1) Definition
a) Drowning is suffocation by submersion, especially in water
b) Near drowning is survival, at least temporarily after suffocation by submersion in water
- wet drowning= aspiration of fluids into lung
- Dry drowning= asphyxia secondary to laryngospasm
c) Secondary drowning (additional knowledge)
Delayed out pouring of fluid into alveoli because of parenchymal damage with protein rich transudation resulting in consequent impairment of gas exchange.
2) Pathophysiology of drowning
3) Comment on vital sign
1) Normothermic
2) Tachypnoea
3) Slightly Bradycardia
4) BP is still in normal range but still low.
Comment; vital sign is consistent with near drowning, but not yet go to 'cold diuresis' that could lead to significant hypovolumia and hypotension.
2) Management
Resuscitation
a) This case should be managed in red zone with emergency trolley and intubation kit ready as patient may collapse anytime.
b) Stabilize the C- spine and avoid neck movement.
c) Secure the airway, consider intubation if patient unconscious
d) Give Oxygen 100% saturation 10L/min via high flow mask.
e) Obtain IV access, ensure there is also a line as close to the heart as patient may go to bradycardia and need drugs to increase heart contractility (Dopamine, adrenaline)
f) ABG to look for 02 level and metabolic acidosis.
g) Vital sign, pulse oxymetry and ECG monitoring (beware of hyperkalaemia)
Acute management
h) Prevent the hypothermia
- Removes all wet clothes
- Cover patient with clean, dry blanket
- Apply external warmer if available.
i) Chest x- Ray to access severity of aspiration.
j) Blood investigation (FBC, Buse/Creat, DIVC screening)
Other measures
k) Beta agonist (Salbutamol) to prevent bronchospasm
l) Secondary survey to exclude other injury and find possible causes of drowning
m) Empirical antibiotic if victims submerged in grossly contaminated water.
n) Optimal fluid resuscitation and inotropic support if there is ‘cold diuresis’ causing significant Hypovolumia and hypotension.
o) Admission to wards for observation at least 12 hours if patient stable. Discharge if
- Patient look well and alert
- Stable vital sign
- Normal CXR
- Reliable care giver at home
p) Admission to ICU if
- Intubated patient
- Continued altered mental status
- Unstable vital sign despite resuscitation.
Reference
1) Shirley Ooi &Peter Manning, “Guide to the essentials in Emergency Medicine”, Mc Graw Hill, 2004
2) Hua Huat Soo, lee Gong Lau & Peng Hong Chew, “Sarawak Handbook of Medical emergency 2nd edition”, C.E Publishing, 2005