Drowning

DROWNING
AND
NEAR DROWNING
PRESENTED BY:-
Dr.K.AGASYA RAJ

WHAT IS DROWNING?
“The process of experiencing
respiratory impairment from
submersion/immersion in liquid ”
It is a form of asphyxia.
Caused due to aspiration of fluids

Epidemiology
Incidence of drowning- 2.5 lakhs to 3.5
lakhs every year
India & China account for 43% deaths.
Males>Females
1-4 yrs & 15-19 yrs(M.C)
Drowning second most common
accidental cause of death in children

Causes of Drowning
CHILDREN YOUNGER THAN 1 YR :
◦• BATHTUB(71%)
◦ • HOUSEHOLD BUCKETS(16%)
CHILDREN 1-4 YR :
◦ • POOL
◦ • IRRIGATION DITCHES
◦ • NEARBY PONDS & RIVERS.
• SCHOOL AGE CHILDREN
◦• SWIMMING OR BOATING ACTIVITIES.
◦• NATURAL WATER RESERVOIRS :
LAKES, PONDS, RIVERS, CANALS.

Causes of Drowning
ADOLESCENT
l M : F = 10 : 1.
◦(LIKELY DUE TO GREATER RISK
TAKING & ALCOHOL USE.)
◦70 % DEATHS DUE TO DROWNING IN
NATURAL WATER RESERVOIRS.
• UNDERLYING CONDITIONS
◦ EPILEPSY
◦ VENTRICULAR ARRHYTHMIAS
◦ ALCOHOL USE
◦ WATER SPORTS & RECREATIONAL
ACTIVITIES

Classification of drowning.
According to type of water
◦Fresh-water drowning: Lakes,pools,rivers
◦Salt-water drowning: seas (about 3%
saline)
• According to water temperature
◦Warm-water drowning: temperatures of >
20° C
lCold-water drowning: temperatures of
<20° C
◦Very-cold-water drowning: temperatures of
<5ºC

TYPES OF DROWNING
FOUR TYPES:-
1.WET DROWNING
2.DRY DROWNING
3.SECONDARY/NEAR DROWNING
4.IMMERSION SYNDROME

WET DROWNING
Water is inhaled into lungs
Victim has severe chest pain
On resuscitation: no pleasant
recollections
Death occurs due to Cardiac arrest or
ventricular fibrillation

Dry drowning
Water does not enter lungs
On resuscitation : panoramic views of
past life.
Death occurs by immediate sustained
laryngeal spasm due to inrush of water
into nasopharynx and larynx

Secondary drowning (near
drowning)
Refers to a submerged victim who is
resuscitated and survives for 24 hours
Death occurs ( from 1/2 h to several
days) by cerebral anoxia & irreversible
brain damage

Immersion Syndrome
Death occurs by cardiac arrest caused
by vagal inhibition (cold water
stimulating nerve endings & water
striking epigastrium & Alcohol induce
such effect)
Mostly seen in suicide cases.

Stages of drowning
Stage of surprise(5-10 secs)
Stage of 1st resp.arrest.(1-2 min)
Stage of deep respiration(1 min)
Stage of 2nd resp.arrest (1 min)
Stage of terminal gasp.

lFRESH WATER
DROWNING
Water absorbed into
circulation
Surfactant washout
Alveolar cell damage
Chemical pneumonitis,
pulmonary edema
Hypervolemia
Hyponatremia
Hemodilution
Hemolysis
Hyperkalemia
lSALT WATER
DROWNING
Hypertonic
Protein rich effusion into
alveoli
Surfactant damage,
alveolar basement
membrane damage
Alveolar cell damage
Chemical pneumonitis,
pulmonary edema
Hypovolemia
Hypernatremia
Hemoconcentration
Hypotonic

Cause of death
Asphyxia: due to airway obstruction
Hypothermia
Ventricular fibrillation: due to anoxia &
disturbed sodium-potassium ratio
Laryngeal spasm
Vagal inhibition: in icy water due to high
emotion & unexpected immersion
Exhaustion
Injury

SYMPTOMS AND SIGNS
75% of kids who develop symptoms do
so within 7 hours of event
Coma to agitated alertness
Cyanosis, coughing, and the production
of frothy white sputum
Tachypnea, tachycardia
Low-grade fever
Rales, rhonchi & less often wheezes
Signs of associated trauma to the head
and neck should be sought
History is the most important

EFFECT ON VARIOUS
SYSTEMS
LUNG :
◦ARDS.
◦PULMONARY OEDEMA
HEART :
◦MYOCARDIAL DYSFUNCTION.
◦ARTERIAL HYPOTENSION.
◦DECREASED CARDIAC OUTPUT.
◦ARRHYTHMIAS & CARDIAC INFARCTION.
 RENAL :
◦ACUTE TUBULAR NECROSIS
◦CORTICAL NECROSIS
◦RENAL FAILURE.

VASCULAR ENDOTHELIAL INJURY MAY INITIATE
◦DIC,
◦HEMOLYSIS,
◦THROMBOCYTOPENIA.
 GASTROINTESTINAL DAMAGE :
◦BLOODY DIARRHEA WITH MUCOSAL
SLOUGHING.
◦SERUM LEVELS OF HEPATIC
TRANSAMINASES AND PANCREATIC
ENZYMES ARE OFTEN ACUTELY INCREASED.
VIOLATION OF NORMAL MUCOSAL
PROTECTIVE BARRIERS PREDISPOSES THE
VICTIM TO BACTEREMIA AND PULMONARY
INFECTIONS

Management
PRE-HOSPITAL MANAGEMENT
HOSPITAL BASED MANAGEMENT
lED MANAGEMENT
lPICU MANAGEMENT
◦CARDIORESPIRATORY
◦NEUROLOGICAL
◦HYPOTHERMIA
◦OTHER

Pre hospital management
ABC’s
Initiation of ventilation is the only way to
interrupt the submersion time
C-Spine control, backboard
IV, O2, monitor, pulse ox
Correction of acidosis by sodium
bicarbonate
NO HEIMLICH
Passive Rewarming
Rapid Transport
All near drowning victims need
evaluation at a medical facility

Hospital management
OBSERVATION 6-8 HRS
MONITORING-VITALS
REPEAT RESPIRATORY SYSTEM
EXAMINATION AND NEUROLOGICAL
STATUS
If SYMPTOMS DECREASE AND
SAO2 ACHIEVED VICTIM CAN BE
DISCHARGED

Hospital management
Management in ED
◦ABC’s, with C-spine control
◦IV, O2, Monitor, Pulse Ox
◦CXR
◦ABGs
◦Electrolytes
◦Trauma workup

Acc to GCS
GCS >12
◦Oxygen to keep sat >
95%
◦Observe 4-6 hours
◦Chest signs absent
◦Saturation normal
◦Discharge home
◦No investigation
needed
GCS>12
◦Oxygen to keep sat >
95%
◦Observe 4-6 hours
◦Chest signs
present
◦Requires oxygen
◦Deteriorates
◦Admit to Monitored
bed

Acc to GCS
GCS <13
◦High flow oxygen
◦Intubation for low PaO2
◦CXR, Labs
◦Continuous cardiac monitoring
◦Frequent reassessments

Cardiopulmonary
resuscitationETT INTUBATION
ADEQUATE OXYGENATION
FLUID RESUSCITATION-ISOTONIC FLUIDS
INOTROPIC AGENTS SHOULD BE
JUDICIOUSLY USED
PERSISTENT CARDIOPULMONARY
ARREST ON ARRIVAL ALONG WITH
• APNEA.
• ABSENCE OF PUPILLARY RESPONSES.
• HYPERGLYCEMIA.
• SUBMERSION DURATIONS >10 MIN.
• FAILURE OF RESPONSE TO CPR GIVEN
FOR 25 MIN.

HYPOTHERMIA
Passive External
Active External
Active Internal
◦IV
◦Vent
◦NG/Bladder/Peritoneal

OTHER MANAGEMENT
ISSUES
ACUTE RENAL
FAILURE :
• DIURETICS,
• FLUID RESTRICTION.
• DIALYSIS IF
REQUIRED
PROFUSE BLOODY
DIARRHEA AND
MUCOSAL SLOUGHING
:
• BOWEL REST.
• NASOGASTRIC
SUCTION.
FEVER
◦COMMON IN 50%
CASES WITHIN 24
HRS
◦PROPHYLACTIC
ANTIBIOTICS ARE
RECOMMENDED
ONLY IF
PNEUMONIA IS
SUSPECTED

Drowning

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