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Information ⬇

Author: Francesca Garnham

Drowning is defined as a process resulting in primary respiratory impairment from submersion or immersion in a liquid medium, and is the third commonest cause of accidental death worldwide. The pathophysiology of drowning is summarized in Figure 108.1.

Priorities ⬆ ⬇

  • If there is cardiorespiratory arrest, resuscitate along standard lines. Clear the airway, removing mud and other foreign bodies. Immobilize the cervical spine if trauma is possible or there is no adequate history of the event.
  • Maintain a clear airway (Chapter 111), with endotracheal intubation if the patient is comatose (Glasgow Coma Scale score <9). Treat bronchospasm using an inhaled beta agonist. If still hypoxic, consider continuous positive airway pressure (CPAP) or bilevel positive airways pressure (BiPAP) if awake and compliant (see Chapter 112).
  • If systolic BP is <80 mmHg in sinus rhythm and the chest is clear, give 500 mL IV crystalloid over 30 min, with further fluid as needed up to 2L.
  • Treat seizures with IV lorazepam (see Chapter 16)
  • Check blood glucose and correct hypo- or hyperglycaemia (Chapters 81 and 82).

Key points in the clinical assessment are given in Table 108.1, and investigations needed urgently in Table 108.2.

Further Management ⬆ ⬇

Outline

Admit or Discharge?!!navigator!!

  • Discharge following observation for 6–8h (as acute respiratory distress syndrome may develop over this period) if there is no or only minor immersion/submersion injury at presentation, as evidenced by:

    • Clear history of only brief immersion/submersion
    • Normal conscious level
    • No significant injuries
    • No bronchospasm, tachypnoea or dyspnoea
    • Normal arterial oxygen saturation breathing air and normal arterial blood gases
    • No comorbidities

    Those discharged should be advised to return if they develop cough, dyspnoea or fever.

  • Patients with moderate immersion/submersion injury (hypoxaemia corrected by oxygen 35–60%, normal conscious level) should be admitted to a high-dependency unit. Those with severe immersion injury (hypoxaemia despite breathing oxygen 60% or more, or reduced conscious level) should be admitted to an intensive care unit. Monitoring is summarized in Table 108.3.

Hypoxia!!navigator!!

  • This may be due to airway obstruction, brain injury, acute respiratory distress syndrome or pneumonia.
  • Consider early intubation and mechanical ventilation. High levels of PEEP may be needed due to reduced lung compliance. After endotracheal intubation, insert a nasogastric or orogastric tube to decompress the stomach.
  • Bronchoscopy or bronchial lavage may be required to remove foreign bodies and clear debris from the airways.
  • Consider extracorporeal membrane oxygenation if adequate oxygenation cannot be achieved by ventilation.

Hypotension!!navigator!!

Rewarming causes vasodilation and the patient is likely to require additional fluid resuscitation. If systolic BP remains <90 mmHg despite adequate filling, use ino-pressor therapy (Chapter 2).

Hypothermia!!navigator!!

  • Hypothermia should be corrected by rewarming: see Chapter 107.
  • After cardiopulmonary arrest, hypothermic patients should not be rewarmed to more than 36°C, and fever should be prevented, for neuroprotection. Body temperature should be maintained at 36°C for 24h in patients with moderate coma (some motor response), and no evidence of cerebral oedema on CT scan; a target temperature of 33°C should be considered for patients with deep coma (loss of motor response or brainstem reflexes), or evidence of cerebral oedema on CT.

Acute Kidney Injury!!navigator!!

  • Acute kidney injury may be due to hypoxaemia, hypotension or rhabdomyolysis.
  • Management of acute kidney injury is detailed in Chapter 25.

Prophylactic Antibiotic or Steroid Therapy?!!navigator!!

There is no benefit from prophylactic corticosteroid or antibiotic therapy unless near drowning occurred in highly contaminated water. In these cases start antibiotic and consider antifungal therapy to cover likely organisms.

Other Injuries!!navigator!!

Advice should be sought from the appropriate specialist.

Estimating Prognosis!!navigator!!

Clinical features indicating a poor prognosis are listed in Table 108.4; survival is possible despite these features, especially if hypothermic on arrival.

Further Reading ⬆

Bierens JJLM, Lunetta P, Tipton M, Warner DS (2016) Physiology of drowning: a review. Physiology 31, 147–166. DOI: 10.1152/physiol.00002.2015.

European Resuscitation Council Guidelines (2015) https://cprguidelines.eu/.

WHO website http://www.who.int/mediacentre/factsheets/fs347/en/.