CXR in any drowning patient with respiratory systems but initial CXRs usually do not provide prognostic value
  • Be careful about the circumstances (i.e fell off a bridge- now have to worry about trauma related injuries in addition to the drowning)

Is there a way to classify patients?

  • Grade 1 = coughing but normal auscultation
  • Grade 2 = abnormal auscultation; rales in some fields
  • Grade 3 = acute pulmonary edema without arterial hypotension
  • Grade 4 = acute pulmonary edema with arterial hypotension
  • Grade 5 = isolated respiratory arrest
  • Grade 6 = cardiopulmonary arrest

When should I admit a patient?

  • Grade 2 to 6 presentation
  • However, for grade 2, can also place on noninvasive oxygen and if oxygenation normalizes, could discharge after 6-8 hours of observation

Can I send someone home who has had “nonfatal drowning?”

  • Awake and look okay (good arterial oxygenation, no need for supplemental oxygen and no other associated injuries) – check lungs and can be discharged

How should I manage these patients?

  • Neurological
    • Keep head of bed raised
    • Low to normal CO2
    • MAP of 80mmHg
    • Benzodiazepines for seizures
  • Respiratory
    • Protective lung ventilation to prevent ALI and ARDS
    • Bronchodilation
    • ECMO
  • Metabolic
    • Severe metabolic acidosis from lactate
    • Rhabdomyolysis
  • Cardiovascular
    • Extravasation of systemic and pulmonary capillaries + cold diuresis -> hypovolemia
    • SIRS post resuscitation, often require cardiac output monitoring
  • Infection
    • Consider antibiotics if submerged in grossly contaminated water

Terminology

  • Dry drowning
    • Those who do not aspirate liquid into the lungs
  • Wet drowning
    • Aspirate liquid into the lungs
  • Secondary drowning
    • Unrelated event (seizures, cervical spine injury or heart attack) that results in the submersion and subsequent drowning
    • Development of ARDS in recovering victim
  • Freshwater drowning VS Seawater drowning
    • Similar degrees of lung injury, despite difference in osmotic gradients
    • You usually don’t swallow enough water to make any difference to your vascular system
  • Afterdrop Phenomenon
    • When applying external heat to the body, return of pooled, cool blood from previously vasoconstricted extremities -> further lower core temperature = afterdrop
    • Rewarming of trunk first may prevent problem by allowing warm blood to perfuse distally constricted cold extremities
    • More common in dehydrated patients and in patients with frostbitten extremities

REFERENCES

Li, S. “Conference: Drowning” Jacobi Medical Center. Jacobi/Montefiore Emergency Medicine Conference. Bronx. Nov 2015. Lecture

Chertoff, A. “Conference: Drowning Jeopardy” Jacobi Medical Center. Jacobi/Montefiore Emergency Medicine Conference. Bronx. Nov 2015. Lecture

Borghei, Sam, MD, Mizuho Spangler, DO, and Andrew Schmidt, DO. “Drowning Resuscitation.” July 2015. EM:RAP.

Nickson, Chris. “Drowning.” Drowning. LITFL Life in the Fast Lane Medical Blog

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