Drowning
(summarised Nelsons)
Definition: respiratory impairment from submersion in liquid
Fatal or non-fatal
Accidental, NAI or suicide
Second to MVA as cause of accidental death
1-4yo is the highest risk
Risk: warm climate near water, and no supervision
<1yo in bath or buckets
1-4yo, in home pools, out of sight for <5mins, or rurally in irrigation ditch/pond/river
School aged: in large bodies of water
15-19: Male, Alcohol, and risk taking
Other risks
Epilepsy and long QT
Pathophysiology: silent, energy is spent trying to take a deep breath or fighting to keep head up or they are in laryngospasm post aspiration
Cold water shock: Temp <15-20C > reflex hyperventilation +↓ breath holding > drowning OR bradycardia then SVT + vasoconstriction/HTN > arrest
Global Hypoxia > coma (to reduce O2 consumption) > medullary depression > terminal apnoea > PEA > VF/asytole > brain death
Hours later cerebral oedema may develop worsening ischemic injury (Ix ICP monitor)
Hypoxia > damage pulm vascular endothelium > ARDS + DIC > haemolysis + thrombocytopenia
Aspiration > wash out surfactant > collapse > VQ mismatch
Acute tubular necrosis, cortical necrosis > renal failure
Bloody diarrhoea
Raise transaminases and lipase
epithelial damage > bacteraemia > SIRS (sepsis)
Deep coma, fixed dilated pupil at temp <29 may give appearance of death > not dead until warm and dead
BUT neuroprotective effect only seen in water <5C and body temp <29C i.e. hypothermia in warmer water ischemic prior to hypothermic
Outcome defined by coldness of water (rarely), duration of submersion, and effectiveness of CPR (i.e. total hypoxia)
Rx
ABCs
Oxygen
Dry and Warm (unrecognised hypothermia can cause myocardial depression)
50% of asymptomatic children develop pulmonary oedema CXR when develop concern
Ventilate to avoid hypercapnia given possible cerebral schema
Minimise further cardiac schema by monitoring: oxygenation, temp, acidosis, BP, electrolytes
IVF and inotropes
Pts with raise ICP have poor outcomes regardless of ICP Mx, it only increases those surviving to vegetative state.
Phenytoin for seizures
No improvement after 72hrs in ICU should prompt consideration of withdrawal of treatment
GUT - NBM, NGT on free drainage, PPI
Rhabdomyolysis > myoglobin injures kidneys
50% have a single fever, ?mechanism. ?no need for antibiotics
SOCIAL WORK 80% divorce rate, difficulties with work and substance abuse
Outcome
Good
91% <5min submersion
87% <10mins
Bad
93% >10min
100% >25mins
One small study of non-icy showed all good recoveries showed purposeful movement and brainstem function at 24 hours, and all that didn't had a bad outcome.
Definition: respiratory impairment from submersion in liquid
Fatal or non-fatal
Accidental, NAI or suicide
Second to MVA as cause of accidental death
1-4yo is the highest risk
Risk: warm climate near water, and no supervision
<1yo in bath or buckets
1-4yo, in home pools, out of sight for <5mins, or rurally in irrigation ditch/pond/river
School aged: in large bodies of water
15-19: Male, Alcohol, and risk taking
Other risks
Epilepsy and long QT
Pathophysiology: silent, energy is spent trying to take a deep breath or fighting to keep head up or they are in laryngospasm post aspiration
Cold water shock: Temp <15-20C > reflex hyperventilation +↓ breath holding > drowning OR bradycardia then SVT + vasoconstriction/HTN > arrest
Global Hypoxia > coma (to reduce O2 consumption) > medullary depression > terminal apnoea > PEA > VF/asytole > brain death
Hours later cerebral oedema may develop worsening ischemic injury (Ix ICP monitor)
Hypoxia > damage pulm vascular endothelium > ARDS + DIC > haemolysis + thrombocytopenia
Aspiration > wash out surfactant > collapse > VQ mismatch
- aspiration of vomit/chlorine/bacteria may also cause damage
Acute tubular necrosis, cortical necrosis > renal failure
Bloody diarrhoea
Raise transaminases and lipase
epithelial damage > bacteraemia > SIRS (sepsis)
Deep coma, fixed dilated pupil at temp <29 may give appearance of death > not dead until warm and dead
BUT neuroprotective effect only seen in water <5C and body temp <29C i.e. hypothermia in warmer water ischemic prior to hypothermic
Outcome defined by coldness of water (rarely), duration of submersion, and effectiveness of CPR (i.e. total hypoxia)
Rx
ABCs
Oxygen
Dry and Warm (unrecognised hypothermia can cause myocardial depression)
- passive warming (dry, dry clothes, warm environment)
- Active
50% of asymptomatic children develop pulmonary oedema CXR when develop concern
Ventilate to avoid hypercapnia given possible cerebral schema
Minimise further cardiac schema by monitoring: oxygenation, temp, acidosis, BP, electrolytes
IVF and inotropes
Pts with raise ICP have poor outcomes regardless of ICP Mx, it only increases those surviving to vegetative state.
Phenytoin for seizures
No improvement after 72hrs in ICU should prompt consideration of withdrawal of treatment
GUT - NBM, NGT on free drainage, PPI
Rhabdomyolysis > myoglobin injures kidneys
50% have a single fever, ?mechanism. ?no need for antibiotics
SOCIAL WORK 80% divorce rate, difficulties with work and substance abuse
Outcome
Good
91% <5min submersion
87% <10mins
Bad
93% >10min
100% >25mins
One small study of non-icy showed all good recoveries showed purposeful movement and brainstem function at 24 hours, and all that didn't had a bad outcome.