Drowning lecture for under graduate students
- 1. DROWNING DR MALIK MOHSIN WAQAR ABDUL
- 2. INTRODUCTION • 3rd leading cause of un intentional death worldwide • 90 percent fatalities in low and middle income coutries • Highest rate seen in males and in 1-4 yr olds.
- 3. CAUSES OF DROWNING 1. Child younger than one year. (Bathtubs, Household buckets ) 2. 1 to 4 years : ( Pool, irrigation ditches, ponds, Rivers ) 3. School age : ( swimming, boating, Ponds, Rivers, Canals, natural water reservoirs ) 4. Adolescent : ( dangerous underwater breath holding behavior DUBB, s. 70% deaths in natural Water reservoirs. 5. Underlying conditions : Epilepsy, Cardiac issues,Alcohal use, water sports,ASD
- 4. PTHOPHYSIOLOGY • Young children struggle for only 10-20 secand adolescents for 30-60 sec before final submersion. • Three processes occur leading to devastating systemic effects: • Anoxic ischemic injury-pulsless electric activity-cerebral edema-acute respiratory distress syndrome-myocardial dysfuction(so called stunning)-arterial hypotension- decreased cardiac output-arrythmias-cardiac infarction-AKI- cortical necrosis-renal failure-DIC-hemolysis-thrombocytopenia-GIT bloody diarrhea- mucosa; sloughing-raised hepatic and pancreatic enzymes-bactremia and sepsis • Pulmonary injury-washout of the surfactant • Cold water injury( less than 15-20 c)-hypothermia-cold water shock-controversial outcomes
- 7. TYPES OF DROWNING 1.Wet drowning : water inhaled in lungs Cause severe chest pain. Death occur due to Cardiac arrest or ventricular fibrillation. 2. Dry drowning : water don’t enter lungs. Death due to Laryngeal spasm in rush of water from nasopharynx & larynx. 3. Secondary / Near drowning : a submerged victim who is resuscitated and survived for 24hours . Death due to cerebral anoxia & irreversible brain damage. 4. Immersion Syndrome : Death by cardiac arrest due to vagal inhibitIon . Mostly seen im suicidal cases. Immersion vs submersion
- 8. CAUSE OF DEATH • Asphyxia • Hypothermia • Laryngeal spasm • Ventricular fibrillation • Vagal inhibition • Exhaustion • Injury
- 9. SIGNS & SYMPTOMS • 70% kids develop symptoms within 7 hours • Coma, agitated alertness. • Cyanosis, cough, Frothy white sputum • Tachypnea, tachycardia • Rhales, rhonchi & sometimes wheeze • Low grade fever • Signs of associated trauma should be Sought • Most important is history
- 10. SYSTEMIC EFFECTS Lungs : ARDS, pulmonary edema Heart: Myocardial dysfunction, arterial hypotension, Dec cardiac output, arrhythmia Kidneys :ATN, Cortical necrosis, Renal failure CNS: Cerebral edema, seizures, coma Vascular Endothelial injury : DIC, Hemolysis,Thrombocytopenia. GIT: bloody Diarrhea with mucosal sloughing., liver n pancreatic enzymes raised. Erosion of normal mucosal protective barriers To bacteremia & pulmonary infections.
- 11. EVALUATION & MANAGEMENT • 4 things determine the outcome in drowning patients • 1. Duration of submersion • 2. Speed of rescue • 3. Effectiveness of resuscitatory efforts • 4. Clinical course
- 14. MANAGEMENT • Pre hospital management • Hospital management 1. ED management 2. PICU management 3. Cardio respiratory management 4. Management of hypothermia 5. Neurological management.
- 15. PREHOSPITAL MANAGEMENT • CPR: goal is to reverse the anoxia from submersion and limit the secondary hypoxic injury after submersion, Abdominal thrusts ? • C-spine control, Backboard • ABC • Oxygen, Monitor, pulse ox saturation • IV line, Intra osseous cather epinephrine- dose0.01 mg/kg 1: 10000 (0,I mg/ml) solution every 3-5 min as needed • Intratracheal adrenaline- dose: 0.1- 0,2 mg/kg of 1:1000 ( 1 mg/ml) solution if no IV accessringer lactate or normal saline 10-20 ml/kg • Acidosis correction by NahCO3 • Passive rewarming to 34 c • Rapid transport to hospital :All drowning victims needs evaluation at hospital
- 17. HOSPITAL MANAGEMENT • Observe for 6-8 hours • Seroial monitoring of vitals • Reassess cardiorespiratory and Neurological Examination • If sp02 Achieved n symptom’s decrease patient can be discharged.
- 18. MANAGEMENT IN ED • AbC • Iv, o2, monitor, pulse ox • Cxr • AbG, s • Electrolytes • ecg • Trauma workup
- 19. ACCORDING TO GCS 1. GCS >12. O2 to keep spo2>95% Observe 6h No chest signs Spo2 normal No investigation , discharge 2. Gcs>12. 02 to keep spo2>95% observe 6H chest signs present Require o2 detoriorates shift to a monitor bed 3. Gcs<13. High flow o2 Endotracheal intubation CXR, Labs, continues Cardiac monitoring and Frequent reassessments.
- 20. CARDIO PULMONARY RESUSCITATION • Ett iNtubation • Adequate oxygenation ( Bipap, HFNC ) • Fluid resuscitation • Inotropic support • If persistent cardiopulmonary arrest on arrival along with apnea, Submersion time >10min , No response to cpR done for 25min, absence of pupillary response
- 21. NEUROLOGICAL • Major manifestation is Seizures after hypoxic brain injury. 2nd intracranial hypertension raised Icp. • Core body temperature and glucose monitoring are important modulators of hypoxic ischmic neurologic injury. • Phenytion is recommended dose ? . Benzodiazepenes, barbiturates & other anti convulsant also have a role but nor proven • Improvement within 24-72 hrs • Comatose patients having seizures always have a poor prognosis Fluid restriction, hyperventilation,muscle relaxants, osmotic agents, diuretics, barbiturates, corticosterois ??
- 22. HYPOTHERMIA MANAGEMENT • Passive external . Dry blankets, warm environment • Active External. Bring a heat source • Active internal .Warm iv fluids , warm fluida through NG tube iv medications for CPR given at lower frequencyin moderate hypothermia due to decreased drug clearance Defibrillation affective only once core body temperature reaches above 30 C Rewarming efforts continued until body tem reaches 32-34 C
- 23. SYSTEMIC MANAGEMENT • Spinal injuries • Internal heamorrhage • Hyperglycemia • Fever and hyperthermia • Acute renal failure: diuretics, Fluid restriction, dialysis if required - rhabdomyolysis • Bloody diarrhea : Bowel rest, nasogastric suction • Fever : common in 50% patients within 24h. Paracetamol • Antibiotics : Prophylactic, only if pneumonia is suspected. • Psychiatric and psychosocial sequelae ?
- 26. PREVENTION IS ALWAYS BETTER THAN CURE
- 28. THANKS