10/1/2015 Describe the need for a universal drowning definition - - PDF document

10/1/2015 1

 Describe the need for a universal drowning

definition

 Name two of the organs that may be

impacted from a submersion injury

 Describe at least three appropriate

prehospital care interventions in caring for the submersion injury patient

 Identify three possible current nursing

management strategies for managing the submersion patient

 Incidence/recent data

• Males 5 times more than females
• 2005-2009 mean 3880 deaths/year
• Estimated 5789 people treated for nonfatal drowning

▪ Difficult to know???

 Preventable measures

• Fence (self closing gate)
• Unattended children

▪ Lifeguard distracted (socializing, other duties or chores)

• Poor pool maintenance

▪ Murky waters make it difficult to see

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 2005 Data

• Most prevalent from May to August
• After 1 year of age males account for 75% of

drowning deaths (riskier behavior?)

• Age distribution (peaks)

▪ <5 years: pools, bath tubs, liquid filled containers

▪ 1-4 years 50% die in swimming pools

▪ 15 – 25 years: natural bodies of water

▪ Beaches-rip currents account for 80%

• Boating drownings: 50% R/T ETOH

▪ >50% adult drownings believed to be R/T ETOH

• Epilepsy (tub)
• LQT Syndrome/Heart issues

▪ Cold water and exercise arrhythmias in LQT Syndrome? ▪ Long QT syndrome difficult to prove but mutations have been identified on some drowning victims ▪ Catecholaminergic polymorphic VT?

• Suicide/homicide

 Infants < 1 year of age

• About 50% drownings occurred in bathtub
• Medical eval, search for other injuries, get social

work involved

• Abuse, neglect?

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 Various, ambiguous, terminology (at least 20)

• Near drowning, silent drowning, passive

drowning, wet/dry drowning etc. etc. etc.

 No uniformity has caused confusion

• Amongst clinicians
• Amongst data interpreters

▪ Studies inconsistent ▪ Enhance future reporting and enable greater analysis for better treatment options  2002 World Congress of Drowning

• “Drowning is a process resulting in primary

respiratory impairment from submersion/immersion in a liquid medium.”

• Term drowning used no matter the outcome
• Outcomes should be classified as death,

morbidity, or no morbidity

• Discourages use of other terms ie wet/dry

drowning, near drowning etc.

• Def accepted by WHO, CDC, ILCOR, AHA

 Head above water

• Child struggles 20 seconds
• Adult struggles 60 seconds

 Head below water = panic and hold breath  H2O in oropharynx/larynx may trigger

involuntary laryngospasm (7-10%)

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 No gas exchange

(hypoxia/hypercarbia)=acidosis

 Water is swallowed  Prolonged hypoxia ceases laryngeal

spasm/obstruction (if occurred)

 Victim inhales liquid  Victim’s O2 levels quickly dwindle  Not enough O2 to the brain

• Loss of consciousness
• Apnea

 Changes in lungs, body fluids, pulm edema,

pulm hypertension

• Death results from prolonged

submersion R/T hypoxia

 Dry drownings happen about 2%

 Fresh vs. saltwater

• Not much difference as

earlier thought (canine studies)

• Aspiration of 22ml/kg

for electrolyte change

• Aspiration of 11 ml/kg

for blood vol change

• Avg. aspiration 2-4 ml/kg
• Aspiration of fluid content may be clinically relevant

▪ Silt, mud, sewage, bacteria , seaweed, sand, etc.  Salt water

• Impurities and bacteria
• Pseudomonas putrefactions, Staph. aureus

Floating in Dead Sea

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 Lung changes (variable length of submersion)

• Sig. impairment to gas exchange aspiration (1-3

ml/kg)

• Surfactant washed out

▪ Alveolar instability ▪ Atelectasis ▪ Dec. lung compliance ▪ V/Q mismatch

Cascade of events leading to secondary drowning

 Damage to alveolar-capillary membrane

leads to pulmonary edema

 Asp. Fluid causes vagal reflexes

which causes pulmon. vasoconstriction and pulmon HTN

 Aspirate vomit further complicate acute lung injury  Bronchospasm

• Fluid in airways

 ARDS (evidence usually occurs promptly)

• Noncardiogenic Pulmonary Edema
• Impaired oxygenation
• Bilat. Pulm infiltrates

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 Cardiovascular Effects

• Hypovolemia R/T increased capillary permeability
• Rewarming (surface)associated with vasodilatation
• Pulmonary HTN

▪ Difficult to pump blood to lungs ▪ Less blood returns from lungs

▪ Decreased cardiac output

• Decreased cardiac output R/T hypoxemia, acidosis
• Myocardial dysfunction R/T arrythmias

 CNS effects

• Initial injury R/T tissue hypoxia and ischemia
• Secondary injury

▪ Reperfusion, Cerebral edema, Excitory transmitters ▪ Impaired cerebral autoregulation ▪ Hypotension ▪ Sustained acidosis ▪ Hyperglycemia, hypoglycemia ▪ Seizures  Hypothermia

• Hypotension, bradycardia, conduction abnormalities

▪ Hypotension from cold water diuresis

• Antiarrythmics, insulin may be ineffective and

accumulate to toxic levels R/T slowed metabolism and excretion

• Neuro protective if rapid hypothermia prior to cardiac

arrest

▪ Icy water submersion (<10-20 C) ▪ Mammalian diving reflex? ▪ Not happening here?

10/1/2015 7

 Drowning

• Factors (anything that can precipitate syncope)

▪ Seizures, hypoglycemia, hyperventilation (divers 87 vs 146 sec), hypothermia, ETOH, drugs, trauma ▪ Epileptics (15-19 times more likely to drown) ▪ LQTS (exertion, cool water, swimming) ▪ Stroke, heart attack (older pop)

• What caused the drowning??
• Most want to breathe so don’t cry for help

 Treatment of drowning patients

• Minimally asymptomatic

▪ Small cough, no foam at mouth or nose ▪ Usually released with instructions to watch for signs

• All patients with respiratory symptoms

▪ Dyspnea, foam, rales ▪ Transport with O2  BLS at scene (biggest factor influencing survival)

• ABC not CAB

▪ IF in water pulse check unnecessary

▪ If not in full arrest should respond with few breaths

▪ IF out of water

▪ Prior to compressions  AHA – 2 breaths  ERC-5 breaths

▪ Pulse may be hard to feel

 Bradycardia, hypoxemia,  Hypothermia, vasoconstriction

Credit Wellcome Library

10/1/2015 8

 Cervical spine injury

• Very uncommon
• 11 out of 2244 victims (0.5%)

▪ All had signs of trauma

▪ Diving, motor vehicle crash

• Use caution but don’t delay resuscitation

 Remove from water  Maintaining airway

• Jaw thrust
• Obstructed with foam or water

 Rescue breathing in water useful

• Ventilation and O2 most important initially

 Chest compressions in water?  Heimlich maneuver?

10/1/2015 9

 100% oxygen

• Until pt is able to keep sats >mid 90’s
• Intubate?

▪ Supraglottic airway (LMA)?

• PPV use cricoid pressure

▪ Full stomach

 Suction

• Vomit

▪ Lateral decubitus ▪ Suction equipment (soft tipped, yankauers, etc)

• Pulmonary edema (copious secretions)?

 Remove wet clothing if possible  Cover with blankets  Monitor VS  Monitor for further vomiting  Monitor for deterioration

• Pulmonary edema
• Shock

 History

• Fluid pt was submerged in
• Temperature of solution
• Duration of submersion
• Resuscitative efforts at scene
• Response to efforts
• ETOH/drugs suspected (Narcan??)
• Pre-existing conditions or diseases

10/1/2015 10

 Crucial in management (full neurologic recovery)

• 60 minutes in icy water?
• 20 minutes in cool water (5-10 mins by other source)?
• Hot springs or hot tubs much shorter times

 Submersions (non icy) greater than 25 mins

likelihood for poor outcome approaches 100%

 Inaccurate (rough estimate)

• Emotional excitement
• Time of call to rescue arrival
• Hence, attempt to resuscitate all victims

 Drowning scope can range from asymptomatic

patient (dunked) to pulseless arrest

• Asymptomatic (observe for approx 4-8 hours then

discharge if physician decides with instructions to responsible parent/adult about symptoms)

▪ Awake, alert ▪ No adventitious breath sounds ▪ No required rescue breathing or supp O2 ▪ Normal pulse ox ▪ Normal x ray  Resuscitation

• PALS guidelines but ABC
• Usually tachycardia then bradycardia then PEA the

asystole

• Hypothermic (<35 C core temp) patient (effects include

arrythmias, coagulopathy, impaired immune function, acidosis)

▪ May appear dead d/t profound bradycardia, intense vasoconstriction, marked depression of brain and cardiovascular patient, dilated pupils—begin CPR if unsure

10/1/2015 11

 AHA unsure of what temp to start defib

• Try at least once—may keep trying? (says to follow

PALS/ACLS protocols)

• Medications

▪ “may be reasonable to consider administration of a vasopressor during arrest” AHA 2010 Part 12 Drowning ▪ Ice water drowning rewarm core to minimum of 30 C before stopping CPR—others experts say higher

 European Resuscitation Council

• Suggest 3 defibrillations performed
• Hold Epi until core temp > 30 C, then double time to

next dose until temp >35 C  Resuscitation

• Hypothermia (never allow hyperthermia)

▪ Aggressive attempts to restore normal body temp and establish safe steady warming rate while maintaining cardiac stability ▪ Rewarm pt 1-2 C/hour to 33-36 C

▪ Passive rewarming  Remove wet cold clothing  Warm blankets to insulate patients

 Resuscitation

• Hypothermia

▪ Rewarming techniques

▪ Active external rewarming  Hot packs  Heat lamps  Forced air external rewarmers

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 Resuscitation

• Hypothermia

▪ Active internal rewarming

▪ Warmed humidified O2 (mask, ETT) ▪ Warmed IVF (40-44 C, shortest possible tubing length) ▪ Warm saline lavage (gastric, peritoneal, rectal, mediastinal) ▪ ECMO (preferred treatment for victim with persistent cardiac instability)

 Treat shock (tissue perfusion,

tachycardia, pulses, cap refill, ALOC, oliguria, etc)

• Myocardial dysfunction (hypoxia, acidosis)
• Fluid shift

▪ 20 ml/kg to achieve euvolemia (wary of pulm edema) ▪ Inotropes

▪ Dobutamine

 Respiratory

• Intubation (age formula vs Broselow tape)

Protects airway

▪ Cuffed vs. uncuffed ▪ Allows administration of higher O2 conc. (protect brain) ▪ Steroids not proven to help and may interfere with healing

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 Respiratory

• PEEP (pulmonary edema, decreased lung compliance)

▪ Recruit atelectic areas of lungs (improve ventilation) ▪ Dec degree intrapulmonary shunting ▪ Dec. V/Q mismatch ▪ Shifts interstitial pulmonary water into capillaries ▪ Inc. diameter small and large airways to improve distribution of ventilation ▪ Start usually at 5 and inc from there watching oxygenation and blood pressure

 Respiratory

• Bronchodilators for bronchospasm (albuterol)
• Surfactant administration

▪ Case studies have shown some effectiveness in peds but not adults

• Wean vent after 24 hours?

▪ Allows time for surfactant regeneration ▪ Pulmonary edema may recur if not resolved sufficiently  Methods of ventilation

• Changes in lung compliance, airway resistance,

cardiovascular status

• Maintain normocarbia and adequate oxygenation
• Prevent ventilator associated lung injury (low tidal

volumes, high PEEP)

• HFOV

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 Save the brain (cerebral edema

ICP R/T hypoxic neuronal injury)

• Maintain adequate oxygenation, ventilation

(avoid hyperventilating, ETCO2 trends with ABG)

 Hyperventilate as temporary measure (surgeon on way)

• Avoid hypotension, hyperthermia (exacerbate

neuro damage)

• Avoid /treat hypo or hyperglycemia

▪ Keep within a range  Save the brain

• Treat seizures

▪ Increases blood flow ▪ Consumes cerebral O2 ▪ May not see (cont EEG?)  Save the brain

• CP monitoring not warranted but may choose to

(still treat but no proof of better outcome)

• Continue to elevate HOB 30 (C-spine cleared)
• No proof of benefit from barbiturates

10/1/2015 15

 Therapeutic hypothermia not working

(increased sepsis)?

• Some experts maintain to consider this option

early in course

▪ Neouroprotective ▪ Some say if pt hypothermic with ROSC, then try it ▪ Many variables at play may not reflect on research studies

▪ Vfib cardiac arrest vs asphyxial cardiac arrest

• NGT/OGT

▪ Removes swallowed water/debris ▪ Warmed gastric saline lavage ▪ Helps ventilation so lungs can expand  Pneumonia

• Pneumonia after submersion showed 60%mortality

rate

▪ Aeromonas highest mortality rate

• Prophylactic ATB not recommended

▪ Unless exposure to grossly contaminated water i.e. sewage

• Tracheal and blood cultures usually drawn in ED

▪ ATB started at 1st signs infection—many will present with them

• Patients with signs of pneumonia, bacterial cause

should be found and treated…if not coverage should be aimed at prevalent nosocomial flora of hospital

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 Special considerations

• Bronchoscopy (removal foreign bodies, debris)

▪ Silt or sand from surfing accident

• ECMO

▪ Extreme hypothermia ▪ Lung injury (evidence lacking but survival case studies published)

▪ To help remove CO2 (help the brain)

▪ Technologically challenging, practical, logistical issues

• ARDS

▪ Altered surfactant volume or function, neurogenic pulmonary edema complicates submersion injury ▪ High mortality rate ▪ Permissive hypercapnea to avoid barotrauma may not be an option with hypoxic CNS injury

 Poor prognosis---No high quality evidence to

predict poor neuro outcomes

• Submersion time > 5 minutes, others say 10 minutes
• Time to BLS > 10 minutes
• Resuscitation > 25 minutes
• Age > 14 years
• GCS < 5 (comatose, about 75% predictive)
• ABG pH < 7.1 upon presentation
• Pupils not reacting after 24 hours (post resuscitation)

 Poor prognosis

• No pupil response 24 hours after resuscitation

(TH)

• EEG patterns (burst suppression, loss of reactivity

to stimulation)

• CT scan

▪ First 24 hours may look normal ▪ Loss of gray/white matter differentiation and/or cerebral edema associated with poor prognosis in patients that have arrested

10/1/2015 17

 Prognosis

• Peds more likely to get ROSC than adults from

drowning

▪ More witnesses, more people to help (bystander CPR) ▪ Comorbidities of adults ▪ Protective mechanisms (diving reflex) ▪ More aggressive treatment

• Unfavorable neuro outcome

 Where do we go?

• Prevention

Resusci Anne –drowned in the 1880’s France

Questions?

 Available upon request