DROWNINGDR NIRAV DHINOJA

DEFINITION

• “DROWNING IS THE PROCESS OF EXPERIENCING RESPIRATORY

IMPAIRMENT FROM SUBMERSION/IMMERSION IN LIQUID.”

• THE TERM DROWNING DOES NOT IMPLY THE FINAL OUTCOME,

DEATH OR SURVIVAL; THE OUTCOME SHOULD BE DENOTED AS

FATAL OR NONFATAL DROWNING.

• USE OF CONFUSING DESCRIPTIVE TERMS SUCH AS “NEAR,” “WET,”

“DRY,” “SECONDARY,” “SILENT,” “PASSIVE,” AND “ACTIVE” SHOULD

BE ABANDONED.

EPIDEMIOLOGY

• HIGHEST DROWNING DEATH RATES WERE SEEN IN CHILDREN AGED 1-4 YR AND

15-19 YR.

• IN CHILDREN, DROWNING IS SECOND ONLY TO MOTOR VEHICLE INJURY AS A

LEADING CAUSE OF DEATH FROM UNINTENTIONAL INJURY.

• 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.

• ADOLESCENT

• M : F = 10 : 1. (LIKELY DUE TO GREATER RISK TAKING BEHAVIOUR & ALCOHOL USE.)

• 70 % DEATHS DUE TO DROWNING IN NATURAL WATER RESERVOIRS.

• UNDERLYING CONDITIONS

• EPILEPSY

• LONG QT SYNDROME

• VENTRICULAR ARRHYTHMIAS

• ALCOHOL USE

• WATER SPORTS & RECREATIONAL ACTIVITIES

PATHOPHYSIOLOGY

• MOST OF DROWNING VICTIMS DROWN SILENTLY.

• VOCALIZATION IS PRECLUDED BY EFFORTS TO ACHIEVE MAXIMAL LUNG VOLUME

OR KEEP THE HEAD ABOVE THE WATER, OR BY ASPIRATION LEADING TO

LARYNGOSPASM.

• YOUNG CHILDREN CAN STRUGGLE FOR ONLY 10-20 SEC BEFORE BEING FINALLY

SUBMERGED.

• GLOBAL HYPOXIA IS THE INJURY, WITH THE SEVERITY OF INJURY DEPENDENT

PRIMARILY ON ITS DURATION.

ANOXIC-ISCHEMIC INJURYSmall amounts of water enter the hypopharynx, triggering

laryngospasmProgressive decrease in arterial blood oxygen saturation

(Sao2), and the victim soon loses consciousness from

hypoxiaProfound hypoxia and medullary depression lead to

terminal apnea

The cardiovascular response leads to progressively

decreasing cardiac output and oxygen delivery.

By 3-4 min, the circulation abruptly fails because of

myocardial hypoxia

Ineffective cardiac contractions with electrical activity may

occur briefly, but there is no effective perfusion (pulseless

electrical activity).

Several hours after cardiopulmonary arrest, cerebral

edema may occur..

Severe cerebral edema can elevate intracranial pressure

(ICP), contributing to further ischemia.

Intracranial hypertension is an ominous sign of profound

CNS damage.

EFFECT OF HYPOXIC-ISCHEMIC INJURY ON OTHER SYSTEM

• LUNG :

• ASPIRATION LEADS TO DAMAGE TO THE PULMONARY VASCULAR ENDOTHELIUM RESULTS IN ARDS.

• HEART :

• MYOCARDIAL DYSFUNCTION.

• ARTERIAL HYPOTENSION.

• DECREASED CARDIAC OUTPUT.

• ARRHYTHMIAS & CARDIAC INFARCTION.

• RENAL :

• ACUTE TUBULAR NECROSIS, CORTICAL NECROSIS, AND RENAL FAILURE.

• VASCULAR ENDOTHELIAL INJURY MAY

INITIATE DIC, HEMOLYSIS, AND

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 INJURY

• IN HUMANS, ASPIRATION OF SMALL AMOUNTS (1-3 ML/KG) CAN LEAD TO

MARKED HYPOXEMIA AND A 10-40% REDUCTION IN LUNG COMPLIANCE.

• ASPIRATED WATER DOES NOT OBSTRUCT AIRWAYS AND IS READILY MOVED INTO

THE PULMONARY CIRCULATION WITH POSITIVE PRESSURE VENTILATION.

• IT CAN WASH OUT SURFACTANT AND CAUSE ALVEOLAR INSTABILITY,

VENTILATION-PERFUSION MISMATCH, AND INTRAPULMONARY SHUNTING.

PULMONARY INJURY

• THE COMPOSITION OF ASPIRATED MATERIAL CAN AFFECT THE

PATIENT’S CLINICAL COURSE:

• GASTRIC CONTENTS, PATHOGENIC ORGANISMS, TOXIC CHEMICALS, AND

OTHER FOREIGN MATTER CAN INJURE THE LUNG OR CAUSE AIRWAY

OBSTRUCTION.

• CLINICAL MANAGEMENT IS NOT SIGNIFICANTLY DIFFERENT IN

SALTWATER AND FRESHWATER ASPIRATIONS, BECAUSE MOST

HYPOTHERMIA

• ACCORDING TO CORE BODY TEMPERATURE MEASUREMENT :

• MILD (34-36°C).

• MODERATE (30-34°C).

• SEVERE (<30°C).

• DROWNING SHOULD BE DIFFERENTIATED FROM COLD WATER IMMERSION

INJURY, IN WHICH THE VICTIM REMAINS AFLOAT, KEEPING THE HEAD ABOVE

WATER WITHOUT RESPIRATORY IMPAIRMENT.

• THE DEFINITION OF COLD WATER VARIES FROM 60 TO 70°F.

• HEAT LOSS THROUGH CONDUCTION AND CONVECTION IS MORE

EFFICIENT IN WATER THAN IN AIR.

• IF THE WATER IS COOL, HEAT PRODUCTION CANNOT BE MATCHED

BY THE BODY’S THERMOGENIC MECHANISMS.

• CHILDREN ARE AT INCREASED RISK FOR HYPOTHERMIA BECAUSE :

• RELATIVELY HIGH RATIO OF BODY SURFACE AREA TO MASS.

• DECREASED SUBCUTANEOUS FAT.

• LIMITED THERMOGENIC CAPACITY.

• HYPOTHERMIA MAY DEVELOP MORE QUICKLY WITH IMMERSION IN

FAST-FLOWING WATER AS A RESULT OF INCREASED CONVECTION.

• AS CORE TEMPERATURE DROPS TO <35°C, COGNITION,

COORDINATION, AND MUSCLE STRENGTH BECOME

PROGRESSIVELY IMPAIRED.

• WITH PROGRESSIVE HYPOTHERMIA, THERE MAY BE LOSS

OF CONSCIOUSNESS, WATER ASPIRATION, DECREASES IN

HEART RATE AND CARDIAC OUTPUT, INEFFECTIVE

BREATHING, AND CARDIAC ARREST.

• IMMEDIATE EFFECTS OF COLD WATER IMMERSION ARE

RESPIRATORY AND CARDIOVASCULAR.

• AFTER THE CHILD IS REMOVED FROM THE WATER, BODY

TEMPERATURE MAY CONTINUE TO FALL AS A RESULT OF COLD AIR,

WET CLOTHES, HYPOXIA, AND HOSPITAL TRANSPORT.

• HYPOTHERMIA IN PEDIATRIC DROWNING VICTIMS IS OBSERVED

EVEN AFTER DROWNING IN RELATIVELY WARM WATER AND IN

WARM CLIMATES.

• UNRECOGNIZED PROGRESSIVE HYPOTHERMIA CAN LEAD TO

FURTHER DECOMPENSATION.

• IN HYPOTHERMIC VICTIMS, COMPENSATORY MECHANISMS USUALLY ATTEMPT

TO RESTORE NORMOTHERMIA AT BODY TEMPERATURES >32°C; AT LOWER

TEMPERATURES, THERMOREGULATION MAY FAIL AND SPONTANEOUS

REWARMING WILL NOT OCCUR.

• WITH MODERATE TO SEVERE HYPOTHERMIA, PROGRESSIVE BRADYCARDIA,

IMPAIRED MYOCARDIAL CONTRACTILITY, AND LOSS OF VASOMOTOR TONE

CONTRIBUTE TO INADEQUATE PERFUSION, HYPOTENSION, AND POSSIBLE

SHOCK.

• AT BODY TEMPERATURE <28°C, EXTREME BRADYCARDIA IS USUALLY PRESENT,

AND THE PROPENSITY FOR SPONTANEOUS VENTRICULAR FIBRILLATION (VF) OR

ASYSTOLE IS HIGH.

• CENTRAL RESPIRATORY CENTER DEPRESSION WITH MODERATE TO SEVERE

HYPOTHERMIA RESULTS IN HYPOVENTILATION AND EVENTUAL APNEA.

COLD WATER SHOCK

• IN HUMAN ADULTS, IMMERSION IN ICY WATER RESULTS IN INTENSE

INVOLUNTARY REFLEX HYPERVENTILATION AND TO A DECREASE IN

BREATH-HOLDING ABILITY TO <10 SECONDS, WHICH LEADS TO FLUID

ASPIRATION, CONTRIBUTING TO MORE RAPID AND DEEP HYPOTHERMIA.

• SEVERE BRADYCARDIA OCCURS IN ADULTS BUT IS TRANSIENT AND

RAPIDLY FOLLOWED BY SUPRAVENTRICULAR AND ECTOPIC

TACHYCARDIAS AND HYPERTENSION.

NEUROPROTECTION AND HYPOTHERMIA

• IT MAY BE POSSIBLE FOR THE BRAIN TO RAPIDLY COOL TO A

NEUROPROTECTIVE LEVEL, IF THE WATER IS COLD ENOUGH, THE

COOLING PROCESS IS QUICK, AND CARDIAC OUTPUT LASTS LONG

ENOUGH FOR SUFFICIENT HEAT EXCHANGE TO OCCUR.

• ONCE SUBMERSION-ASSOCIATED HYPOXIA, APNEA, AND

CARDIOVASCULAR COMPROMISE DECREASE BLOOD CIRCULATION,

THE EFFECT OF HYPOTHERMIA’S NEUROPROTECTION IS

MITIGATED.

MANAGEMENT

• PRE-HOSPITAL MANAGEMENT

• HOSPITAL BASED MANAGEMENT

• CARDIORESPIRATORY

• NEUROLOGICAL

• HYPOTHERMIA

• OTHER

PRE-HOSPITAL MANAGEMENT

• THE GOAL IS TO REVERSE THE ANOXIA FROM SUBMERSION AND PREVENT

SECONDARY HYPOXIC INJURY AFTER SUBMERSION.

• INITIAL RESUSCITATION MUST FOCUS ON RAPIDLY RESTORING OXYGENATION,

VENTILATION, AND ADEQUATE CIRCULATION.

• THE AIRWAY SHOULD BE CLEAR OF VOMITUS AND FOREIGN MATERIAL, WHICH

MAY CAUSE OBSTRUCTION OR ASPIRATION.

• ABDOMINAL THRUSTS SHOULD NOT BE USED FOR FLUID REMOVAL, BECAUSE

MANY VICTIMS HAVE A DISTENDED ABDOMEN FROM SWALLOWED WATER;

ABDOMINAL THRUSTS MAY INCREASE THE RISK OF REGURGITATION AND

ASPIRATION.

• THE CERVICAL SPINE SHOULD BE PROTECTED IN ANYONE WITH

POTENTIAL TRAUMATIC NECK INJURY.

• THE NECK SHOULD BE MAINTAINED IN A NEUTRAL POSITION AND

PROTECTED WITH A WELL-FITTING CERVICAL COLLAR.

• IF THE VICTIM HAS INEFFECTIVE RESPIRATION OR APNEA,

VENTILATORY SUPPORT MUST BE INITIATED IMMEDIATELY(MOUTH-

TO- MOUTH OR MOUTH-TO-NOSE BREATHING).

• AS SOON AS IT IS AVAILABLE, SUPPLEMENTAL OXYGEN SHOULD BE

ADMINISTERED TO ALL VICTIMS.

• POSITIVE PRESSURE BAG-MASK VENTILATION WITH 100% INSPIRED

OXYGEN SHOULD BE INSTITUTED IN PATIENTS WITH RESPIRATORY

INSUFFICIENCY.

• IF APNEA, CYANOSIS, HYPOVENTILATION, OR LABORED

RESPIRATION PERSISTS, TRAINED PERSONNEL SHOULD PERFORM ET

INTUBATION AS SOON AS POSSIBLE.

• INTUBATION IS ALSO INDICATED TO PROTECT THE AIRWAY IN

PATIENTS WITH DEPRESSED MENTAL STATUS OR HEMODYNAMIC

INSTABILITY.

• HYPOXIA MUST BE CORRECTED RAPIDLY TO OPTIMIZE THE CHANCE

OF RECOVERY.

• SLOW CAPILLARY REFILL, COOL EXTREMITIES, AND ALTERED

MENTAL STATUS ARE POTENTIAL INDICATORS OF SHOCK.

• HEART RATE AND RHYTHM, BLOOD PRESSURE, TEMPERATURE, AND

END-ORGAN PERFUSION REQUIRE URGENT ASSESSMENT.

• CONTINUOUS MONITORING OF THE ECG ALLOWS APPROPRIATE

DIAGNOSIS AND TREATMENT OF ARRHYTHMIAS.

• CPR SHOULD BE INSTITUTED IMMEDIATELY IN PULSELESS,

BRADYCARDIC, OR SEVERELY HYPOTENSIVE VICTIMS.

• IV FLUIDS AND CARDIOACTIVE MEDICATIONS ARE REQUIRED TO

IMPROVE CIRCULATION AND PERFUSION.

• EPINEPHRINE IS USUALLY THE INITIAL DRUG OF CHOICE IN VICTIMS

WITH CARDIOPULMONARY ARREST.

HOSPITAL BASED MANAGEMENT

• PEDIATRIC DROWNING VICTIMS SHOULD BE OBSERVED FOR AT LEAST 6-8 HR,

EVEN IF THEY ARE ASYMPTOMATIC ON PRESENTATION.

• SERIAL MONITORING OF VITAL SIGNS AND REPEATED PULMONARY

EXAMINATION, AND NEUROLOGIC ASSESSMENT SHOULD BE PERFORMED IN ALL

DROWNING VICTIMS.

• MOST ALERT CHILDREN WITH EARLY RESPIRATORY SYMPTOMS RESPOND TO

OXYGEN AND, DESPITE ABNORMAL INITIAL RADIOGRAPHS, BECOME

ASYMPTOMATIC WITH A RETURN OF NORMAL ROOM AIR SAO2 AND PULMONARY

EXAMINATION BY 4-6 HR.

• SUBSEQUENT DELAYED RESPIRATORY DETERIORATION IS EXTREMELY UNLIKELY

IN SUCH CHILDREN.

• SELECTED LOW- RISK PATIENTS WHO ARE ALERT AND ASYMPTOMATIC WITH

NORMAL PHYSICAL FINDINGS AND OXYGENATION LEVELS MAY BE CONSIDERED

CARDIORESPIRATORY MANAGEMENT

• ADEQUATE OXYGENATION AND

VENTILATION IS A PRE-REQUISITE TO

IMPROVING MYOCARDIAL FUNCTION.

• FLUID RESUSCITATION AND INOTROPIC

AGENTS ARE OFTEN NECESSARY TO

IMPROVE HEART FUNCTION AND RESTORE

TISSUE PERFUSION.

• FOR PATIENTS WITH PERSISTENT

CARDIOPULMONARY ARREST ON ARRIVAL

AFTER NON–ICY WATER DROWNING, THE

DECISION TO WITHHOLD OR STOP

RESUSCITATIVE EFFORTS CAN BE

ADDRESSED BY REVIEW OF THE HISTORY

AND THE RESPONSE TO TREATMENT.

• DEATH OR SEVERE NEUROLOGIC

SEQUELAE ARE QUITE LIKELY IN

PATIENTS WITH

• DEEP COMA.

• APNEA.

• ABSENCE OF PUPILLARY RESPONSES.

• HYPERGLYCEMIA.

• SUBMERSION DURATIONS >10 MIN.

• FAILURE OF RESPONSE TO CPR

GIVEN FOR 25 MIN.

NEUROLOGICAL MANAGEMENT

• DROWNING VICTIMS WHO PRESENT TO THE HOSPITAL AWAKE AND ALERT USUALLY HAVE NORMAL NEUROLOGIC OUTCOMES.

• COMATOSE DROWNING PATIENTS ARE AT RISK FOR INTRACRANIAL HYPERTENSION.

• ICP MONITORING AND THERAPY TO REDUCE INTRACRANIAL HYPERTENSION WOULD SEEM LIKELY TO PRESERVE CEREBRAL PERFUSION AND PREVENT HERNIATION, BUT THERE IS LITTLE EVIDENCE THAT THESE MEASURES IMPROVE OUTCOMES FOR DROWNING VICTIMS.

• CONVENTIONAL NEUROLOGIC INTENSIVE CARE THERAPIES, SUCH AS FLUID RESTRICTION, HYPERVENTILATION, AND ADMINISTRATION OF MUSCLE RELAXANTS, OSMOTIC AGENTS, DIURETICS, BARBITURATES, AND STEROIDS, HAVE NOT BEEN SHOWN TO BENEFIT THE DROWNING VICTIM, EITHER INDIVIDUALLY OR IN COMBINATION.

• EEG MONITORING HAS ONLY LIMITED VALUE IN THE MANAGEMENT

AND IS GENERALLY NOT RECOMMENDED, EXCEPT TO DETECT

SEIZURES OR AS AN ADJUNCT IN THE CLINICAL EVALUATION OF

BRAIN DEATH.

• SEIZURES SHOULD BE TREATED IF POSSIBLE, ALTHOUGH THEY TEND

TO BE VERY REFRACTORY.

• THERE IS NO EVIDENCE THAT TREATMENT OF SEIZURES AFTER

DROWNING IMPROVES OUTCOME.

• FOSPHENYTOIN OR PHENYTOIN LOADING DOSE FOLLOWED BY

MAINTENANCE DOSING MAY BE CONSIDERED.IT MAY HAVE SOME

NEUROPROTECTIVE EFFECTS AND MAY MITIGATE NEUROGENIC

PULMONARY EDEMA.

• WITH OPTIMAL MANAGEMENT, MANY INITIALLY COMATOSE

CHILDREN CAN HAVE IMPRESSIVE NEUROLOGIC IMPROVEMENT,

BUT USUALLY DO SO WITHIN THE 1ST 24-72 HR.

• ALMOST HALF OF DEEPLY COMATOSE DROWNING VICTIMS

ADMITTED TO THE PICU DIE OF THEIR HYPOXIC BRAIN INJURY OR

SURVIVE WITH SEVERE NEUROLOGIC DAMAGE.

• MANY CHILDREN BECOME BRAIN DEAD.

• DEEPLY COMATOSE DROWNING VICTIMS WHO DO NOT SHOW

SUBSTANTIAL IMPROVEMENT ON NEUROLOGIC EXAMINATION

AFTER 24-72 HR AND WHOSE COMA CANNOT BE OTHERWISE

EXPLAINED SHOULD BE SERIOUSLY CONSIDERED FOR WITHDRAWAL

OF SUPPORT.

HYPOTHERMIA MANAGEMENT

• DAMP CLOTHING SHOULD BE REMOVED FROM ALL DROWNING VICTIMS.

• THE GOAL IS TO PREVENT OR TREAT MODERATE OR SEVERE HYPOTHERMIA.

• REWARMING MEASURES ARE GENERALLY CATEGORIZED AS PASSIVE, ACTIVE

EXTERNAL, OR ACTIVE INTERNAL.

• PASSIVE REWARMING MEASURES CAN BE APPLIED IN THE PRE-HOSPITAL OR

HOSPITAL SETTING.

• THEY INCLUDE THE PROVISION OF DRY BLANKETS, A WARM ENVIRONMENT, AND

PROTECTION FROM FURTHER HEAT LOSS.

• REWARMING MEASURES SHOULD BE INSTITUTED AS SOON AS POSSIBLE FOR

HYPOTHERMIC DROWNING VICTIMS WHO HAVE NOT HAD A CARDIAC ARREST.

• FULL CPR WITH CHEST COMPRESSIONS IS INDICATED FOR

HYPOTHERMIC VICTIMS IF NO PULSE CAN BE FOUND OR IF

NARROW COMPLEX QRS ACTIVITY IS ABSENT ON ECG.

• WHEN VF IS PRESENT IN SEVERELY HYPOTHERMIC VICTIMS (CORE

TEMPERATURE <30°C), UP TO 3 DEFIBRILLATION ATTEMPTS

SHOULD INITIALLY BE DELIVERED, BUT FURTHER DEFIBRILLATION

ATTEMPTS SHOULD BE HELD UNTIL THE CORE TEMPERATURE IS

≥30°C, AT WHICH TIME SUCCESSFUL DEFIBRILLATION MAY BE

MORE LIKELY.

• THERE IS SIGNIFICANT CONTROVERSY REGARDING THE

DISCONTINUATION OF PROLONGED RESUSCITATIVE EFFORTS IN

HYPOTHERMIC DROWNING VICTIMS.

• VICTIMS WITH PROFOUND HYPOTHERMIA MAY APPEAR CLINICALLY

DEAD, BUT FULL NEUROLOGIC RECOVERY IS POSSIBLE, ALTHOUGH

RARE.

• BODY TEMPERATURE, WHETHER THE WATER WAS ICY OR THE

COOLING WAS VERY RAPID WITH FAST-FLOWING COLD WATER

SHOULD BE TAKEN INTO ACCOUNT BEFORE RESUSCITATIVE

EFFORTS ARE TERMINATED.

• REWARMING EFFORTS SHOULD USUALLY BE CONTINUED UNTIL THE TEMPERATURE IS

32-34°C.

• IF THE VICTIM CONTINUES TO HAVE NO EFFECTIVE CARDIAC RHYTHM AND REMAINS

UNRESPONSIVE TO AGGRESSIVE CPR, THEN RESUSCITATIVE EFFORTS MAY BE

DISCONTINUED.

• COMPLETE REWARMING IS NOT INDICATED FOR ALL ARREST VICTIMS BEFORE

RESUSCITATIVE EFFORTS ARE ABANDONED.

• DISCONTINUING RESUSCITATION IN VICTIMS OF NON–ICY WATER SUBMERSION WHO

REMAIN ASYSTOLIC DESPITE 30 MINUTES OF CPR IS PROBABLY WARRANTED.

• ONCE A DROWNING VICTIM HAS UNDERGONE SUCCESSFUL CPR AFTER A CARDIAC

ARREST, TEMPERATURE MANAGEMENT SHOULD BE CAREFULLY CONSIDERED, AND

BODY TEMPERATURE SHOULD BE CONTINUOUSLY MONITORED.

• VICTIMS IN WHOM RESUSCITATION DURATION HAS BEEN LONGER ARE MORE

LIKELY TO REMAIN COMATOSE; TEMPERATURE MANAGEMENT IN THESE

INDIVIDUALS IS AN AREA OF CONTROVERSY.

• FEVER COMMONLY DEVELOPS WITHIN THE 1ST 24-48 HR OF DROWNING.

• FEVER OR HYPERTHERMIA (CORE BODY TEMPERATURE >37.5°C) IN COMATOSE

DROWNING VICTIMS RESUSCITATED FROM CARDIAC ARREST SHOULD BE

PREVENTED AT ALL TIMES IN THE ACUTE RECOVERY PERIOD (AT LEAST THE 1ST

24-48 HR).

• HYPERTHERMIA AFTER DROWNING MAY INCREASE THE RISK OF MORTALITY AND

EXACERBATE HYPOXIC-ISCHEMIC CNS DAMAGE.

THERAPEUTIC HYPOTHERMIA

• FOR DROWNING VICTIMS WHO REMAIN COMATOSE AFTER SUCCESSFUL CPR,

MORE IMP ISSUES INCLUDE:

• REWARMING OF HYPOTHERMIC VICTIMS.

• CONTROLLED APPLICATION OF THERAPEUTIC HYPOTHERMIA.

• HYPOTHERMIC DROWNING VICTIMS WHO REMAIN UNRESPONSIVE BECAUSE OF

HYPOXIC-ISCHEMIC ENCEPHALOPATHY AFTER RESTORATION OF ADEQUATE

SPONTANEOUS CIRCULATION SHOULD NOT BE ACTIVELY REWARMED TO

NORMAL BODY TEMPERATURES.

• ACTIVE REWARMING SHOULD BE LIMITED TO VICTIMS WITH CORE BODY

TEMPERATURES <32°C, BUT TEMPERATURES 32-37.5°C SHOULD BE ALLOWED

WITHOUT FURTHER REWARMING EFFORTS.

• THE 2002 WORLD CONGRESS ON DROWNING RECOMMENDED

THAT HYPOTHERMIA (32-34°C) BE INSTITUTED AS SOON AS

POSSIBLE AFTER RESUSCITATION AND SUSTAINED FOR 12-24 HR.

• THESE PATIENTS SHOULD BE INTUBATED, MECHANICALLY

VENTILATED, AND TREATED WITH SEDATIVES AND/OR ANALGESICS

(WITH OR WITHOUT NEUROMUSCULAR BLOCKING AGENTS) AS

NECESSARY TO PREVENT SHIVERING AND MAINTAIN

HYPOTHERMIA.

• REWARMING AFTER THIS PERIOD SHOULD BE VERY GRADUAL.

• A SPECIFIC RECOMMENDATION FOR THERAPEUTIC HYPOTHERMIA,

ESPECIALLY IN CHILDREN, IS NOT YET GENERALLY ACCEPTED.

• THE ADVANCED LIFE SUPPORT TASK FORCE OF THE

INTERNATIONAL LIAISON COMMITTEE ON RESUSCITATION (2002)

DID NOT RECOMMEND THERAPEUTIC HYPOTHERMIA IN CHILDREN

RESUSCITATED AFTER CARDIOPULMONARY ARREST.

OTHER MANAGEMENT ISSUES

• ACUTE RENAL FAILURE :

• DIURETICS,

• FLUID RESTRICTION.

• DIALYSIS IF REQUIRED.

• PROFUSE BLOODY DIARRHEA AND

MUCOSAL SLOUGHING :

• BOWEL REST.

• NASOGASTRIC SUCTION.

• GASTRIC PH NEUTRALIZATION.

• FEVER :

• ALMOST HALF OF DROWNING

VICTIMS HAVE A FEVER DURING THE

1ST 48 HR AFTER SUBMERSION.

• HYPERTHERMIA IS USUALLY NOT DUE

TO INFECTION AND RESOLVES

WITHOUT ANTIBIOTICS IN

APPROXIMATELY 80% OF PATIENTS.

• PROPHYLACTIC ANTIBIOTICS ARE

NOT RECOMMENDED.

PROGNOSIS

• THE OUTCOMES FOR DROWNING VICTIMS ARE REMARKABLY BIMODAL.

• MAJORITY OF VICTIMS EITHER HAVE A GOOD OUTCOME (INTACT OR MILD

NEUROLOGIC INJURY) OR A BAD OUTCOME (PERSISTENT VEGETATIVE STATE OR

DEATH).

• FINNISH STUDY OF PEDIATRIC DROWNING SHOWED SUBMERSION DURATION WAS

THE BEST PREDICTOR OF OUTCOME.

• THE GCS SCORE HAS SOME LIMITED UTILITY IN PREDICTING

RECOVERY.

• IMPROVEMENT IN THE GCS SCORE DURING THE FIRST SEVERAL

HOURS OF HOSPITALIZATION MAY INDICATE A BETTER PROGNOSIS.

• NEUROLOGIC EXAMINATION AND PROGRESSION DURING THE 1ST

24-72 HR ARE CURRENTLY THE BEST PROGNOSTIC INDICATORS OF

LONG-TERM CNS OUTCOME.

THANK YOU