What is Near- Drowning?

is survival for at least 24 hours after submersion temporarily surviving near suffocation due to submersion

What is Drowning?

is death from suffocation due to submersion.

Drowning….According to National Center for Health

Statistics 1997, drowning is the second leading cause of injury-related deaths in children aged 1-14 years.

number one cause of injury-related death in California, Arizona and Florida.

US Consumer Product Safety Commission

- reports that a swimming pool is 14 times more likely than a motor vehicle cause death of a child younger than 5 years.

Drowning….US- Estimated 7000 drownings

90,000 near drownings occur yearly

approximately 1000 deaths by drowning every

yearActive drowning – Drowning in which the victim is

struggling in the water and is still breathing

Passive drowning – Drowning in which the victim is not breathing and is face – down in the water.

Submersion injuries may be further classified as

cold-water or warm-water injuries :Warm-water drowning occurs at

water temperatures of 20°C or higher

Cold-water drowning occurs at water temperatures of less than 20°C.

Some references include very-cold-water drowning, which refers to submersion in water at temperatures of 5°C or less.

Two main mechanisms: dry drowning and wet drowning

Dry drowning occurs after immersion in cold water; the cold water causes laryngospasm and vagal stimulation, which leads to asphyxiation, hypoxia, and cardiac arrest.

Wet drowning occurs more commonly in drowning and near drowning, when the water is aspirated into the lungs along with large volumes of water that has been swallowed.

Difference between Near drowning and Secondary drowning

Near drowning occurs when the victim recovers spontaneously or is successfully resuscitated – at least temporarily (submersion with recovery).

Secondary near drowning is the delayed onset of respiratory insufficiency from submersion. It can occur in 72 hours after the initial insult; therefore the victim should be taken to the hospital for observation, regardless of how he or she appears immediately after the event.

Risk FactorsHypothermiaInability to swimDiving accidentsAlcohol and drug ingestionExhaustion

CausesCauses grouped by age of persons follows:In infants younger than 1 year

Bathtubs and buckets of water are the most common means of drowning.

Child abuse should be considered in all such cases.

In children aged 1-5 years: Residential swimming pools are the most common venue.

In young adults aged 15-19 yearsSubmersion injuries occur in ponds, lakes, rivers,

oceans, and other natural bodies of water.Injuries are frequently associated with boating,

alcohol, or both.

Pathophysiology

Submersion injury occurs when a person is submerged in water, attempts to breathe, and either aspirates water (wet drowning) or has laryngospasm without aspiration (dry drowning). The most important contributory factors to morbidity and mortality from near drowning are hypoxemia and a decrease in oxygen delivery to vital tissues (hypoxic), leading to unconsciousness and cardiac arrest.

Submersion Panic or struggle

Breath holding

Aspiration or laryngospasm

Hypoxemia and acidosis

Cardiac arrest Death

Physiologic Responses stimulated with drowning

Near drowning victims exhibit symptoms that vary, depending on the length of submersion, water temperature, quality of water, associated injuries, onset of CPR, and the patient’s resuscitative response.

Infrequently, near drowning victims may be asymptomatic.

Physiologic Responses stimulated with drowning

Conversely, most exhibit:mild dyspneaa deathlike appearance with blue or gray coloring apnea or tachypneahypotension, a heart rate as slow as four to five

beats per minute or pulselessness cold skindilated pupil (known as fish eyes)hypothermia, and vomiting

Neurologic injury results from hypoxia and can lead to cerebral edema and brainstem herniation.

Hypothermia is an important clinical feature in determining the outcome because it decreases the metabolic demands of the body, thereby delaying or even preventing severe cerebral hypoxia.

A common finding in near drowning patients is acidosis. Metabolic acidosis is primarily due to tissue hypoxia, but respiratory component may present itself after aspiration.

Near drowning survivalFactors that increase survival include:Immediate, quality CPRCold water 24C (<76F)Clean waterShort immersion timeLess struggleNo associated injuries

Signs and Symptoms of Pulmonary Failure

Pulmonary failure is common after drowning unless aspiration is prevented by laryngospasms. Two mechanisms that may cause pulmonary failure are fresh water and salt water aspiration.

Fresh water aspiration – causes pulmonary damage because of wash out of surfactant and reflex mechanisms that cause increased airway resistance.

Salt water aspiration – causes pulmonary damage via an osmotic gradient, leading to shift of protein rich fluid into the alveoli.

 

The fluid shifts caused by both types of aspiration generally do not cause significant severe electrolytes imbalances. Water contaminates add to the damage from either type of aspiration. Particulate material such as sand or mud, gastric contents, chemical irritants, or microorganisms may be aspirated along with water and result in pneumonia.

Most patients have fluid aspiration of less than 4 mL/kg. Fluid aspiration of at least 11 mL/kg is required for alterations in blood volume to occur, and aspiration of more than 22 mL/kg is required before significant electrolyte changes develop. Ingestion, rather than aspiration, is more likely to cause clinically significant electrolyte imbalances, including hyponatremia from ingestion of large volumes of fresh water (especially in children).

First Aid Care for Near-Drowning:Activate EMS (Emergency Medical Service)

Follow the 6 STEPS:

1.Remove the victim from the water as quickly and as safely as you can

2.If you do not suspect spinal injury, place the victim on the left side so that water, vomitus and secretions can drain from the upper airway

3.Assess for breathing and pulse

4. If there is no breathing, establish an airway as rapidly as you can and begin ventilations.

Note:

Water in the airway can cause resistance to ventilations. Once you have determined that there are no foreign objects in the airway, apply ventilations with more force until you see the victim’s chest rise and fall.

5. If there is no pulse begin chest compressions and perform CPR.

Head Splint Technique:A. Extend the victim’s arms. Press them against the

head to create a splint.

Head Splint Technique:B. Move the victim forward to a horizontal position.

Begin to rotate the victim

Head Splint Technique:C. Lower yourself until the water is at the shoulder

level and the victim is faceup

Head Splint Technique:D. Bring the victim’s head to rest in the crook of your

arm until help arrives

Treatment for the near drowning victim

Before the emergency departmentMonitor the patient’s ABC (cervical spine precautions).Initial CPREstablish IV access - Intravascular volume expansion

and inotropic agents ( used to manage hypotension and impaired tissue perfusion.)

Correct hypoxiaCorrect acidosisCorrect hypotensionTransport victim to nearest hospital.

In the emergency departmentMonitor the patient’s ABC (cervical spine

precautions).Initiate monitoring (cardiac and pulse oximeter).Provide rewarming therapy.Prescribed rewarming procedures:

1.Extracorporeal rewarming

2.Warmed peritoneal dialysis

3.Inhalation of warm aerosolized oxygen

4.Torso warming

 

Determine duration of submersionRemove wet clothing; wrap in dry blankets.Provide aggressive rewarming efforts if core

temperatures fall below 32C (90F).Gently handle patient to prevent arrhythmias.Anticipate profound neurologic changes.Monitor ICP (hyperventilation, administer

diuretics and barbiturates)Monitor hypoxic seizures (oxygen, ventilation,

administer diazepam, phenytoin).

PreventionsAvoid drinking alcohol whenever swimming or

boating.Drowning can occur in any container of water. Do

not leave any standing water (in empty basins, buckets, ice chests, kiddy pools, or bathtubs).

Secure the toilet seat cover with a child safety device.

Fence all pools and spas. Secure all the doors to the outside, and install pool and door alarms.

If your child is missing, check the pool immediately

PreventionsNever allow children to swim alone or unsupervised

regardless of their ability to swim.Never leave children alone for any period of time or

let them leave your line of sight around any pool or body of water. Drowning has occurred when parents left for just a minute to answer the phone or door.

Observe water safety rules.Take a water safety course.

Hypoxic or ischemic cerebral injury

Acute respiratory distress syndrome

Pulmonary damage secondary to aspiration

Life threatening cardiac arrest

Sources:Medical Surgical Nursing by

Brunner and Suddarths

10th Edition vol. 2

An Introduction to First Aid for Colleges and Universities by

K. Karren, B. Happen, D. Limmer, J. Mistovich

8th Edition

Critical care and Emergency Nursing by Schumacher and Chernecky

Thank You…