paediatric emergencies burns hemorrhage foreign bodies
TRANSCRIPT
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PAEDIATRIC
EMERGENCIESBURNS HEMORRHAGEFOREIGN BODIES ASPIRATIONPOISONINGDROWNINGFALL - FRACTURE
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BURNS
• Burn injuries caused by extreme heat sources but may also result from exposure to cold, chemicals, electricity, or radiation.
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Incidence
• Approximately 1/4th of cases are below 10 yrs of age.
• About 65% of burnt children are <5yrs of age.• >80% of burn accidents occurs in the child’s
own home.• Scalds from hot liquids constitute maximum
numbers than others(flame, electrical, chemical).
• Incidence increased in diwali festival & winter season.
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ETIOLOGY• Scald injury from moist heat : kitchen or
bathroom – (water at 68oC / 156oF can cause 3rd degree burn in one second.
• Flame injury : faulty
electrical wiring, cigarettes,
kerosene stove, gas stove,
cloths catches fire, crackers.
• Electrical injury : inserting
conductive objects into electrical outlets, bite or suck in electrical cords.
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Causes contd..
• Chemical injury and contact injury : handling or ingestion of caustic household agents.
• Radiation injury : overexposure to ultra violet rays from the sun
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Radiation burn
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The effect of burns …• Circulating plasma volume loss →decrese cardiac output (by 36
hrs. of burn).
• Hypovolemia → diminished renal perfusion → reduced GFR→renal failure.
• Water, electrolyte, albumin & protein extravate into interstitial & intracellular compartments, forming edema.
• Decrease perfusion in peripheral tissue, metabolic acidosis, hypotension.
• Polycythemia due to hemoconcentration
• Increase blood viscosity leading to slugging in the vasculature.
• Acute gastric dilation→abdominal distension→ regurgitation; decrease blood supply→decrease motility→malabsorption; gastric ulceration.
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Clinical manifestations• Body surface area burnt
• Shock (pallor, cyanosis, poor muscle tone, rapid pulse, hypotension, subnormal temp.)
• Inhalation cases – inflammation /edema of airway → obstruction of airway ( dyspnea, tachypnea, hoarseness, stridor, chest retractions, nasal flaring, restlessness, cough, drooling)
• Pulm. Edema, spasm leads to severe airway obstruction, bronchiolitis
• Toxemia- fever, vomiting, ededma, oliguria, tachycardia, glycosuria, unconsciousness
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Classification According to depth of burn injury :• Superficial (partial thickness) –
- Superficial partial thickness
- Superficial deep thickness
• Full thickness
According to event of burn injury :• 1st degree
• 2nd degree
• 3rd degree
According to severity :• Minor
• Major
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Estimation of depth of burn injury
• First degree : affecting the epidermal layer is characterized by erythema due to vascular response, edema occurs in the basal layer irritating the nerve ending & causing discomfort.
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• Second degree : subdivided into superficial partial & deep partial thickness burns.
-- In superficial partial thickness – the surface may be covered with blisters, the skin beneath it is glistening bright pink & red, sensitive to touch, temp. & airflow.
-- Deep partial thickness –destroys entire thickness of epidermis.
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• Third degree : full thickness burns involves all epidermis & dermis. The burnt skin is hard & dry, tan or fawn colored. Higher morbidity.
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4th degree
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Classification --• Minor – 1st degree, 2nd degree of <10% of
body surface area, 3rd degree <2% of BSA.
• Moderate – 2nd degree with 10-25% of BSA, 3rd degree <10% of BSA (except face, hand & feet).
• Major – 2nd degree >25% of BSA or 3rd degree over face, hand or feet or/ > 10% of BSA.
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Estimation of burn area
• Rule of hand : one hand surface(child’s own hand) with closed fingers amounts to 1% of body surface area.
• Rule of nines : first described by Pulaski & Tennison & popularized by Wallace; applicable only to children >10yrs of age & adults.
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*Leg= 13.5 each leg
*Head front
& back=18%
Adult & *children
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Rule of five – Lynch & Blocker, 1963
Area Age 0-5 yrs. Age 5-10 yrs. Age 10 yrs. & avove
Head & neck 20% 15% 10%
Trunk frontTrunk backUpper limbsLower limbs
20%20%10X2=20%10X2=20%
100%
20%20%10X2=20%15X2=30%
105%(105-5= 100%)[to be deducted from trunk]
20%20%10X2=20%15X2=30%
100%
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EMERGENCY FIRST AID• Immediate removal from heat source
• Stop, drop, and roll……
• Stopping the burning process
• Cool water should be poured on flamed area
• Protection of burn area
• Prevention of hypothermia (wrap with clean sheet)
• Observation of ABC
• Transportation to a medical facility
• Lavage for chemical (ingestion) burn for 10 minutes
• Emotional support of family members
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IMMEDIATE MANAGEMENT
MINOR BURN INJURY
• History & Assessment
• Fluid management
• Cleansing .
• Debridement.
• Application of sterile protective dressing.
• Tetanus immunoglobulin are administered.
• Patient should return to the OPD every 48hrs for redressing.
• Antibiotic therapy
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MAJOR BURN INJURY• A complete trauma assessment.
• Assess for Airway ,Breathing and Circulation.
• Initiate CPR as an indication
• Removal of pulmonary secretion
• O2 administration by mask for 24hrs.
• Fluid management
- Start IV therapy
-Monitor vital signs closely
• Catheterize & record urinary output hrly (adequate renal perfusion = 0.5ml / kg / hr.).
• Clean burn area with betadine or antiseptic solution & apply silver sulpha diazine cream.
• Tetanus toxoid, antibiotic, analgesic
• Dressing (closed/open method)
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Fluid management (Parkland, Brooks & Evans)
Parkland Formula (>15-20% TBSA):
• In first 24hrs – 4ml RL X wt. in kg. X % of TBSA burned.
• One half amount of calculated fluid is given in first 8 hrs calculated from the time of injury.
• The remaining half of the fluid is given over next 16 hrs.
• Next 24 hrs. – 2ml of RL / kg / % of burns
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Brook’s formula Fluid requirement :
• Estimate % of TBSA & accurate/approximate body wt.
• First 24 hrs. – colloids (blood,plasma,dextran) 0.5ml/kg/% of burn, saline 1.5ml/kg/% of burn.
• Second 24 hrs. – colloids 0.25ml/kg/% of burn, saline 0.75ml/kg/%of burn
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NURSING MANAGEMENT
EMERGENT PHASE:
• Initiating emergency resuscitation.
• Orienting family member.
• Initiating prescribed therapies.
• Monitoring physiologic responses to treatment.
• Initiating measures to prevent later complications.
• Providing emotional support.
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RESUSCITATIVE PHASE• Assessment of trauma
• Use of resuscitative measures
• Proper positioning
• Obtaining ECG,X-RAY and laboratories studies.
• Establishing the airway.
• Initiating fluid therapy.
• Inserting foley’s catheter.
• Completing initial wound evaluation and management.
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Contd…..• Providing nutritional support.(Davies
formula : calories – 60Kcal/kg b.wt. + 35Kcal/1%of burn; Proteins 3g/kg b.wt. + 1g/1%of burn)
• Providing pain relief.
• Monitoring for complications.
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REHABILATATIVE PHASE• Burn care.
• Providing skin care and wound management.
• Providing a physical exercise program.
• Providing for scar management.
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Some facts about wound management
• Daily or twice daily
• Cleansing of wound with debridement (natural/ mechanical /surgical/Biological)
• Hydrotherapy (32degree C)
• Wound dressing after sedation or analgesic administration
• Environmental temp. (28-30 degree C)
• Sterile/clean technique
• Wound cleaning with NS
• Blisters can be pricked & fluid can be drained
• Open / closed method
• Application of antibacterial cream/ointment
• Surgery
• Grafting
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Complications… Immediate :
• Shock (hypovolemic)
• Resp. tract injury (24-48hrs), pneumonia, resp. failure
• Septicemia
• Thrombophlebitis
• GI hemorrhage (7-10 days)
• Bone & joint abnormalities
• Seizures
Late :
• Anemia, Malnutrition, growth failure
• Post burn scar; cosmetic problems
• Psychological trauma
• Contractures
• Burn scar carcinoma (Marjolin’s ulcer)
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HEMORRHAGE
• Hemorrhage is a condition in which a person bleeds too much and can not stop the flow of blood.
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CLASSIFICATION
• IT IS CLASSIFIED ACCORDING TO APPEARANCE AS:
1. EARLY ONSET
2. CLASSIC ONSET &
3. LATE ONSET
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EARLY
• Sign and symptoms of hemorrhagic disease typically appear within hours of birth.
SIGN AND SYMPTOMS:
• Oozing from the umbilicus or circumcision site
• Bloody or black stool
• Hematuria
• Epistaxis or bleeding from punctures.
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CLASSIC
• It occurs usually at 1-7 days after birth
• Sign and symptoms are same as that of early onset
DIAGNOSTIC MEASURES:
1. Prolonged prothrombin time
2. Partial thromboplastin time
3. Fibrinogen level
4. Platelet count
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LATE ONSET• It appears at approximately 2 -12 weeks of
age . This form occurs in totally or predominantly 2 to 12 weeks of age
CLINICAL MANIFESTATION:
• Evidence of intracranial hemorrhage
• Deep echymoses and
• Bleeding from the gastrointestinal tract, mucous membranes, skin punctures or surgical incision.
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ASSESSMENT
• The prothrombin time ,blood coagulation time are prolonged.
• Levels of prothrombin (II) and factors (VIII),(IX) and(X)are markedly decreased.
• Haematemesis, epistaxis, malena
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NURSING MANAGEMENT• Careful administration of vitamin-k into the
vastus lateralis muscle or ventrogluteal injection sites.
• Observe for signs of disorder.
• Notify the physician for appropriate diagnosis and treatment.
• Breast feeding mother are encouraged to increase their intake of food containing vitamin k eg. green leafy vegetables.
• Protection of child
• Education to parents
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FOREIGN BODY INGESTION AND ASPIRATION
• Common in infants and children between the age group of 6 months and 3 years.
• Boys are twice as
likely as girl to
aspirate.
• Coins, nuts, metals,
bones, vegetables
and plastic objects
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WHY …..• Small children are curious & innocent for
inserting various object into their orifices like mouth, nose, ears, anus & vagina.
• Severity is determined by the location, type of object aspirated, extent of obstruction.
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SIGN AND SYMPTOMS
❑Dysphagia, choaking, gagging,
coughing
❑ Inability to speak
❑ Poor feeding
❑ Vomiting
❑ Neck or throat pain
❑ Refusal to eating or drinking
❑Cyanosis, dyspnea, stridor, wheezing
❑Unconsciousness, death
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Treatment • Laryngoscopic or bronchoscopic removal of
foreign body.
• If the object is lodged in the larynx, tracheostomy may be necessary.
• After removal of foreign body, child is placed in a high humidity atmosphere.
• Antibiotics to prevent secondary infection.
• Observation.
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NURSING MANAGEMENT
• Recognize the sign of aspiration →immediate removal.
• Foreign bodies should not be allowed to remain in the esophagus more than 24 hours
• Prepare the patient for flexible endoscopy if prescribed.
• Teach family and parents regarding prevention of foreign body ingestion.
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4/18/2020
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Contd……
• Teach children not to put anything in their mouth except food.
• Promote safe environment to infant and toddlers.
• Teach to immediately seek treatment if a child swallows an object.
• Prevent secondary infection
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Prevention • Keeping small objects such as toys with
movable parts, safety pins, small candies, nuts, marbles out of children.
• Adult should not do such danger activities which children can imitate.
• Supervised play for small children.
• Teaching parents regd. safety & security
• Constant supervision
• (? Effect of mass media)
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POISONING
• Common medical emergency in children.
• Under 5 yrs. of age all poisoning are accidental.
• Nearly 75% of all poisoning episodes involve ingestion of substance which are nontoxic or have mild toxicity.
• Poisoning is defined as a morbid condition caused by the ingestion of a toxic substance.
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POISON!
• A poison is any substance that when ingested, inhaled or absorbed even in relatively less amounts can cause damage to a structure or disturbance of body function by its chemical action.
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Definitions
• A poison exposure is the ingestion of or contact with a substance that can producetoxic effects.
• A poisoning is a poison exposure that results in bodily harm.
• Poison exposures can occur by accident without intent, and these exposures are defined as unintentional poisonings. In some situations, poison exposures are the result of a conscious, willful decision; these cases are defined as intentional poisonings.
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Poisoning agents
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Shannon M. N Engl J Med 2000;342:186-191
Agents Most Commonly Ingested by Children Less Than Six Years of Age, 1995 to 1998
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Epidemiology: “the numbers”
• Nearly 90% of exposures occurring at home
• During pre-adolescence : slight high in male
– This reverses in ages 13-19 with females accounting for 55 percent of poisonings
• Children, especially those under age 6, are more likely to have unintentional poisonings than older children and adults (Ref.- Litovitz 2001).
• Adolescents are also at risk for poisonings, both intentional and unintentional. About half of all poisonings among teens are classified as suicide attempts (Ref.- Litovitz 2001).
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Common clinical manifestations
• GI Disturbances : nausea, vomiting, anorexia, abdominal pain, diarrhea, discomfort.
• Respiratory & Circulatory : possible unexplained cyanosis, shock, collapse.
• CNS : lethargy, sudden loss of consciousness, convulsion, dizziness, coma.
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• Approach begins with initial
evaluation and stabilization (ABCDE)!!!!!!!
• This is followed by a thorough approach
to identify the agent(s) involved
• Often, the suspected toxic agent will determine the priorities of management
• Supportive cares, prevention of poison absorption, antidotes, enhanced elimination may subsequently be involved
Approaching the Poisoned Child
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Management for poisoning & overdose…
• Evaluation of child status in terms of immediate , potential or no danger.
• Weight & age to estimate level of potential toxicity.
• Time of ingestion
• Type, amount & route of exposure
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Poisoning in ChildrenABC’s of Toxicology:• Airway• Breathing• Circulation• Drugs:
• Resuscitation medications if needed• Universal antidotes
• Draw blood: • chemistry, coagulation, blood gases, drug levels
• Decontaminate• Expose / Examine• Full vitals / Foley / Monitoring• Give specific antidotes / treatment
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Poisoning in Children• Decontamination:
1. Ocular:– Flush eyes with saline
2. Dermal:– Remove contaminated clothing– Brush off– Irrigate skin
3. Gastro-intestinal:– Activated charcoal:
– May Prevent /delay absorption of some drugs/toxins– Almost always indicated
– Naso/oro-gastric Lavage– Bowel Irrigation:
– Recent ingestions 4-6 hrs– Awake alert patient– 500 cc NS Children / 2000cc adults– Oro / Nasogastric tube
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Shannon M. N Engl J Med 2000;342:186-191
Agents Used for Gastrointestinal Decontamination in Children
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EMERGENCY ANTIDOTESPoison Antidote Dosage Comments
Cyanide Amyl nitrate 1-2 pearl /2 min. Then Na nitrat
Acetaminophen N-Acetyl cystiene 140mg/kg PO then 70mg/kg /4h. 17 doses
Effective within 16 h of ingestion
Atropine Physostigmine 0.01-0.03mg/kg IV Possible seizures, bradycardia
Benzodiazepine Flumazenil 0.01-0.02mg/kg IV 0.2 max.
Possible seizures, arrhythemia
β-Blocking agents Atropine 0.01-0.1mg/kg IV Min. dose 0.1mg
Calcium channel blockers
Glucagon 0.05-0.1mg/kg IV
Carbon monoxide Oxygen 100%,hyperparic
Coumarin Vitamin K 2-5mg IV/ SC Monitor PT
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Cyclic antidepressants Sodium bicarbonate 0.5-1mEq/kg IV
Digoxin Digoxin–specific Fab antibody fragments
1 vial (40mg) neutralizes 0.6mg digoxin
Iron Deferoxamine 15-15mg/kg /hr IV
Isoniazid Pyridoxine Up to 250mg/kg/d for 5days
Lead EDTA= Edetate calcium BAL=Birish-anti-Lewisite DMSA=Dimercaptosuccinic acid. Penicillamine.
1500mg/m2/d for 5 days iv 3-5mg/kg/dose/4hr 3-7 d. 10mg/kg/day PO tid X5 d 20-30mg/kg/day PO /8hr
Mercury, Arsenic, Gold BAL 5mg/kg IM as soon as possible.
Nitrites/ methemoglobinemia Methylene blue 1-2mg/kg repeat 1-4 hr
Opiates,Darvon,Lomotil Naloxone 0,1mg/kg IV,ET,SC,IM up 2mg in children
Organophosphates Atropin 0.02-0.05mg/kg IV
EMERGENCY ANTIDOTES
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Primary assessment & intervention
• Vital functions
• Maintain an open airway because some substance may cause soft tissue swelling of the airway.
• Ventilation and oxygenation
• Systemic support for airway security, ventilation, hemodynamic stability, and adequate CNS function
• Careful attention to pain and agitation
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Subsequent assessment
• Identify the poison – try to determine the product taken : where, when, why, how much, who witnessed, time since ingestion.
• Call/rush to emergency.
• Obtain blood & urine tests or gastric contents for toxicology screening.
• Monitor fluid & electrolyte imbalance.
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General interventionsSupportive care –
• Initiate IV access
• Administer O2
• Monitor & treat shock
• Prevent aspiration(sidelying with head down, use of oropharyngeal airway & suctioning).
• Insert urinary catheter to monitor renal function.
• Support child having convulsion.
• Monitor & treat – hypotension, coma, cardiac dysrrhythmia, seizure
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• Gastric lavage (gastric aspirate
for toxicology screening).
• Forced diuresis (increased urine formation by isotonic fluid & diuretics)
• Hemoperfusion (process of blood through an extracorporeal circuit & a cartridge containing an absorbent, such as charcoal, after which the detoxified blood is returned to patient).
• Dermal cleansing with water or normal saline
– Pay close attention to burns, pain, infection
– Water is absolutely contraindicated with reactive metals; use mineral oil instead
– Tar can be removed safely with vaseline
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• Hemodialysis
• Providing antidote -
Opiates, Lomotil – NaloxoneIsoniazid – PyridoxineIron – DeferoxamineAtropine – ProstigmineB-blocker – AtropineCA Channel Blocker – GlucagonCarbon Monoxide – OxygenBenzodiazepine - Flumazenil
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Management Considerations• Prevention Strategies – (vigilance & firm guiding)
– Store potentially toxic substances in higher places or out of reach/sight or lock
– Store safe items within the child’s reach; don’t take medicine in front of kids
– Avoid keeping chemicals in the fridge
– Remove toxic plants; avoid exposure to toxic animals
– Keep matches, combustibles out of reach
– Dispose of partially consumed alcohol
– Read labels on products carefully
– Label poisonous substances with stickers & teach children
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Management Considerations
• Drugs that can kill the toddler in one or two doses!:– Benzocaine, camphor, chloroquine, Lomotil,
Sulfonylureas, theophylline, phenothiazines, hydrocarbon aspiration.
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“Prevention is the vaccine for the disease of injury.”
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Drowning
DROWNING
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• Drowning = process resulting in primary respiratory impairment from submersion/immersion in a liquid medium
• Submersion in a fluid resulting immediate death or death within 24hrs.
• Drowning without aspiration does not occur
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Near Drowning
Is a submersion incident in which the individual survives for more than 24 hrs. irrespective of the eventual outcome.
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EPIDEMIOLOGY• Freshwater drowning is more
common than saltwater drowning.
• Places: lakes/rivers/canals/pools
• Toddlers:
– Any container of water can be responsible:
• Buckets/fish tanks/washing machine/toilets/bathtub
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Drowning modalities• Infants (age <1) - bathtubs, buckets & toilets
• Children ages 1-4 years - swimming pools, hot tubs & spas
• Children ages 5-14 years - swimming pools & open water sites
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Near DrowningGroups at Risk
• Toddlers (40% of deaths < 5 yrs.)
• School age boys
• Teenagers
• Males > females (5:1)
• Children with:
– seizures
– cardiac dysrrhythmias
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Toddler Drownings• Tend to occur because of
lapse in supervision
• Majority in afternoon/early evening-meal time
• Responsible supervising adult in 84% of cases
• Only 18% of cases actually witnessed
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Causes of Near DrowningRecreational Boating
• 90% of deaths due to drowning
• Small, open boats
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Recreational Water Activities
20% of deaths :
too few or no
floatation
devices !
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Other CausesDiving Injuries
• Peak incidence 18-31 years
– No formal training
– 40-50% alcohol related
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Ethanol & Water Activities
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Epilepsy
• 2.5-4.6% of drowning victims had pre-existing seizure disorder
• Drowned children with epilepsy more likely to: be older than 5, drown in bathtub, not be supervised
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Occupational Water Activities
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Pathophysiology
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Atelectasis
Aspiration leads to
collapse of the alveoli due to loss
of surfactant and
pulmonary edema
normal
alveoli
surfactant
collapsed alveoli
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Pulmonary Edema
capillary
Interstitial fluid shift
AlveoliO2
CO2
Reduced perfussion
O2 CO2
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Consequences • Panic, struggling, voluntary breath-
holding
• Aspiration of small amounts into larynx
• Involuntary laryngospasm
• Swallow large amounts
• Aspiration into lungs
• Hypoxia
• Anoxia
• Hypercapnia
• Acidosis
• Pulmonary edema
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• Decrease in saturation
• Decrease in cardiac output
• Intense peripheral vasoconstriction
• Hypothermia
• Bradycardia
• Circulatory arrest
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Labs & tests
• ABG – metabolic acidosis & hypoxemia
• Electrolytes changes
• CBC
• EKG
• CXR
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Essential First Aid Management
Conscious Unconscious
Evaluate for CPR (prolonged)
Aspiration 100% oxygen
NO YES
Observe 100% oxygen transfer to hospital
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TreatmentTransport
• Continue CPR
• Establish airway → O2 as soon as possible
• Remove wet clothes
• Hospital evaluation
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Immediate hospital management• Assess and manage ABC
• Humidified 100% oxygen at the rate of 8-10 L/min.
• Pulse oximetry
• Mechanical ventilation if required
• Aspiration of stomach contents
• ABGs & Electrolytes, CXR
• Observation
• Management of associated hypothermia
• Observe in ED for minimum 4-6 hours if:
– Submersion > 1 min.
– Cyanosis
– CPR required
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• IV access
• Administer drugs(electrolyte imbalance, metabolic acidosis)
• Foley’s catheter
• Bed rest with head elevation
• Monitoring (general condition,T.P.R, BP, I/O)
• Exogenous surfactant
• Re-warming ( 20-30degree to prevent hypothermia)
• ICP monitoring -
Low ICP → Better outcome
High ICP → Poor outcome
• Antibiotics
• Aseptic technique
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Predicting Ability for Discharge
• Child can safely be discharged home if at 6 hours :
– GCS > 13
– Normal physical exam/respiratory effort
– Room air pulse oximetry oxygen saturation > 95%
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The problem with looking well
Aspiration of water can cause late complications:
• Pulmonary oedema, Pneumonia, Haemolysis, Hepatic & renal failure, bowel necrosis
• Complications of hypothermia
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Bad prognostic indicators• Submerged >10 min
• Time till BLS >10 min
• CPR >25 min
• Initial GCS <5• Age <3 years
• CPR in ER
• Initial ABG pH <7.1
• Initial core temp <330C
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Near/ Drowning The Best Approach Therefore:
• P revention !
• P revention !
• P revention !
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Prevention: Pool Fencing
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Near Drowning Keeping Your Child Safe
• Never leave a child alone in or near water, even for a minute
• Limit pool access.
• Supervise closely when near any source of water
• Keep bathroom door closed
• Teach swimming & water safety measures
• Training of first aid & BLS
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Prevention: Targeted Education
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Children with Epilepsy: Safety Recommendations
• Child can swim in lifeguard-supervised swimming pool - no open water
• Leave bathroom locked
• Supervision!
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