Drowning Patients...Part1..In the ER

Drowning is uncommon but by no means rare in the U.S.: it’s the second leading cause of death by injury in the U.S. among toddlers (3 per 100,000 among children aged 1 to 4), and you are 200 times more likely to die by drowning during a boat ride as to die from trauma during a trip by automobile. Drowning kills about 500,000 people a year worldwide, according to the WHO.









What happens?


We can only hold our breath for about a minute. Eventually, a person submerged in water gasps for air, aspirates water, and starts coughing as a reflex response; continued aspiration follows. Hypoxemia leads to unconsciousness, apnea, and cardiac decompensation: tachycardia, then bradycardia, pulseless electrical activity (PEA), then asystole. From the last breath of air to final cardiac arrest, drowning may take less than a minute, to several minutes. Colder water (hypothermia) slows the entire process.


Patient in ER...

Recognize that only 6% of people rescued by lifeguards require hospital-level medical care. For those that do require care in the emergency department, authors advise standard measures of supportive care: Restore oxygenation and secure an airway if needed; restore circulation with crystalloid and vasopressors if necessary; insert a gastric tube. Also, they say:

• Thermally insulate the patient.
• Expect a metabolic acidosis that will correct itself in most patients as they (or you) increase their minute ventilation;
• Patients on mechanical ventilation may require high delivered minute ventilations, and may benefit from high peak inspiratory pressures (authors mention 35 cm H2O).
• Routine sodium bicarbonate for metabolic acidosis is not advised by the authors.
• Consider ingestions or intoxications, or cervical spine or head injuries, especially for patients who remain unresponsive despite the above measures. Other lab abnormalities (e.g., electrolytes, creatinine, hematocrit) are rarely contributory, authors say.
• Many patients will improve to baseline with normal oxygen saturation on ambient air within 6 to 8 hours, and in the absence of complicated comorbidities may be safely discharged (authors say); others should be admitted to an intermediate care or ICU setting.

 May 31 2012 New England Journal of Medicine.