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TomSilfvast

Treatment of a Near-Drowning Person

Essentials

  • This article is written in Finland where, due to the low salinity of the brackish sea, the submersion incidents practically always occur in freshwater and are treated accordingly. Consequently, not all aspects relevant for submersion incidents in sea water with higher salinity are covered.
  • It is of primary importance to ensure a patent airway and to provide effective ventilation and oxygenation.
  • After ensuring a patent airway and, if needed, 5 initial breaths, normal closed chest massage should be started (see Treatment of Cardiac Arrest in Primary Health Care). Only then should the electrical heart activity be examined.
    • In a lifeless, near-drowned person, the initial heart rhythm is usually non-defibrillatable (asystole or pulseless electrical activity (PEA) and there is no need for defibrillation).
    • If there is a defibrillatable rhythm, it may, for example, be due to an arrhythmia that caused the near-drowning.

Causes of near-drowning

  • A medical incident (e.g. acute coronary syndrome, convulsive seizure, cerebral haemorrhage)
  • There may be a cervical injury if the submersion event occurred after jumping into the water.
  • A scuba diver
    • Lifelessness is most commonly due to breathing water.
    • A scuba diver having problems may also develop decompression sickness (see Diving Medicine).

Pathophysiology

  • This article is written in Finland where, due to the low salinity of the brackish sea, the submersion incidents practically always occur in freshwater and are treated accordingly. Consequently, not all aspects relevant for submersion incidents in sea water with higher salinity are covered.
  • Freshwater destroys the surfactant in the alveoli. As a result, alveoli collapse, causing intrapulmonary shunting which, in turn, leads to hypoxaemia.
    • Water quality is not of very great significance because the amount of aspirated water is usually quite small.
    • Contaminated water may cause a pulmonary infection, even a difficult one.
  • In some patients, aspiration of water will cause an epiglottic spasm in association with the first inhalation underwater.
  • Strong respiratory movements against a closed epiglottis often lead to pulmonary oedema. This can often be seen during resuscitation, already, but it may appear as long as several hours later.
  • Holding the breath, suffocation and, lastly, not breathing cause worsening asphyxia that will lead to cardiac arrest.
  • Blood gas analysis after the heart starts beating again often reveals significant metabolic acidosis.

Initial treatment

  • Let water run out from the patient's mouth and throat; there is no need to use suction.
  • If the patient is unconscious, immediately ensure a patent airway (see Airway Management and Assisted Ventilation in an Emergency).
  • Start ventilation with 100% oxygen.
    • Use an oxygen reservoir mask.
  • Subsequently, the aim should be an inhaled air oxygen content ensuring normal oxygenation or > 94% SpO2 according to blood gas analysis.
    • Too high oxygen levels may impair neurological recovery.

Conscious patient

  • If blood gas analysis shows adequate respiratory function, provide oxygen via an oxygen mask.
  • If oxygenation is insufficient (SpO2< 90% despite oxygen supplementation) and the patient is cooperative, start non-invasive ventilation (NIV) support.
  • Due to an increased risk of aspiration, the patient should be closely monitored at first. There is often water in the stomach.
  • Hospital monitoring is indicated until the following morning.

Lifeless patient

  • Treat the asystole or PEA with adrenaline according to the standard resuscitation protocol if the attempt of resuscitation is considered justifiable.
    • The prognosis is dire if the patient has been under water for over 30 minutes.
  • Patients submerged in very cold water may be hypothermic if they have swum or floated for a longer time before submersion.
    • If the core temperature is below 30 °C, the heart cannot be started.
    • If the decision is made to resuscitate but the heart cannot be started within 5-10 minutes from the start of the resuscitative measures, while continuing resuscitation the hypothermic patient should be transported to hospital to be warmed up.

Further treatment of the resuscitated patient

  • The patient should be treated according to the principles of treating resuscitated patients.
  • Breathing should be monitored particularly closely, as hypoventilation will raise intracranial pressure significantly, impairing cerebral circulation.
  • Direct intracranial pressure monitoring should be started, as far as possible, for any unconscious resuscitated near-drowned patient.
    • The intracranial pressure often rises, sometimes as late as more than 24 hours after the event.
  • There is no specific treatment available to protect the brain.
    • Hypothermia therapy can be considered individually depending on the overall situation.
  • Later, a significant proportion of the patients will develop ARDS.

Workup

  • Basic blood count with platelets
  • P-Hb to exclude haemolysis
    • If > 50 g/l, consider urinary alkalization or dialysis.
  • Blood glucose level
  • Electrolytes (K, Na)
  • Blood gas analysis
  • CK
  • Creatinine
  • ECG
  • Chest x-ray
  • Cervical x-ray if there is suspicion of injury
  • If a medical incident is suspected, perform appropriate investigations.
  • Take samples to test for any intoxication.