drowning and submersion injury
Post on 08-Feb-2016
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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
hunger2. reflex inspiratory and
aspiration. 3. laryngospasm that leads to
hypoxemia4. 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 years3. CPR>25minutes4. patient core<T33c 5. GCS<56. 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
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