Kembara Xtra - Medicine - Non fatal Drowning
Liquid immersion causes respiratory impairment Affected systems include the cardiovascular, neurological, pulmonary, and renal The expressions "near drowning," "secondary drowning," and "wet drowning" should be avoided. The correct term is submersion injury. Three age-related peaks: toddlers and early children (1 to 5 years), adolescents and young adults (15 to 25 years), and the elderly. Epidemiology Incidence From 2010 to 2019, an average of 3,957 fatal unintentional drownings occurred in the United States.Nearly 80% of drowning victims are men, while black children aged 10 to 14 drown at a rate 7.6 times greater than that of white youngsters. Prevalence The second most common injury-related cause of death for children aged 1 to 14 in the United States is motor vehicle accidents. For every child under the age of 15 who drowns, 8 more are treated in the emergency room for nonfatal submersion injuries. Drowning is the most common injury-related cause of death for children aged 1 to 4 in the United States. Caution In order to reduce drowning-related morbidity and mortality, proper water supervision and safety measures are essential. Pathophysiology and Etiology Cerebral hypoxia brought on by aspiration and/or reflex laryngospasm, resulting in multisystem organ dysfunction 10-20% of victims drown without aspirating; this is most likely caused by a protracted laryngospasm. Children under the age of one drowning in bathtubs and buckets, children and teenagers drowning in swimming pools, automobile accidents involving submerged vehicles, head injuries sustained when diving or swimming, and suicide. Pulmonary: Hypoxia is the main cause of illness in this area. Acute respiratory distress syndrome (ARDS), atelectasis, development of intrapulmonary right-to-left shunting, obstruction from laryngospasm and bronchospasm, and cardiac complications such as hypoxic-ischemic injury and arrhythmia (primary or secondary) are all caused by aspiration. Neurologic: hypoxic-ischemic brain injury with damage to the hippocampus, insular cortex, and basal ganglia in particular, as well as cerebral edema. Renal: acute tubular necrosis from hypoxemia, shock, hemoglobinuria, and myoglobinuria. Coagulation includes coagulopathy and hemolysis. Risk factors include: inadequate physical barriers around swimming pools; male sex; low socioeconomic status; use of illicit drugs; seizure disorder; inability to swim; pre-underwater hyperventilation; inadequate adult supervision of children; inadequate instruction in swimming; concurrent stroke or myocardial infarction; and insufficient adult supervision of water sports accidents involving boats. Basic Prevention Regular training on adequate adult supervision and drowning prevention for those who look after young children. adequate adult supervision of children, especially when they are near water. Pool alarms and buddy systems. Knowledge of water safety rules. Avoid drinking or using recreational drugs near water. Teach children to swim at a young age. Teach pool owners and parents how to perform CPR. Child Safety Considerations Never leave kids unsupervised near water. Small amounts of water (such as those in bathtubs, buckets, and toilets) can cause young children to drown. Trauma, seizure disorder, alcohol or illicit drug use, hypothermia, concurrent stroke or MI, familial long QT and familial polymorphic VT cardiac arrhythmias, hyperventilation, and hypothermia are all associated conditions. Diagnosis The updated Utstein-style approach divides data into core (considered important and feasible to be reported in most systems worldwide) and supplemental data, providing a standard template for evaluating drowning incidents and providing guidance for the history, physical exam, and appropriate management: Core victim information: victim identification—a special number or code; sex; age; incident date and time; precipitating event; and (vi) whether the victim's face was submerged at any point before to or during rescue. (vii) a current sickness; additional: (viii) race/ethnicity Core details about the scene: (i) water temperature, (ii) who saw the drowning? (iii) Was non-EMS bystander CPR administered? (iv) Was ventilation provided for onlookers? (v) Was CPR or ventilation-only performed by a trained first responder? (vi) Vital status as determined by the first trained responder: Was the victim awake and alert? Doing a typical breath? Pulse audible? (vii) The heart's initial rhythm. Supporting information X: Type of water/liquid, viii: vital signs at initial EMS examination, ix: pulmonary state at initial EMS assessment, xi: body of water Time intervals and points from EMS Core information: (i) the moment the victim's face was first noticed to be submerged; (ii) the moment the victim was pulled from the water; (iii) the amount of time the victim was submerged (submersion duration); (iv) the moment the first trained responder treated the victim; (v) the moment the first trained responder began performing CPR on the scene; (vi) the moment the victim became conscious or awake; and (vii) the time between the moment the victim's face was first clinical assessment Glasgow Coma Scale (GCS) Pulmonary: rales, wheezing Cardiac: rate, rhythm Neurologic assessment Airway state and degree of respiratory distress Pulse: absent, weak, or normal Vital signs, including pulse oximetry Multiple Diagnoses Syncopal event, head injury, arrhythmia, seizure, MI, stroke, overdose on alcohol or another drug, and other types of trauma that are not unintentional Laboratory Results Initial examinations (lab, imaging) If the initial GCS and pulse oximetry are both normal (and stay that way for 6 to 8 hours), it is not essential. Otherwise, think about: With differential, CBC Electrolytes: hypokalemia, hyponatremia, and hypernatremia Arterial blood gas (ABG): hypoxia, hypercarbia, and acidosis Blood glucose: Elevated levels may impede the recovery of neurologic function following ischemic brain damage. BUN, creatinine: acute tubular necrosis; serial troponin, ECG, and cardiac monitoring: MI If all of the following conditions are present, a chest x-ray (CXR) is not necessary. Creatine kinase (CK) and urine myoglobin indicate rhabdomyolysis. Coagulation studies indicate coagulopathy. - Initial GCS and pulse oximetry are normal - There is no sign of respiratory distress - There is no change after 4 to 6 hours of observation - In more serious cases, the CXR may reveal signs of aspiration, atelectasis, pneumothorax, or ARDS. For trauma, head CT and/or C-spine imaging Tests in the Future & Special Considerations Observe patients in the emergency department (ED) for 4 to 6 hours if their initial GCS was 15 and their pulse oximetry was over 95% (6). Early on, CXR findings could be scant or nonexistent. Other/Diagnostic Procedures Continuous cardiac monitoring, pulse oximetry, 12-lead ECG, monitoring of central venous pressure (CVP) in critically ill patients with hypotension resistant to IV fluids, and electroencephalogram (EEG) if seizure is suspected. Management The objective is to reverse hypoxemia and ketosis as soon as possible. General Actions Prehospital: Never approach a victim who is struggling by themselves. - Start an evaluation of basic life support (BLS) and advanced cardiovascular life support (ACLS). - If the sufferer is submerged and cannot be retrieved, rescue breathing may be beneficial; chest compressions are ineffective underwater and could be dangerous for both the rescuer and the victim.- As soon as practical, remove the sufferer from the water and start effective resuscitation. - Immediate CPR (ABC sequence: airway, breathing, and circulation) Even in the case of a hypothermic victim whose heart rate may be extremely bradycardic, begin CPR if a pulse cannot be felt for at least 10 seconds. - Except in cases when trauma is suspected, routine cervical collar use and spinal precautions are not necessary. - If necessary, early intubation with mechanical breathing and additional oxygen - If hypotension is present and not resolved by oxygenation, rapid crystalloid infusion should be administered.Ventricular fibrillation is uncommon in drowning, but if an AED is accessible, use it during the first stage of CPR; using an AED in a moist environment is not harmful. - Consider placing the patient in the right lateral decubitus position to prevent aspiration of vomit or gastric contents if the patient is breathing on his or her own and does not require spinal precautions. - Transport patients to more advanced medical care by evacuating them if they have abnormal lung sounds, a severe cough, foamy sputum, debris in their airways, depressed mood, or hypotension. - If another person can stay with an asymptomatic patient for the next 4 to 6 hours to monitor their symptoms and the patient has a normal lung examination, the patient may be allowed to leave the scene. ED - Use lung-protective ventilator settings if intubation is necessary (lower end-inspiratory airway pressures, lower tidal volumes of 6 mL/kg, higher positive end-expiratory pressures of 6 to 12 cm H2O) to prevent barotrauma. - Use continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or intubation if supplemental oxygen alone is insufficient. - Intubation indications Deterioration of the nervous system Inability to keep the airway open PaCO2 >50 mm Hg or inability to maintain oxygen saturation >90% while using high-flow supplementary oxygen - Take off drenched garments and start rewarming. - To rule out hypothermia, measure your core temperature. - Rewarm with less intrusive treatments such warm IV fluids, warm/humidified oxygen, and external blanketing if you are hypothermic. - Active core rewarming is only used in circumstances of resistance. First Line of Medicine For bronchospasm, use albuterol (Proventil, Ventolin), aerosolized bronchodilator, in a dose of 3 mL of 0.083% solution or 0.5 mL of 0.5% solution diluted in 3 mL of saline. Prophylactic antibiotics are not advised (1)[B]. Vasopressors should only be used when necessary for hypotension that is resistant to IV fluid resuscitation. Next Line antibiotics based on sputum or endotracheal lavage culture for pneumonia Admission Accept all patients who are symptomatic or who have aberrant vital signs, mental state, oxygenation, CXR, or laboratory results. Keep an eye on the patient's vital signs and reevaluate their neurologic condition, heart function, and pulse oximetry. Induce hypothermia with core temperature maintained between 32°C and 34°C for 24 hours after first resuscitation; this measure may be neuroprotective for patients who stay unconscious or experience a decline in their neurological condition.If a patient's mental state and respiratory function are normal and there is no additional deterioration, they can leave the emergency department (ED) within 4 to 6 hours. Take Action Follow-up with your general care doctor, orthopedic, neurologic, cardiac, pulmonary, and any other specialists you need as needed patient observation As said, ABG monitoring In unstable individuals, a pulmonary artery catheter might be required for hemodynamic monitoring. Monitoring of intracranial pressure in a subset of patients Evaluation of serum electrolytes UNTIL MENTAL STATUS NORMALIZES, DIET NPO Education of Patients When a patient is released from the hospital, the emphasis on preventive measures should be reemphasized. Parents should also get parenting advice. 75% of drowning victims will survive; 6% will still have brain abnormalities. Patients who initially have a GCS of 13 and an oxygen saturation of 95% or higher have a low risk of complications and a very good likelihood of making a full recovery. Patients with dilated and fixed pupils and no spontaneous respiratory activity as well as those who are unconscious or receiving CPR at the time of presentation have a dismal prognosis. After the initial manifestation, neurogenic pulmonary edema may develop within 48 hours. Early complications include aspiration, bronchospasm, and vomiting as well as hypoglycemia, hypothermia, and convulsions. - Arrhythmia from hypoxia or hypothermia (rarely from electrolyte imbalance) - Hypovolemia, abnormal electrolytes, or both - Hypertension Late Complications: empyema, pneumonia, ARDS, and lung abscess - Barotrauma, anoxic encephalopathy, and seizure - Sepsis, coagulopathy, and renal failure
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