1 NEAR DROWNING

Prepared by : Adnan Ali

2 Lecture outlines

 Introduction & basic definitions  Further Management

 Pathophysiology & diving reflex  Prognosis
 Causes  Near drowning classification
 Clinical manifestations  Prevention
 Diagnosis  References
 Laboratory & imaging studies
 Immediate responce
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Introduction
 Drowning: “ death by suffocation from submersion in any
liquid”
 OR
 Drowning is defined as death by asphyxia due to submersion
in a liquid medium.

 “Near-drowning” is defined as immediate survival for >

24hours after asphyxia due to submersion.
 Last stage before fatal drowning which results in death.
4 Pathophysiology

 Initially, submersion or immersion results in aspiration of small amounts of

fluid into the larynx, triggering breath holding or laryngospasm.
 In many cases, the laryngospasm resolves & larger volumes of water or
gastric contents are aspirated into the lungs, destroying surfactant and
causing alveolitis & dysfunction of the alveolar-capillary gas exchange.
 The resulting hypoxemia leads to hypoxic brain injury that is exacerbated
by ischemic injury after circulatory collapse
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A. Wet Drowning:

 involves significant aspiration of fluids in to the lungs.

 This causes pulmonary vasoconstriction & hypertension with ventilation-
perfusion mismatch aggrevated by surfactant destruction & washout,
increasing lung compliance & atelactasis.
 ABG’S Results: will show hypoxia, hypercarbia & mixed respiratory
metabolic acidosis
 Symptoms may appear rapidly & but in lesser insult symptms may be
delayed
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contamination
 Water contaminated with chemical wastes, detergents e.t.c may
induce further lung injury.
Electrolytes:
 Irrespective of wether the aspirated water is salt, fresh or
swimming pool, changes in serum electrolytes & blood
volume are similar & rarely immediatly life threatening
Gastric fluid:
 swollowing of fluid into the stomach with gastric dialatation,
vomiting & aspiration is common
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B. Dry Drowning
 In about 10-20% of deaths from drowning, a small amount of water
entering the larynx causes persisitent laryngospasm which results in
asphyxia & immediate outpouring of thick mucus froth & foam but
without significant aspiration this is called dry drowning.
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C. Secondary Drowning
 It is a nonspecific term for death after 24 hours from complications
of submersion.
 It may occur in 10-15% of the survivors.
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Diving Reflex

 This is probably seen only in young children, but may explain why
successful resuscitation without neurological deficits can occur after
prolong immersion.
 Cold water stimulates fascial nerve afferent, while hypoxia
stimulates the carotid body chemoreceptors.
 These effects reflexly increase heart rate & vasoconstrict skin, GI
Tract & skeletal muscles vesseles redistributing blood to the brain &
heart.
10 Near drwoning- causes
 Inability to swim
 Panic in the water
 Leaving children unattended near bodies of water
 Leaving babies unattended, even for a short period of time, in bath
tubs
 Falling through thin ice
 Alcohol consumption while swimming or on a boat
 Seizure
 Heart attack while in water
 Suicide attempt.
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Clinical Manifestations
 Cold & bluish skin- larynx stays closed
 Hypoxemia- As result of laryngospasm & aspiration during drowning.
 Respiratory distress
 Clinical manifestations include tachypnea, tachycardia, increased work of
breathing & decreased breath sounds with or without crackles
 Altered mental status may be present & requires frequent monitoring of
neurologic status.
 Following submersion in cold water, hypothermia may result in relative
bradycardia & hypotension & place the child at risk for cardiac
dysrhythmias & even cardiovascular collapse.
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 Abdominal swelling
 Cough and frothy pink sputum material expelled from the respiratory
tract by coughing
 Shortness, tachypnea or lack of breath
 Vomiting
 Conscious victims may appear confused, lethargic, or irritable
13 Diagnosis
 Diagnosis relies on a physical examination of the victim & a wide range of
tests & procedures
 Examination
 Non-palpable pulse:
 Hypothermic near-drowning victims can have weak, difficult-to-
palpate pulses. The pulse should be palpated for approximately 10 seconds
before chest compressions are commenced.
 The neurological status of the patient.
 Signs of respiratory distress
 These include tachypnoea, nasal flaring, retractions & accessory
muscle use.
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Laboratory & Imaging Studies

 ABG’S: will show hypoxia, hypercarbia & mixed respiratory
metabolic acidosis
 LFT’s/ RFT’s: Elevated liver enzymes if hypoxemia & ischemia
were of long duration & provide baseline renal functions.
 S/E: Electrolytes are often obtained, although alterations of serum
electrolytes are minimal, even in freshwater drowning
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 Chest x-ray:
 To assess for the degree of aspiration & lung injury.
 The clinical course cannot be predicted by the CXR.
 However, patients who are asymptomatic 4 to 6 hours after the
incident and have a normal CXR can be discharged from the
emergency department.
 Serial CXRs are warranted in the setting of a changing clinical
examination, or worsening or refractory hypoxaemia.
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 ECG:
 All near-drowning patients should have an ECG on initial
evaluation, as they can have cardiac arrest, supraventricular
tachycardia, or ventricular fibrillation resulting from hypoxaemia
and acidosis.
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 Toxicology screening:
 it can clarify the situations of the near-drowning incident, alert the
healthcare provider to any clinically important toxicology
syndromes, and clarify the causes of a patient's neurological
impairment.
18 Immediate response
 You may attempt to rescue the person from water, but only if it’s
safe for you to do so.

 Tips for helping someone who is drowning include:

 Use safety objects, such as throw ropes, to help the victim if
they’re still conscious.
 You should only enter the water to save an unconscious person if
you have the swimming skills to safely do so.
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 It’s important to start rescue breathing as soon as possible if the

person has stopped breathing.
 CPR involves giving oxygen to the person through mouth-to-
mouth movements.
 Chest compressions are equally important, because they help
increase oxygen flow through the blood to prevent lethal
complications
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Further Management
 ABC maintenance – if the patient cannot breath intubation should be done
 unwitnessed drowning: stabilize C-spine because of the possibility of a fall
or diving injury.
 Optimize oxygenation & maintain cerebral perfusion
 Rewarm the hypothermic patient
 Further treatment is based on the patient response to initial resuscitation.
Some children begin breathing spontaneously & awaken before arrival at
an E.D.
 If the episode was significant, these children still require careful
observation for pulmonary complications over the subsequent 6 to 12
hours.
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 Mechanical ventilation may be needed in patients with significant

pulmonary or neurologic dysfunction.
 Cardiovascular compromise is often the result of impaired
contractility because of hypoxic-ischemic injury.
 Prophylactic antibiotics have not been shown to be beneficial
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Prognosis
 Outcome depends on success of the immediate resuscitation efforts &
severity of the hypoxic- ischemic injury to the brain
 Patients who have regained consciousness on arrival to the hospital will
likely survive with intact neurologic function
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 Unfavorable prognostic markers include:

 the need for CPR for more than 25 minutes,
 continued CPR at the hospital
 Glasgow Coma Scale of 5 or less
 fixed and dilated pupils
 Seizures
 coma for more than 72 hours
24 Near drowning & drowning classification
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Prevention
 Implementation of mandatory four-sided fencing around pools
(decreasing the number of children <5 years of age who drown)
 immediate provision of CPR to children who drown.
 The use of safety flotation devices in older children during water
sport activities may be beneficial.
 Enhanced supervision is required to reduce the incidence of infants
drowning in bathtubs
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References:
Oxford Hand Book of Accident & Emergency