with cassie woodall ( 12 / 8 / 21 )
works with anybody from 2 days old to 19 years old
TERMINOLOGY
Multiple definitions of drowning, nonfatal drowning, and submersion injury have
been proposed in the medical literature, creating confusion and underlining the need for a more consistent approach to reporting and studying these incidents.
Nonfatal Drowning
Nonfatal drowning generally is defined as survival, at least temporarily, after suffocation by submersion in a liquid medium. Most authors include the loss of consciousness while submerged as a criteria. However, some authors have argued that since pulmonary complications may follow the aspiration of water without the loss of consciousness, nonfatal drowning should be defined as survival, at least temporarily, after aspiration of fluid into the lungs ("wet nonfatal drowning") or after a period of asphyxia secondary to laryngospasm ("dry nonfatal drowning")
Risk Factors
•lnadequate adult supervision.
•lability to swim or overestimation of swimming capabilities.
•Risk-taking behavior.
•Use of alcohol and illicit drugs (more than go percent of adult drowning
deaths are believed to be alcohol-related)
•Hypothermia, which can lead to rapid exhaustion or cardiac arrhythmias.
•Concomitant trauma, stroke, or myocardial infarction.•Seizure disorder or developmental/behavioral disorders in children
•Undetected primary cardiac arrhythmia (may be a more common cause of drowning than generally appreciated). As an
example, cold water immersion and exercise can cause fatal arrhythmias in patients with the congenital long QT syndrome
type 1. Similarly, mutations in the cardiac ryanodine receptor (RyR)-2 gene, which is associated with familial polymorphic
VT in the absence of structural heart disease or QT prolongation, have been identified in some individuals with unexplained drowning.
•Hyperventilation prior to a shallow dive. Swimmers commonly hyperventilate in order to prolong the duration of
underwater swimming, and by so doing they reduce the arterial partial pressure of carbon dioxide (PaCO2) while the
content of oxygen (CaO2) does not increase appreciably. As the individual swims, oxygen is consumed and the partial
pressure of oxygen (PaO2) falls to 3o to 40 mmHg before the PaCO2 rises sufficiently to trigger the urge to breathe. This
can lead to cerebral hypoxia, seizures, and loss of consciousness, which can result in drowning.
Pathophysiology
Fatal and nonfatal drowning typically begins with a period of panic, loss of the normal breathing pattern, breath-holding, air hunger, and a struggle by the victim to stay above the water. Reflex inspiratory efforts eventually occur, leading to hypoxemia by means of either spiration or reflex laryngospasm that occurs when water contacts the lower respiratory traHypoxemia in turn affects every organ system, with the component of morbidity and mortality being related to cerebral hypoxia.
-Cardiovascular - Arrhythmias secondary to hypothermia and hypoxemia are often
observed in nonfatal drowning victims. The initial arrhythmias described following nonfatal drowning include sinus tachycardia, sinus bradycardia, and atrial fibrillation. In addition, swimming (including diving) can precipitate fatal ventricular arrhythmias in patients with congenital long QT syndrome type 1.
-Acid-base and electrolytes - A metabolic and/or respiratory acidosis is often observed. Significant electrolyte imbalances generally do not occur in nonfatal drowning survivors except those submerged in unusual media, such as the Dead Sea, where the extremelyconcentrated seawater can produce life-threatening hypernatremia, hypermagnesemia, and hypercalcemia due to absorption of swallowed seawater.
-Renal - Renal failure rarely can occur after submersion, and is usually due to acute tubular necrosis resulting from hypoxemia, shock, hemoglobinuria, or myoglobinuria.
-Coagulation - Hemolysis and coagulopathy are rare potential complications of nonfatal drowning.
Management
Management of drowning victims can be divided into three phases: prehospital care, emergency department(ED) care, and inpatient care. Little high-quality evidence is available to guide the management of drowning victims; the guidance provided below is drawn from observational studies and clinical experience
Prehospital care and acute interventions - Rescue and immediate resuscitation by bystanders improves the outcome of drowning victims. The need for cardiopulmonary resuscitation (CPR) is determined as soon as possible without compromising the safety of the rescuer or delaying the removal of the victim from the water.
Ventilation is generally considered the most important initial treatment for victims of submersion injury. Rescue breathing should begin as soon as the rescuer reaches shallow water or a stable surface. Note that the priorities of CPR in the drowning victim differ from those in the typical adult cardiac arrest patient, which emphasize immediate uninterrupted chest compression. If the patient does not respond to the delivery of two rescue breaths that make the chest rise, the rescuer should immediately begin performing high-quality chest
compression. CPR, including the application of an automated external defibrillator, is then performed according to standard guidelines.
Neurological Injuries
• Seizure activity, which increases cerebral oxygen consumption and blood flow, should be aggressively controlled.
• Neuromuscular blocking agents should be avoided, if possible, because they can mask neurologic signs.
• Both hypoglycemia and hyperglycemia may be harmful to the brain, and euglycemia should be meticulously maintained.
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