Rosen & Barkin's 5-Minute Emergency Medicine Consult (224 page)

DIAGNOSIS

• Cardiopulmonary arrest
  
• Cyanosis
  
• Dyspnea
  
• Copious pulmonary secretions
  
• Loss of consciousness
  
• Cerebral edema/injury
  
• Evidence of trauma:
  
  • Intracranial hemorrhage
    
  • Cervical spine injury rare (<0.5%)
    
• Hypothermia
  

• Information from witnesses or emergency medical services personnel at the scene
  
• Early airway management and CPR
  
• Rectal temperature for hypothermia
  

• Arterial blood gas (pH)
  
• CBC
  
• Electrolytes, BUN, creatinine, glucose:
  
  • Usually normal (>85%)
    
  • Hypernatremia or hyponatremia
    
• Alcohol and toxicology screen
  

• CXR:
  
  • Diffuse or focal infiltrates, acute respiratory distress syndrome
    
  • May be normal initially
    
• ECG:
  
  • Long QT interval
    
  • Sinus bradycardia
    
  • Sinus tachycardia
    
  • Atrial fibrillation
    
• CT scan:
  
  • Brain: Abnormality at any time during hospitalization is associated with poor neurologic outcome
    
  • Cervical spine: Traumatic injury
    

• Consider reason for submersion:
  
  • Dysrhythmia (long QT syndrome, familial polymorphic ventricular tachycardia)
    
  • Myocardial infarction
    
  • Seizure
    
  • Syncope
    
  • Trauma
    
  • Suicide attempt
    

Consider child abuse/neglect:

• Especially infants in bathtub near drowning
  

TREATMENT

• Attention to ABCs:
  
  • Avoid further aspiration
    
  • Secure airway—intubate
    
  • Early CPR
    
• Cervical spine precautions if injury suspected or concerning mechanism
  
• Early rewarming attempts
  
• 90% survival with appropriate intervention
  
• All drowning victims need ED evaluation
  
• Abdominal thrust to remove water
  not
  recommended:
  
  • Useful only if foreign body in airway
    
  • Increases risk for aspiration
    
  • Delays effective CPR
    

• ABCs
  
• Core temperature:
  
  • Initiate rewarming (see “Hypothermia”)
    
  • Remove wet clothing
    

• Correct hypoxemia:
  
  • Titrate to oxygen saturation
    
  • Intubate and provide mechanical ventilation with positive end-expiratory pressure
    
• Evaluate and treat traumatic injuries
  
• Correct acidosis
  
• Cardiopulmonary arrest:
  
  • Initiate advanced cardiac life support measures
    
  • Continue rewarming efforts:
    
    • Passive: Blankets, insulators
      
    • Active external: Warm blankets, radiant heat, warm baths
      
    • Active internal: Pleural or peritoneal lavage, cardiopulmonary bypass
      
  • Continue resuscitation until core temperature >32°C or until spontaneous pulse and respirations return
    
• No value to steroids
  
• Poor prognostic signs:
  
  • Prolonged submersion time
    
  • Severe acidosis (pH ≤7.0)
    
  • Need for CPR
    
  • Low oxygen saturation
    
  • Low Glasgow Coma Score (GCS)
    

• Epinephrine: 1 mg (peds: 0.01 mg/kg) IV
  
• Vasopressin: 40 U (peds: 0.04 U/kg) IV
  
• Lidocaine: 1 mg/kg IV
  
• Sodium bicarbonate: 1 mEq/kg IV
  

• Hypothermia may be protective:
  
  • Aggressive rewarming
    
  • Aggressive resuscitation
    
• Evaluate for abuse/neglect
  
• Family history: Sudden death, similar episode:
  
  • Long QT syndrome
    
  • Familial polymorphic ventricular tachycardia
    
• Prevention is key to treatment:
  
  • Supervision around water
    
  • Empty pails and buckets
    

FOLLOW-UP

• Delayed symptomatology occurs:
  
  • Pulmonary edema (up to 12 hr later)
    
  • Neurologic abnormalities
    
• ICU:
  
  • Patients who required CPR or artificial ventilation
    
  • Abnormal chest radiograph
    
  • Arterial blood gas abnormalities
    
  • GCS <13
    
• Admit observation status:
  
  • All symptomatic patients
    
  • Submersion for >1 min
    
  • History of cyanosis or apnea
    
  • Patients who required brief assisted ventilation
    

• Questionable history of submersion:
  
  • Observe in ED for 8 hr:
    
    • No respiratory distress
      
    • No neurologic impairment
      
• Discharge to reliable home
  
• Home-going instructions:
  
  • Return for shortness of breath or mental status changes
    

Close primary care follow-up for all patients discharged from ED

• All patients with drowning incident require at least 8 hr of observation
  
• Indicators of poor prognosis:
  
  • Acidemia (pH <7.1 on presentation)
    
  • Age <3 yr
    
  • Submersion >10 min
    
  • Time to basic life support care >10 min
    
  • GCS ≤ 5
    
  • Long transportation time to ED
    
  • Persistent apnea or need for cardiopulmonary resuscitation in the ED
    
  • Water temperature >10°C
    

• Burford AE, Ryan LM, Stone BJ, et al. Drowning and near-drowning in children and adolescents: A succinct review for emergency physicians and nurses.
  Pediatr Emerg Care.
  2005;21(9):610–619.
  
• Layon AJ, Modell JH. Drowning: Update 2009.
  Anesthesiology
  . 2009;110(6):1390–1401.
  
• Szpilman D, Bierens JJ, Handley AJ, et al. Drowning.
  N Engl J Med.
  2012;366(22):2102–2110.
  
• Wagner C. Pediatric submersion injuries.
  Air Med J
  . 2009;28(3):116–119.
  
• Youn CS, Choi SP, Yim HW, et al. Out-of-hospital cardiac arrest due to drowning: An Utstein Style report of 10 years of experience from St. Mary’s Hospital.
  Resuscitation
  . 2009;80(7):778–783.
  

See Also (Topic, Algorithm, Electronic Media Element)

Hypothermia

CODES

• 507.0 Pneumonitis due to inhalation of food or vomitus
  
• 991.6 Hypothermia
  
• 994.1 Drowning and nonfatal submersion