Drowning In The Adult

Population
Emergency Department
Resuscitation and Treatment

DR KAMINI A/P VINATHAN

Definition
The process of experiencing respiratory impairment

due to submersion / immersion in a liquid

3 possible outcomes : no morbidity, morbidity and
mortality
The primary physiological insult is always hypoxia
Modifiers
Near drowning
Dry drowning
Wet drowning
Active drowning
Passive drowning
Secondary drowning

Epidemiolo
gy

In US approximately 4000-5000 people die from

drowning annually.
Primarily affects younger individuals.
In 2010 it was leading cause of death in children
aged 1-4yo and second leading cause of death in
children aged 5-9yo.
In adult patient being male, engaging in high risk
activities and consuming alcohol during water
activity increase the risk of drowning
Among people aged 18- 84 most common location
of drowning is natural body of water and in people
aged >85 years more likely drown in bathtub

Pathophysiolog
Airway drops below the surface of
water
y
Attempt to hold breath ,
protecting aspiration
(30sec to 1 min)
Voluntary Action
Attempt at inspiration
allow small amount of
water enter airway
Involuntary Action
Laryngospasm due to the
presence of water in the
airway
Hypoxia Systemic
hypoxia LOC
Dry drowning

Direct alveolar damage

and surfactant
washout
Broncospasm,
atelectasis and
pulmonary edema
Ventilation- perfusion
mismatch
Hypoxi
a

Neurological effect

-hypoxic effect on the brain

-Hypoxia causes irreversible acute neuronal

injury resulting in demyelination , tissue

death , edema and hemorrhage
-causes chronic morbidity ranging from mild
cognitive impairment to persistent
vegetative state

Cardiovascular
effects
- Sinus tachycardia ( panic and physical effort)
- Ischemic , infarct and other dysrhythmia ( in

cardiac patient because of stress factor )

- Bradycardia and cardiac arrest , PEA and
asystole( due to systemic hypoxia and acidosis)
- Cold water autonomic conflict stimulation
(simultaneous sympathetic cold shock response
and parasymphathetic mamalian diving
response) resulting in dysrhythmogenic effect

Pulmonary effect
- Direct alveolar injury
- Bronchospasm
- Airway inflammation
- Surfactant washout ( alveolar collapse increase

in alveolar- capillary interface permeability)

- Aspiration of debris from petroleum , sewage ,
sand and organic matter contamination causes
further pulmonary inflammation and infection.
- Pulmonary fluids shift due to difference in water
salinity

Renal effect

- Peripheral vasocontriction and peripheral

hydrostatic results in increased pressure

sensed by kidney and increased urination
- Struggle during drowning leads to
rhabdomyolysis resulting in renal damage

Differential
Diagnosis
Intoxication
Cardiac disease
Seizures
Trauma
Suicide / homicide

Prehospital
Care
Rescue
Resuscitation
Prehospital outcome data

Rescue
Faster removal of patient from water

increase the survival rate of patient.

Therefore individuals with formal water rescue

training is required - to prevent rescuer death

Prehospital
resuscitation
ABC
hypothermic patient might have weak pulse and

respiratory effort ( perform initial evaluation 30

60 sec)
Re-warming for hypothermic patient
For cardiac arrest patient initiate CPR transfer to
advance care
VF utilize AED or manual defibrilation
Pulse +, but respiratory distress maintant patent
airway and provide PPV with 100% O2
Stable patient with foam in the airway , cough ,
emesis transport to hosp as well because may
deteriorate 4-8 hours

Hypothermic patient requires addition

consideration in prehospital setting.

- Mildly hypothermic patient (32C -34C) who is
still shivering removal from cold environment
, removal of wet cloths and application of
insulating materials for transportation.
- Patient with moderate to severe hypothermia
(< 32C) or who have lost their shivering
mechanism active rewarming techniques
such as warmed inhaled O2, warmed IV fluids
(40C-44C) and forced-air blankets and
consider transfer patient to ECMO equipped
centers

Prehospital outcome
data

Emergency Department
Evaluation
INITIAL EXAMINATIONS
- ABC
- GCS
- VS
- TRAUMA (ATLS)
SECONDARY SURVEY
- Neurological exam pupils, cranial nerves,

limb strength
- Trauma
- Cervical injury cervical collar

Diagnostic testing
History

Laboratory studies

Imaging

Chest xray respiratory distress or arrest ,

hypoxia , h/o trauma, altered mental status
CT brain traumatic brain injury, altered
mental status , focal neurological deficit
Cervical spine imaging high risk activities,
those who unable to cooperate focused
cervical spine exam

Treatment

Prognostic
indicators
The primary factor associated with survival

with good neurological outcome is shorter

submersion time

Preventio
n
Pediatric population : close supervision ,

pool fencing and swimming lessons

Adult :
- familiarization with and confidence in
aquatic environment/swimming ability.
- Avoid risk factors such as alcohol use ,
participation in high risk activities, lack of
life jacket use while boating

Controversies and Cutting

Edges
Swimming induced (immersion) pulmonary

edema
Temporary changes in pulmonary function test,
no changes in cardiac function.
Following strenuous water activity such as long
distance swims and military training .Also
diversely used in diving and hyperbaric
medicine for diving with compressed gas.
Warranted for a period of observation with
disposition based on ventilatory status and
symptoms
No indication for diuresis

 The Heimlich Maneuver

-

The application of abdominal thrusts will delay

much needed ventilations
likely lead to emesis, further complicating
patients airway.
Cervical spine immobilization
By placing patient on spinal board and
securing the head,the rescuer may be placing
patients airway at risk of obstruction and
aspiration
Needs for patient with high risk activities ,
signs of trauma or altered mental status

Summary
Early reversal of systemic hypoxia has the greatest

impact on outcome and must remain the focus of

resuscitation and treatment.
In the prehospital environment, focus on providing
effective ventilations, treating hypothermia, and
rapidly transporting any symptomatic patient to
advanced care.
On arrival to the ED, keep the focus on protecting the
airway and assuring adequate ventilations based on
patient condition, and continue treating hypothermia.
Once stabilized in the ED, determine disposition
based on the examination and response to treatment,
consider patients displaying mild injury for
observation and discharge, and admit patients
displaying moderate to severe or worsening
symptoms.